Brian Shaller

All Publications

• State of the art: peripheral diagnostic bronchoscopy. Journal of thoracic disease Sumner, E. T., Chang, J., Patel, P. R., Bedi, H., Shaller, B. D. 2024; 16 (8): 5409-5421

  Abstract

  Lung cancer is the leading cause of cancer related death worldwide and in the United States according to the World Health Organization and National Cancer Institute. Improvements in the diagnosis and treatment of lung cancer are of the utmost importance. A prompt diagnosis is a crucial factor to improve outcomes in the treatment of lung cancer. Although the implementation of lung cancer screening guidelines and the overall steady growth in the use of computed tomography have improved the likelihood of detecting lung cancer at an earlier stage, the diagnosis of peripheral pulmonary lesions (PPLs) has remained a challenge. The bronchoscopic techniques for PPL sampling have historically offered modest diagnostic yields at best in comparison to computed tomography guided transthoracic needle aspiration (TTNA). Fortunately, recent advances in technology have ushered in a new era of diagnostic peripheral bronchoscopy. In this review, we discuss the introduction of advanced intraprocedural imaging included digital tomosynthesis (DT), augmented fluoroscopy (AF), and cone beam computed tomography. We discuss robotic assisted bronchoscopy with a review of the currently available platforms, and we discuss the implementation of novel biopsy tools. These technologic advances in the bronchoscopic approach to PPLs offer greater diagnostic certainty and pave the way toward peripheral therapeutics in bronchoscopy.

  View details for DOI 10.21037/jtd-24-346

  View details for PubMedID 39268128

  View details for PubMedCentralID PMC11388231

• Application of Diagnostic Stewardship to Fungal Polymerase Chain Reaction: Low Yield of Follow-up Testing on Plasma and Bronchoalveolar Lavage After a Negative Result. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Wang, T., Park, B., Anderson, G., Shaller, B., Budvytiene, I., Banaei, N. 2024

  Abstract

  Early diagnosis of invasive fungal disease is essential for optimizing management. Although the clinical utility of fungal polymerase chain reaction (PCR) testing on plasma and bronchoalveolar lavage (BAL) has been established, the role of follow-up testing remains unclear.This was a retrospective single-center study. The yield of follow-up PCR for Aspergillus species, Mucorales agents, Fusarium species, Scedosporium species, dimorphic fungi, Pneumocystis jirovecii, and Candida species on plasma and/or BAL was measured at intervals of 1, 2, 3, and 4 weeks following a negative result.A total of 1389 follow-up tests on 406 plasma specimens from 264 patients and 983 BAL specimens from 431 patients were evaluated. Overall, the positivity rate at 1, 2, 3, and 4 weeks was 2.7% (4/148), 3.3% (4/123), 5.1% (4/78), and 3.5% (2/57), respectively, on plasma, and 0% (0/333), 0.3% (1/288), 0.4% (1/228), and 0.7% (1/134), respectively, on BAL. Conversions occurred with Aspergillus species, Mucorales agents, and Fusarium species PCR on plasma and Aspergillus species and P jirovecii PCR on BAL. All patients who converted were immunocompromised. Within 1 week of a prior negative test, 2 Aspergillus and 2 Mucorales PCRs were positive on plasma, and zero tests were positive on BAL. In week 1, only 1 Aspergillus species that was positive on day 7 was classified as probable fungal disease.Fungal PCR follow-up testing on plasma and BAL within 4 weeks of a prior negative result was of low yield and rarely generated a positive result considered clinically significant in the first week.

  View details for DOI 10.1093/cid/ciae382

  View details for PubMedID 39162527

• Added Value of a Robotic-assisted Bronchoscopy Platform in Cone Beam Computed Tomography-guided Bronchoscopy for the Diagnosis of Pulmonary Parenchymal Lesions. Journal of bronchology & interventional pulmonology Shaller, B. D., Duong, D. K., Swenson, K. E., Free, D., Bedi, H. 2024; 31 (3)

  Abstract

  BACKGROUND: Cone beam computed tomography (CBCT)-guided bronchoscopic sampling of peripheral pulmonary lesions (PPLs) is associated with superior diagnostic outcomes. However, the added value of a robotic-assisted bronchoscopy platform in CBCT-guided diagnostic procedures is unknown.METHODS: We performed a retrospective review of 100 consecutive PPLs sampled using conventional flexible bronchoscopy under CBCT guidance (FB-CBCT) and 100 consecutive PPLs sampled using an electromagnetic navigation-guided robotic-assisted bronchoscopy platform under CBCT guidance (RB-CBCT). Patient demographics, PPL features, procedural characteristics, and procedural outcomes were compared between the 2 cohorts.RESULTS: Patient and PPL characteristics were similar between the FB-CBCT and RB-CBCT cohorts, and there were no significant differences in diagnostic yield (88% vs. 90% for RB-CBCT, P=0.822) or incidence of complications between the 2 groups. As compared with FB-CBCT cases, RB-CBCT cases were significantly shorter (median 58 min vs. 92 min, P<0.0001) and used significantly less diagnostic radiation (median dose area product 5114 Gym2 vs. 8755 Gym2, P<0.0001).CONCLUSION: CBCT-guided bronchoscopy with or without a robotic-assisted bronchoscopy platform is a safe and effective method for sampling PPLs, although the integration of a robotic-assisted platform was associated with significantly shorter procedure times and significantly less radiation exposure.

  View details for DOI 10.1097/LBR.0000000000000971

  View details for PubMedID 38953732

• State of the art: peripheral diagnostic bronchoscopy Journal of Thoracic Disease Sumner, E. T., Chang, J., Patel, P. R., Bedi, H., Shaller, B. D. 2024; (online ahead of print)
• Imaging in peripheral bronchoscopy. Current opinion in pulmonary medicine Shaller, B. D., Sethi, S., Cicenia, J. 2023

  Abstract

  PURPOSE OF REVIEW: Historically the sampling of peripheral lung lesions via bronchoscopy has suffered from inferior diagnostic outcomes relative to transthoracic needle aspiration, and neither a successful bronchoscopic navigation nor a promising radial ultrasonographic image of one's target lesion guarantees a successful biopsy. Fortunately, many of peripheral bronchoscopy's shortcomings - including an inability to detect and compensate for computed tomography (CT)-body divergence, and the absence of tool-in-lesion confirmation - are potentially remediable through the use of improved intraprocedural imaging techniques.RECENT FINDINGS: Recent advances in intraprocedural imaging, including the integration of cone beam CT, digital tomosynthesis, and augmented fluoroscopy into bronchoscopic procedures have yielded promising results. These advanced imaging modalities may improve the outcomes of peripheral bronchoscopy through the detection and correction of navigational errors, CT-body divergence, and malpositioned biopsy instruments.SUMMARY: The incorporation of advanced imaging is an essential step in the improvement of peripheral bronchoscopic procedures.

  View details for DOI 10.1097/MCP.0000000000001028

  View details for PubMedID 37933680

• Tracheal stenosis and airway complications in the Coronavirus Disease-19 era. Annals of thoracic surgery short reports Krishnan, A., Guenthart, B. A., Choi, A., Trope, W., Berry, G. J., Pinezich, M. R., Vunjak-Novakovic, G., Shaller, B., Sung, C. K., Liou, D. Z., Damrose, E. J., Lui, N. S. 2023

  Abstract

  Severe Coronavirus Disease 2019 (COVID-19) infection is associated with prolonged intubation and its complications. Tracheal stenosis is one such complication that may require specialized surgical management. We aimed to describe the surgical management of post-COVID-19 tracheal stenosis.This case series describes consecutive patients with tracheal stenosis from intubation for severe COVID-19 infection at our single, tertiary academic medical center between January 1st, 2021, and December 31st, 2021. Patients were included if they underwent surgical management with tracheal resection and reconstruction, or bronchoscopic intervention. Operative through six-month, symptom-free survival and histopathological analysis of resected trachea were reviewed.Eight patients are included in this case series. All patients are female, and most (87.5%) are obese. Five patients (62.5%) underwent tracheal resection and reconstruction (TRR), while three patients (38.5%) underwent non-resection-based management. Among patients who underwent TRR, six-month symptom free survival is 80%; one patient (20%) required tracheostomy after TRR due to recurrent symptoms. Two of the three (66.7%) of patients who underwent non-resection-based management experienced durable relief from symptoms of tracheal stenosis with tracheal balloon dilation, and the remaining patient required laser excision of tracheal tissue prior to experiencing symptomatic relief.The incidence of tracheal stenosis may increase as patients recover from severe COVID-19 infection requiring intubation. Management of tracheal stenosis with TRR is safe and effective, with comparable rates of success to TRR for non-COVID-19 tracheal stenosis. Non-resection-based management is an option to manage tracheal stenosis in patients with less severe stenosis or in poor surgical candidates.

  View details for DOI 10.1016/j.atssr.2023.05.013

  View details for PubMedID 37360840

  View details for PubMedCentralID PMC10246306

• Immediate and Follow-up Imaging Findings after Cone-Beam CT-guided Transbronchial Lung Cryobiopsy. Radiology. Cardiothoracic imaging Pogatchnik, B. P., Swenson, K. E., Duong, D. K., Shaller, B., Bedi, H., Guo, H. H. 2023; 5 (2): e220149

  Abstract

  To evaluate findings after transbronchial lung cryobiopsy (TBLC) using intraprocedural cone-beam CT (CBCT) and follow-up chest CT examinations.A single-center, prospective cohort study was performed with 14 participants (mean age, 65 years ± 13 [SD]; eight male participants) undergoing CBCT-guided TBLC between August 2020 and February 2021 who underwent follow-up chest CT imaging. Intraprocedural CBCT and follow-up chest CT images were interpreted for changes compared with baseline CT images. Statistical analyses were performed using independent samples t test and analysis of variance.A total of 62 biopsies were performed, with 48 in the field of view of CBCT immediately after biopsy. All 48 biopsy sites had evidence of postprocedural hemorrhage, and 17 (35%) had pneumatoceles at the biopsy site. Follow-up CT images showed resolution of these findings. Solid nodules developed at 18 of the 62 (29%) biopsy sites.Postbiopsy hemorrhage and pneumatoceles on intraprocedural CBCT images (which were clinically occult and resolved spontaneously) and new solid nodules on follow-up chest CT images were commonly observed after TBLC. These findings may help alleviate unnecessary follow-up imaging and tissue sampling.Keywords: Biopsy/Needle Aspiration, CT, Lungs, Lung Biopsy, Interventional Bronchoscopy© RSNA, 2023.

  View details for DOI 10.1148/ryct.220149

  View details for PubMedID 37124647

  View details for PubMedCentralID PMC10141444

• Endobronchial Ultrasound-guided Transbronchial Needle Aspiration of Primary Cardiac Synovial Sarcoma of the Left Ventricle. American journal of respiratory and critical care medicine Irfan, H., Filsuf, D., Mooney, K. L., Bedi, H., Shaller, B. D. 2022

  View details for DOI 10.1164/rccm.202207-1362IM

  View details for PubMedID 36480961

• Malignant Central Airway Obstruction: What's New? Seminars in respiratory and critical care medicine Shaller, B. D., Filsoof, D., Pineda, J. M., Gildea, T. R. 2022

  Abstract

  Malignant central airway obstruction (MCAO) is a debilitating and life-limiting complication that occurs in an unfortunately large number of individuals with advanced intrathoracic cancer. Although the management of MCAO is multimodal and interdisciplinary, the task of providing patients with prompt palliation falls increasingly on the shoulders of interventional pulmonologists. While a variety of tools and techniques are available for the management of malignant obstructive lesions, advancements and evolution in this therapeutic venue have been somewhat sluggish and limited when compared with other branches of interventional pulmonary medicine (e.g., the early diagnosis of peripheral lung nodules). Indeed, one pragmatic, albeit somewhat uncharitable, reading of this article's title might suggest a wry smile and shug of the shoulders as to imply that relatively little has changed in recent years. That said, the spectrum of interventions for MCAO continues to expand, even if at a less impressive clip. Herein, we present on MCAO and its endoscopic and nonendoscopic management-that which is old, that which is new, and that which is still on the horizon.

  View details for DOI 10.1055/s-0042-1748187

  View details for PubMedID 35654419

• Systemic arterial gas embolism (SAGE) as a complication of bronchoscopic lung biopsy: a case report and systematic literature review. Journal of thoracic disease Swenson, K. E., Shaller, B. D., Duong, K., Bedi, H. 2021; 13 (11): 6439-6452

  Abstract

  Systemic arterial gas embolism (SAGE) is a rare yet serious and underrecognized complication of bronchoscopic procedures. A recent case of presumed SAGE after transbronchial needle aspiration prompted a systematic literature review of SAGE after biopsy procedures during flexible bronchoscopy.We performed a systematic database search for case reports and case series pertaining to SAGE after bronchoscopic lung biopsy; reports or series involving only bronchoscopic laser therapy or argon plasma coagulation (APC) were excluded. Patient data were extracted directly from published reports.A total of 29 unique patient reports were assessed for patient demographics, specifics of the procedure, clinical manifestations, diagnostic findings, and clinical outcomes. Cases of SAGE occurred after multiple types of bronchoscopic biopsy and under both positive and negative pressure ventilation. The most common clinical findings were neurologic, followed by cardiac manifestations; temporal patterns included acute onset of cardiac or neurologic emergencies immediately after biopsy, or delayed awakening post-procedure. There was a high mortality rate among cases (28%), with residual neurologic deficits also common (24%).SAGE is an underrecognized but severe adverse effect of bronchoscopic lung biopsy, which often presents with acute coronary or cerebral ischemia or delayed awakening from sedation. It is important for all physicians who perform bronchoscopic biopsies to be aware of the clinical manifestations and therapeutic management of SAGE in order to mitigate morbidity and mortality among patients undergoing these procedures.

  View details for DOI 10.21037/jtd-21-717

  View details for PubMedID 34992823

  View details for PubMedCentralID PMC8662492

• Prospective validation of an 11-gene mRNA host response score for mortality risk stratification in the intensive care unit. Scientific reports Moore, A. R., Roque, J., Shaller, B. T., Asuni, T., Remmel, M., Rawling, D., Liesenfeld, O., Khatri, P., Wilson, J. G., Levitt, J. E., Sweeney, T. E., Rogers, A. J. 2021; 11 (1): 13062

  Abstract

  Several clinical calculators predict intensive care unit (ICU) mortality, however these are cumbersome and often require 24h of data to calculate. Retrospective studies have demonstrated the utility of whole blood transcriptomic analysis in predicting mortality. In this study, we tested prospective validation of an 11-gene messenger RNA (mRNA) score in an ICU population. Whole blood mRNA from 70 subjects in the Stanford ICU Biobank with samples collected within 24h of Emergency Department presentation were used to calculate an 11-gene mRNA score. We found that the 11-gene score was highly associated with 60-day mortality, with an area under the receiver operating characteristic curve of 0.68 in all patients, 0.77 in shock patients, and 0.98 in patients whose primary determinant of prognosis was acute illness. Subjects with the highest quartile of mRNA scores were more likely to die in hospital (40% vs 7%, p<0.01) and within 60days (40% vs 15%, p=0.06). The 11-gene score improved prognostication with a categorical Net Reclassification Improvement index of 0.37 (p=0.03) and an Integrated Discrimination Improvement index of 0.07 (p=0.02) when combined with Simplified Acute Physiology Score 3 or Acute Physiology and Chronic Health Evaluation II score. The test performed poorly in the 95 independent samples collected>24h after emergency department presentation. Tests will target a 30-min turnaround time, allowing for rapid results early in admission. Moving forward, this test may provide valuable real-time prognostic information to improve triage decisions and allow for enrichment of clinical trials.

  View details for DOI 10.1038/s41598-021-91201-7

  View details for PubMedID 34158514

• "I Now Walk Into the Wild": Atelectasis During Peripheral Bronchoscopy Under General Anesthesia. Chest Shaller, B. D., Almeida, F. A. 2020; 158 (6): 2268–69

  View details for DOI 10.1016/j.chest.2020.07.029

  View details for PubMedID 33280747

• What is the value of electromagnetic navigation in lung cancer and to what extent does it require improvement? Expert review of respiratory medicine Shaller, B. D., Gildea, T. R. 2020; 14 (7): 655-669

  Abstract

  Lung nodules are being identified with increasing frequency. With this growing burden of nodules comes a growing need for diagnostic technologies extending beyond the current reach of conventional bronchoscopy. One such method for diagnosing peripheral lung lesions is electromagnetic navigational bronchoscopy (ENB), which comprises a set of tools designed to aid the bronchoscopist in identifying, accessing, and sampling peripheral lung lesions under virtual guidance.Herein we present an in-depth review of ENB, including commercially available electromagnetic navigation platforms, factors influencing diagnostic yield, adjunctive imaging and biopsy tools, potential risks, cost, technical shortcomings, and competing technologies. A review of the scientific literature was conducted primarily through PubMed, ScienceDirect, and Google Scholar, and pertinent publications and abstracts from the inception of electromagnetic navigation through early 2020 were considered. We also share our perspective on the future of ENB from both a diagnostic and a therapeutic standpoint.ENB is currently a leading tool in the diagnostic evaluation of peripheral lung lesions. The future of ENB rests not only on its potential to expand into the therapeutic realm but also on its ability to keep pace with competing diagnostic and therapeutic technologies.

  View details for DOI 10.1080/17476348.2020.1748012

  View details for PubMedID 32216487

• Atypical Blastomycosis Masquerading as Lofgren Syndrome. American journal of respiratory and critical care medicine Shaller, B. D., Chen, S. B., Ho, D. Y., Yu, D. H. 2020

  View details for DOI 10.1164/rccm.201911-2158IM

  View details for PubMedID 32516540

• A generalizable 29-mRNA neural-network classifier for acute bacterial and viral infections. Nature communications Mayhew, M. B., Buturovic, L., Luethy, R., Midic, U., Moore, A. R., Roque, J. A., Shaller, B. D., Asuni, T., Rawling, D., Remmel, M., Choi, K., Wacker, J., Khatri, P., Rogers, A. J., Sweeney, T. E. 2020; 11 (1): 1177

  Abstract

  Improved identification of bacterial and viral infections would reduce morbidity from sepsis, reduce antibiotic overuse, and lower healthcare costs. Here, we develop a generalizable host-gene-expression-based classifier for acute bacterial and viral infections. We use training data (N=1069) from 18 retrospective transcriptomic studies. Using only 29 preselected host mRNAs, we train a neural-network classifier with a bacterial-vs-other area under the receiver-operating characteristic curve (AUROC) 0.92 (95% CI 0.90-0.93) and a viral-vs-other AUROC 0.92 (95% CI 0.90-0.93). We then apply this classifier, inflammatix-bacterial-viral-noninfected-version 1(IMX-BVN-1), without retraining, to an independent cohort (N=163). In this cohort, IMX-BVN-1 AUROCs are: bacterial-vs.-other 0.86 (95% CI 0.77-0.93), and viral-vs.-other 0.85 (95% CI 0.76-0.93). In patients enrolled within 36h of hospital admission (N=70), IMX-BVN-1 AUROCs are: bacterial-vs.-other 0.92 (95% CI 0.83-0.99), and viral-vs.-other 0.91 (95% CI 0.82-0.98). With further study, IMX-BVN-1 could provide a tool for assessing patients with suspected infection and sepsis at hospital admission.

  View details for DOI 10.1038/s41467-020-14975-w

  View details for PubMedID 32132525