Background: Current medical society guidelines recommend a procedural number for obtaining electromagnetic navigational bronchoscopy (ENB) competency and for institutional volume for training. Objective: To assess learning curves and estimate the number of ENB procedures for interventional pulmonology (IP) fellows to reach competency. Methods: We conducted a prospective multicenter study of IP fellows in the United States learning ENB. A tool previously validated in a similar population was used to assess IP fellows by their local faculty and two blinded independent reviewers using virtual recording of the procedure. Competency was determined by performing three consecutive procedures with a competency score on the assessment tool. Procedural time, faculty global rating scale, and periprocedural complications were also recorded. Results: A total of 184 ENB procedures were available for review with assessment of 26 IP fellows at 16 medical centers. There was a high correlation between the two blinded independent observers (rho = 0.8776). There was substantial agreement for determination of procedural competency between the faculty assessment and blinded reviewers (kappa = 0.7074; confidence interval, 0.5667-0.8482). The number of procedures for reaching competency for ENB bronchoscopy was determined (median, 4; mean, 5; standard deviation, 3.83). There was a wide variation in the number of procedures to reach competency, ranging from 2 to 15 procedures. There were six periprocedural complications reported, four (one pneumomediastinum, three pneumothorax) of which occurred before reaching competence and two pneumothoraces after achieving competence. Conclusion: There is a wide variation in acquiring competency for ENB among IP fellows. Virtual competency assessment has a potential role but needs further studies.

Convex probe endobronchial ultrasound (CP-EBUS) and stereotactic body radiotherapy (SBRT) are valuable tools in the diagnosis, staging, and treatment of thoracic malignancies. With widespread clinical adoption, novel uses of CP-EBUS beyond mediastinal diagnosis and staging continue to be discovered. SBRT is an attractive treatment strategy in early-stage lung cancer and oligo-metastatic disease of the chest when a surgical approach is either not feasible or desirable. Accurate application of SBRT is aided by the placement of radio-opaque fiducial markers (FM) to compensate for respiratory cycle movements. We describe eight patients with central thoracic lesions, either known or suspected to be malignant, who underwent EBUS bronchoscopy with lesion sampling and successful intralesional placement of modified FM via our technique, review the existing literature on this topic, and discuss the nuances of coding and billing aspects of FM placement.

SESSION TITLE: Interventional Pulmonology SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Bronchoscopy with Endobronchial ultrasound guided transbronchial needle aspiration (EBUS TBNA) provides an accurate and minimally invasive option for mediastinal staging. EBUS TBNA is typically performed using either 21 or 22 gauge (G) needles, with no proven impact of needle size on yield. Larger samples are needed to perform molecular and histologic analysis. A 19 G needle can provide these larger samples. We evaluated 19 G needle for safety, efficacy, and adequacy of the specimen for diagnosis and molecular testing. METHODS: Retrospective data review of all mediastinal and hilar adenopathy patients, January 2016 to March 2017, who underwent EBUS guided core biopsy with 19 G ViziShot needle using an Olympus BF-UC 180 F scope (Olympus America, Inc. Center Valley, PA). Rapid onsite evaluation (ROSE) was performed on all and sample was deemed adequate with the presence of lymphocytes or a definite diagnosis. Diagnostic yield was defined as a specific diagnosis made on EBUS TBNA sample. The specimen was considered adequate for molecular testing if all molecular markers like EGFR, ALK, ROS and PDL-1 could be performed. RESULTS: 32 patients underwent 19 G EBUS TBNA. Mean age was 64.3 ± 16.2 with 53 % female and 47 % male. 40 Lymph nodes stations and three lung mass were sampled out of which 16 (40%) were obtained from station 7, 13 (33%) from station 4 and 11 (27%) from station 11. Mean lymph node size was 27± 14mm with average 3.7± 1.5 passes per lymph node. The median size of sample was 61.5 mm3. Sample was adequate in 100% of cases. Diagnostic yield was 91% (29/32). Malignancy was diagnosed in 24/29 (83%), non-caseating granuloma in 3/29 (10%), lymphoma in 1/29 (3.5%) and bronchial cyst in 1/29 (3.5%). Adenocarcinoma was diagnosed in 8 patients, and 100% of the samples were adequate for molecular testing. There was no significant bleeding or complications CONCLUSIONS: EBUS guided 19 G needle sampling is safe with high diagnostic yield. Specimen sizes are adequate for histological assessment and molecular testing. CLINICAL IMPLICATIONS: EBUS TBNA with 19 G needle is safe and effective. Adequate specimen can be collected for required studies. DISCLOSURE: The following authors have nothing to disclose: Bikash Bhattarai, John Egan, Benjamin Seides, Sara Greenhill, Kevin Kovitz, Neeraj Desai No Product/Research Disclosure Information

SESSION TITLE: Disorders of the Mediastinum 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Primary carcinoid tumor arising in thymus is rare with very few cases reported. Recurrence and metastases are common. We present a case of carcinoid tumor of thymus that recurred 6 years post treatment. CASE PRESENTATION: 28 yo female presented with adrenocorticotrophic hormone( ACTH) secreting low-grade carcinoid tumor of thymus causing Cushing syndrome. She underwent trans-sternal thymectomy and adjuvant radiotherapy. Postoperative CT scan and ACTH levels were stable for 5 years with no evidence of disease. Several month prior to presentation to us she noted a left neck mass , her ACTH levels rose and she was admitted for pneumonia. CT and Positron Emission Tomography (PET) scans demonstrated PET-avid mass in the left neck just behind the sternocleidomastoid, and along the right internal jugular lymph node chain. Fine needle aspiration of the left supraclavicular mass demonstrated neuroendocrine carcinoma. She underwent successful resection of the mass along with extended left neck dissection with en-bloc resection of the internal jugular vein down to the left subclavian junction including thoracic duct resection and bilateral lymphadenectomy of jugular nodes. Post surgery her ACTH level declined from 81-19.7 pg./ml ( Normal:10-50 pg/ml) DISCUSSION: Carcinoid tumors are unusual tumors and account for less than 5 % of all anterior mediastinal tumors. It is incidentally found in over one third of patients. Others present with signs and symptoms of rapidly expanding mass such as cough, chest pain, superior vena cava syndrome. At least 20% have metastases at presentation with extra thoracic disease in 20-30%. Almost 50% are functionally active and associated with endocrinopathies such as Cushing syndrome as in our patient and multiple endocrine neoplasia. Invasion of adjacent structures such as in our patient occur in 30-50% and metastases to lung, bone and liver in about 30%. Surgical resection is the treatment of choice although recurrence is 67% and often after long intervals. Radiotherapy and chemotherapy is recommended but without clear-cut benefit. Survival varies and in one review 51% survived three years, 27% survived five years and 9% survived 10 years or more CONCLUSIONS: Thymic carcinoids are slow growing aggressive tumors, which commonly invade surrounding structures. Despite extensive resection late recurrence may occur. Reference #1: Carcinoid tumor of the thymus. Thorax 1994; Wang et al Reference #2: Primary Neuroendocrine carcinoma of thymus: Niger med J 2013 jan feb:Gaude et al DISCLOSURE: The following authors have nothing to disclose: Bikash Bhattarai, Kevin Kovitz, Benjamin Seides No Product/Research Disclosure Information

SESSION TITLE: Interventional Pulmonary Procedural Safety and Outcomes SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, October 26, 2016 at 02:45 PM - 04:15 PM PURPOSE: To determine the safety of medical thoracoscopy (MT) in a community based interventional pulmonology fellowship program. METHODS: We performed an observational cohort study including all MT procedures performed by our program in three community hospitals. Patients were referred to the Interventional Pulmonology (IP) service for evaluation of recurrent exudative pleural effusion or for palliation of known or suspected malignant pleural effusion. Procedures were performed by an attending interventional pulmonologist. An IP fellow participated in most cases. The majority of MT cases were performed with ultrasound guidance and used a Wolf rigid thoracoscopy set (Richard Wolf, Vernon Hills, IL). All MT were performed under monitored anesthesia care in the operating room. Primary endpoints included major complications directly related to the MT such as clinically significant bleeding, infection, pneumothorax, respiratory failure, and any procedure related mortalities. RESULTS: 193 MT were performed on 185 patients between January 2007 and March 2016. Ten cases were excluded as there was no procedural data available. Of the remaining 183 cases there were 107 men and 76 women with mean age 67.6 ± 13.8 years. Parietal pleural biopsies were performed in 155 of the 183 procedures to investigate the etiology of recurrent exudative pleural effusion and their diagnostic yield was 98%. The most common results were pleuritic and chronic inflammation (42%), followed by mesothelioma (13%), lung cancer (12%), and breast cancer (11%). There were 119 palliative procedures performed during MT. Of these, 66% (79/119) received a tunneled pleural catheter. The remaining 34% (40/119) were found at the time of MT to have a fully expandable lung or a partially trapped lung. These patients underwent talc poudrage (TP) and data was availble in 37 of the 40 cases. The overall proportion of successful TP was 78% (29/37) and this proportion increased when considering patients who had no evidence of partially trapped lung at the time of thoracoscopy to 87% (26/30). The major adverse event (MAE) rate was 2.1% (4/183). MAE included 2 cases of pneumomediastium and subcutaneous emphysema requiring either placement of a new chest tube or connecting tunneled pleural catheter to in-line suction. There was one case of hemorrhage requiring open thoracotomy and one case of respiratory failure requiring intubation. There were no deaths associated with the procedure. CONCLUSIONS: Our analysis confirms the safety of the procedure with an adverse event rate of 2.1% and no deaths, consistent with published safety data for MT. To our knowledge, this is the first community based IP safety analysis of MT. CLINICAL IMPLICATIONS: Medical thoracoscopy can be performed safely in a community based setting with high diagnostic and palliative outcomes. DISCLOSURE: The following authors have nothing to disclose: John Egan, Benjamin Seides, Sara Greenhill, Elsa Garza, Amit Goyal, Kevin Kovitz, Neeraj Desai No Product/Research Disclosure Information

We present a case of a woman with medically refractory ulcerative colitis (UC) who developed severe bronchiectasis, bronchitis, bronchiolitis and Mycobacterium intracellulare (MAC) infection 2 years after total colectomy. Despite being on optimal therapy for her MAC and sterilising multiple consecutive sputum cultures, she remained highly symptomatic, and this led to further investigations that revealed the presence of UC-related airways disease. Addition of immunosuppressive therapy to her antimycobacterial treatment resulted in sustained and complete clinical remission of her disease. To our knowledge, this is the only case published in the literature that describes a case of successful treatment of concomitant UC-related pulmonary disease and symptomatic MAC.

SESSION TITLE: Interventional Pulmonary Cases SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Sunday, October 25, 2015 at 10:45 AM - 11:45 AM INTRODUCTION: Fiducial marker (FM) guided stereotactic body radiotherapy (SBRT) is an attractive strategy for early stage lung cancer when surgery is not preferable, and in oligo-metastatic or recurrent neoplastic disease in the thorax[1]. FM placement is usually done by CT-guided transthoracic needle placement, a procedure with a 40% or higher rate of pneumothorax[2]. It is also an impractical approach for central nodal lesions. We present an alternative strategy with several examples of successful placement of FM via real-time ultrasound visualization using convex probe endobronchial ultrasound (CP-EBUS). CASE PRESENTATION: 1. 76M with h/o treated oropharyngeal cancer with a hypermetabolic infrahilar lesion. 2. 84F with remote h/o treated squamous cell lung cancer with a hypermetabolic paratracheal lesion. 3. 68M with h/o treated NSCLC and SCLC with a hypermetabolic infrahilar lesion. 4. 57F h/o treated breast carcinoma with a hypermetabolic paratracheal lesion. In each case, the following steps were employed (Fig 1.): A. Lesion of interest located and sampled via CP-EBUS B. Rapid on-site evaluation (ROSE) cytology to confirm malignancy C. A FM coil is modified by straightening and then dividing it into shorter segments. D. These segments are backloaded into tip of EBUS needle, and the needle tip is sealed with sterile bone wax to prevent dislodgement. E. The lesion is then relocated, and punctured under real-time ultrasound guidance. The internal stylet is then advanced to the end of the needle, thereby pushing the FM into the lesion with placement confirmed by ultrasound. DISCUSSION: The above outlined technique is easy to learn and perform, and adds little procedural time to the diagnostic and staging portion of the EBUS procedure. The FM placed by this method perform well and remain well positioned over time (Fig.2). The revolutionary impact of CP-EBUS in the diagnosis and staging of intrathoracic malignancies is well known. Its value continues to increase as new applications of CP-EBUS are elucidated. CP-EBUS is widely available; being taught in most pulmonary fellowship programs, and has an excellent safety profile. By using CP-EBUS for real time placement of FM for SBRT, we highlight a new application of CP-EBUS for select patients. CONCLUSIONS: Use of CP-EBUS to place FM is a safe, efficient, and cost effective technique that can be easily learned by anyone proficient with CP-EBUS. Reference #1: Kelsey, C.R., et al. Surg Oncol Clin N Am, 2013. 22(3): p. 463-81. Reference #2: Kothary, N., et al. J Vasc Interv Radiol, 2009. 20(2): p. 235-9. DISCLOSURE: The following authors have nothing to disclose: Benjamin Seides, Sara Greenhill, Kevin Kovitz, Neeraj Desai No Product/Research Disclosure Information

SESSION TITLE: Procedures Case Report Posters SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Bronchial mucous gland adenoma (MGA) is a rare benign neoplasm of the lung. It is derived from salivary gland epithelium, and comprised of mature acini of mucous secreting cells. [1-3] We report the first case of MGA treated with complete endoscopic resection via rigid bronchoscopy and laser ablation. CASE PRESENTATION: 53 year-old male former smoker presented with a long history of asthma symptoms and recurrent pneumonias, unresponsive to usual therapies. CT of the chest revealed an obstructing lesion at the distal left mainstem bronchus (fig.1). PET-CT of the mass indicated a standard uptake value (SUV) of 2.2 without hypermetabolism elsewhere. With clinical suspicion for carcinoid, we took the patient to the operating room for diagnostic and therapeutic bronchoscopy. The lesion was fleshy, smoothly marginated, spherical, and completely occluding the airway in a ball-valve fashion (fig. 2). It was hypovascular by endobronchial ultrasound. Using a rigid bronchoscope, we cored out the lesion, removing residual tissue with rigid forceps. The base of the lesion was then ablated using a 980 nm diode laser. 100% patency to the left mainstem was restored with immediate remission of symptoms. The patient was sent home that day. Pathology of the lesion revealed it to be a bronchial MGA. The patient remains asymptomatic. DISCUSSION: Bronchial MGA is a rare benign neoplasm of the lung. It exerts symptoms via obstruction, thus treatment by removal is curative. Prior to diagnosis, many patients present with years of unexplained respiratory symptoms, unresponsive to usual therapies, as in our patient. [1, 2] Virtually all published cases have described treatment of MGA by major surgery including surgical resection and bronchoplastic reconstruction.[1-3] We highlight the successful management of MGA via a less invasive, outpatient-based approach. Though there remains a theoretical concern for local recurrence, the indolent and benign nature of the tumor makes this entity easily manageable with surveillance and additional bronchoscopy, if needed. CONCLUSIONS: Bronchial MGA is a rare neoplasm of the lung, which is successfully treatable via a minimally invasive approach. Reference #1: Milenkovic, B., et al. J Asthma, 2007. 44(9): p. 789-93. Reference #2: Badyal, R.K., et al. Lung India, 2014. 31(3): p. 274-6. Reference #3: Ferguson, C.J. et al. J Thorac Cardiovasc Surg, 1988. 95(2): p. 347-50. DISCLOSURE: The following authors have nothing to disclose: Benjamin Seides, Sara Greenhill, Kevin Kovitz, Neeraj Desai No Product/Research Disclosure Information

SESSION TITLE: Interstitial Lung Disease Case Report Posters I

SESSION TITLE: Interstitial Lung Disease Cases II

SESSION TITLE: Miscellaneous Case Report Posters II

SESSION TYPE: Airway Case Report Posters