Invasive pulmonary aspergillosis caused by Aspergillus terreus diagnosed using virtual bronchoscopic navigation and endobronchial ultrasonography with guide sheath and successfully treated with liposomal amphotericin B.

Invasive aspergillosis is a significant cause of mortality in patients with hematological malignancy. Early diagnosis of invasive pulmonary aspergillosis (IPA) by bronchoscopy is recommended but is often difficult to perform because of small lesion size and bleeding risk due to thrombocytopenia. A 71-year-old woman had received initial induction therapy for acute myeloid leukemia. On day 22 of chemotherapy, she had a high fever, and the chest computed tomography scan revealed a 20-mm-sized nodule with a halo sign. Bronchoscopy assisted by virtual bronchoscopic navigation (VBN) and endobronchial ultrasonography with a guide sheath (EBUS-GS) was performed, and Aspergillus terreus was identified from the culture of obtained specimens. A. terreus is often resistant to amphotericin B; thus, voriconazole is usually recommended for treatment. However, the obtained A. terreus isolate showed minimal inhibitory concentrations of 2 µg/mL for voriconazole and 0.5 µg/mL for amphotericin B. Therefore, the patient was successfully treated with liposomal amphotericin B. For patients suspected of having IPA, early diagnosis and drug susceptibility testing are very important. This case suggests that bronchoscopy using VBN and EBUS-GS is helpful for accurate diagnosis and successful treatment even if the lesion is small and the patient has a bleeding risk.

[Surgical Treatment and Outcomes for Synchronous Multiple Lung Cancer].

OBJECTIVES: With the advent of high-resolution chest imaging systems and lung cancer screening programs, the number of patients diagnosed with multiple primary lung cancers is increasing. For the treatment of multiple lung cancers, a surgical procedure that preserves the lung function while ensuring curability is required. We herein report the surgical strategy and outcomes of synchronous multiple lung cancer. SUBJECTS: The subjects were 83 patients with synchronous multiple lung cancer who received surgical resection between January 2010 and March 2020. Cases within the same lobe were excluded, and only cases with two or more lobes involved were included in this study. RESULTS: The study enrolled 39 male and 44 female patients, and the mean age was 67.8 years old. Sixty-five patients had cancers within a unilateral lobe, and all had undergone surgery for one term. Eighteen patients had cancers in bilateral lobes, and 17 of them received secondary surgery for more advanced cancer. Bilobectomy was performed in 9 patients( 10.8%), consisting of 5 upper-middle lobectomies, 3 middle-lower lobectomies, and 1 right middle lobectomy with left lower lobectomy. Seventy-four patients (89.2%) underwent combination surgery with sublobar resection, such as segmentectomy and partial resection. Pneumonectomy was not performed in any patients. The histologic type was adenocarcinoma in 78 patients (94.0%), and 37 patients (47.4%) had adenocarcinoma in situ. Regarding the most advanced pathological stage, 57 patients( 68.7%) were stage≤Ⅰ, and 26( 31.3%) were stage≥Ⅱ. Postoperative complications were observed in 29 patients( 34.9%), and persistent pulmonary fistula of ≥7 days after the surgery was the most common, being observed in 16 patients. Operative death within 30 days after surgery occurred in 2 patients( 2.4%)[ due to pneumonia in 1 and cerebral infarction in 1]. None of the patients required home oxygen therapy after surgery. Recurrence occurred in 20 patients;14 of these had pathological stage ≥Ⅱ, 11 had lymph node metastases, and 2 had pleural dissemination. The recurrence patterns were metastasis to other organs, pleural dissemination, or lymph node metastasis;no local recurrence was observed. The mean recurrence-free survival was 32.4 months, and the five-year survival rate was 84.8%. On comparing outcomes according to the most advanced pathological stage, the five-year survival rate for stage ≤Ⅰdisease was 94.9%, and that for stage ≥Ⅱ disease was 61.7%, showing a significantly better prognosis for stage ≤Ⅰdisease (p<0.001). CONCLUSIONS: Selecting an appropriate operative procedure for synchronous multiple lung cancer renders the prognosis equivalent to that of single cancer. Surgical treatments, including sublobar resection, are thus deemed important.

Disseminated Mycobacterium abscessus subsp. massiliense infection in a Good's syndrome patient negative for human immunodeficiency virus and anti-interferon-γ autoantibody: a case report.

BACKGROUND: Good's syndrome (GS) is characterized by immunodeficiency, and can lead to severe infection, which is the most significant complication. Although Mycobacterium rarely causes infection in patients with GS, disseminated nontuberculous mycobacterial (NTM) infection frequently occurs in GS patients that are also positive for the human immunodeficiency virus (HIV) or anti-interferon (IFN)-γ autoantibodies. Here, we report a rare case of GS with NTM without HIV or IFN-γ autoantibodies. CASE PRESENTATION: A 57-year-old Japanese male with GS and myasthenia gravis (treated with prednisolone and tacrolimus) was diagnosed with disseminated NTM infection caused by Mycobacterium abscessus subsp. massiliense. He presented with fever and back pain. Blood, lumbar tissue, urine, stool, and sputum cultures tested positive for M. abscessus. Bacteremia, spondylitis, intestinal lumber abscess, and lung infection were confirmed by bacteriological examination and diagnostic imaging; urinary and intestinal tract infections were suspected by bacteriological examination but not confirmed by imaging. Despite multidrug combination therapy, including azithromycin, imipenem/cilastatin, levofloxacin, minocycline, linezolid, and sitafloxacin, the patient ultimately died of the infection. The patient tested negative for HIV and anti-IFN-γ autoantibodies. CONCLUSIONS: Since myasthenia gravis symptoms interfere with therapy, patients with GS and their physicians should carefully consider the antibacterial treatment options against disseminated NTM.

The effect of intervention by an antimicrobial stewardship team on anaerobic bacteremia.

The effect of antimicrobial stewardship (AS) on anaerobic bacteremia is uncertain. This study aimed to assess the effect of interventions by the AS team (AST) on clinical and microbiological outcomes and antimicrobial use. An AS program was introduced at Osaka City University Hospital in January 2014; an interdisciplinary AST was established. We enrolled patients with anaerobic bacteremia between January 2009 and December 2018. Patients were classified into the pre-intervention group (from January 2009 to December 2013) and the post-intervention group (from January 2014 to December 2018). A significant decrease in definitive carbapenem use (P = 0.0242) and an increase in empiric tazobactam/piperacillin use (P = 0.0262) were observed in the post-intervention group. The de-escalation rate increased significantly from 9.38% to 32.7% (P = 0.0316) in the post-intervention group. The susceptibility of Bacteroides species and 30-day mortality did not worsen in the post-intervention group. These results showed that interventions by an AST can reduce carbapenem use and increase the de-escalation rate without worsening patient outcomes.

The intervention by an antimicrobial stewardship team can improve clinical and microbiological outcomes of resistant gram-negative bacteria.

Antibiotic stewardship (AS) improves patient outcomes and rates of antibiotic susceptibilities. However, the long-term effect of AS programs (ASPs) on mortality is unclear. This study aimed to assess the impact of bedside interventions by an AS team (AST) on clinical and microbiological outcomes. This retrospective study enrolled patients with bloodstream infections (BSI) and long-term use of broad-spectrum antibiotics (more than 7 days). The main outcomes were 30-day and in-hospital mortality of patients with BSI. The secondary outcomes were the day of therapy (DOT) and susceptibility of antipseudomonal agents. Cases were classified into two groups: the pre-ASP group comprised cases between 2011 and 2013 and the post-ASP group, between 2014 and 2016. The outcomes were then compared between the two groups. Among the patients with all BSI (n = 1187), no significant differences in 30-day mortality were observed between those in the pre-ASP and post-ASP groups. However, in-hospital mortality was significantly lower in the post-ASP group than that in the pre-ASP group (24.8% vs. 18.0%; P = 0.004). Furthermore, the 30-day and in-hospital mortality of resistant gram-negative bacteraemia was significantly lower (20.4% vs.10.5%; P = 0.04 and 28.0% vs.16.1%; P = 0.03). The DOT of broad-spectrum antibiotics decreased except that of tazobactam/piperacillin. The susceptibilities of tazobactam/piperacillin, ceftazidime, cefepime, sulbactam/cefoperazone, gentamicin, ciprofloxacin levofloxacin, imipenem and meropenem were significantly better. Interventions by the AST can improve the clinical and microbiological outcomes, especially resistant gram-negative bacteria. Furthermore, this effect of our ASP can continue for a long term.

[Outcome of Surgical Treatment of Locally Advanced Lung Cancer after Induction Chemoradiotherapy].

OBJECTIVE: The outcome of surgical treatment of non-small-cell lung cancer after induction chemoradiotherapy was investigated. SUBJECTS: The subjects were 74 patients with non-small-cell lung cancer who received induction chemoradiotherapy( ICRT) between 1998 and 2016. ICRT was administered to pT3 lung cancer invading the chest wall(20 patients), pT4 lung cancer invading the adjacent organ(22 patients), and cN2 lung cancer(32 patients). cN2 was confirmed by mediastinoscopy(13 patients) and endobronchial ultrasound-guided transbronchial needle aspiration(EBUS-TBNA)(19 patients). RESULTS: Sixty-eight and 6 patients were male and female, respectively, and the mean age was 59.6 years old. The histologic type was adenocarcinoma in 43 patients, squamous cell carcinoma in 24, adenosquamous carcinoma in 5, and others in 2. In chemotherapy, 2 or more anticancer drugs including platinum agent were administered. The radiation dosage was 36 Gy in 1 patient, 40 Gy in 43, 50 Gy in 28, and 60 Gy in 2. The effect of ICRT was complete response( CR) in 1 patient, partial response( PR) in 40, and stable disease (SD) in 33 (CR+PR:55.4%). The surgical procedure was lobectomy in 60 patients, pneumonectomy in 10, bilobectomy in 3, and segmentectomy in 1. Tracheobronchoplasty was performed in 9 patients, and combined resection of the vertebral body, left atrium, carina, superior vena cava, aorta, and brachiocephalic subclavian artery was performed in 7, 5, 4, 3, 3, and 3 patients, respectively. Regarding postoperative complications, empyema developed in 5 patients, acute respiratory distress syndrome(ARDS)in 3, pneumonia in 3, tracheobronchial dehiscence in 2, postoperative hemorrhage in 1, atrial fibrillation in 1, and others in 5. Postoperative complication rate was 27.0%, and operative death occurred due to postoperative hemorrhage in 1 patient. Complete resection was achieved in 69 patients(93.2%). Regarding the histological effect of ICRT, Ef.1/2/3 = 32/28/14(Ef.2-3:56.7%), and down stage was achieved in 24 patients (32.4%). The 5-year survival rate of all 74 patients was 51.0%, median survival time (MST)was 62.7 months, and the recurrence-free survival rate was 47.3%. Recurrence occurred in 28 patients (40.6%)with complete resection and the recurrence was distant metastasis in 20 of them. Regarding the outcome by the effect of ICRT, the 5-year survival rates of patients who achieved CR+PR/SD, Ef.2-3/Ef.0-1, and down stage/non-down stage were 66.0%/34.3%(p=0.009), 73.2%/20.1%(p=0.001), and 83.7%/44.0%(p=0.02), respectively, showing that the outcomes of patients who achieved CR/PR, Ef.2-3, and down stage were significantly favorable. CONCLUSION: The morbidity and mortality rates of patients who underwent surgery after ICRT were 27 and 1.4%, respectively. More than half of the patients achieved CR-PR and Ef.2-3, 1/3 of the cases were down staged, and the outcomes of these patients were significantly favorable. Surgery after ICRT may improve the treatment outcome of patients with locally advanced lung cancer.

Impaired nuclear factor erythroid 2-related factor 2 expression increases apoptosis of airway epithelial cells in patients with chronic obstructive pulmonary disease due to cigarette smoking.

BACKGROUND: Cigarette smoking-induced oxidative stress is known to be a key mechanism in COPD pathogenesis. Nuclear factor erythroid 2-related factor 2 (Nrf2) is a central transcription factor that regulates the antioxidant defense system. The aim of this study was to compare Nrf2 expression in COPD subjects and control subjects, and to determine the role of Nrf2 in protecting against oxidative stress-induced apoptosis. METHODS: We enrolled 8 COPD subjects and 7 control subjects in this study. We performed bronchial brushing by bronchoscopy and obtained bronchial epithelial cells from the airways. Nrf2 expression in bronchial epithelial cells was evaluated by real-time PCR and Western blotting. We examined the effect of 10 or 15 % cigarette smoke extract (CSE) induced A549 cells apoptosis using a time-lapse cell imaging assay with caspase-3/7 activation detecting reagent and performed Terminal deoxynucleotidyltransferase-mediated dUTP nick end labelling assay for confirming A549 cells apoptosis. We also examined the effects of Nrf2 knockdown and, 0.1, 0.5, and 1.0 mM N-acetyl cysteine on CSE-induced apoptosis. Statistical analyses were performed using t-test, paired t-test or an analysis of variance followed by the Tukey-Kramer method. RESULTS: Nrf2 mRNA expression in COPD subjects was significantly lower than that in control subjects and Nrf2 mRNA were negatively correlated with pack year. Nrf2 protein in COPD subjects was significantly lower than that in control subjects. CSE-induced A549 cells apoptosis was increased in a time-, concentration-dependent manner, and was significantly increased by Nrf2 knockdown. N-acetyl cysteine significantly ameliorated CSE-induced apoptosis. CONCLUSIONS: Nrf2 expression was lower in COPD patients than in control subjects. Nrf2 might have a protective role against apoptosis caused by CSE-induced oxidative stress. These results suggest an involvement of Nrf2 in COPD and administration of antioxidants to patients with COPD might be a basic therapeutic option.

[A Patient with Lung Adenocarcinoma, Lymphangitis Carcinomatosa, and Multiple Bone Metastases Who Achieved Long-Term Survival after Successful Treatment with Carboplatin, Paclitaxel, and Bevacizumab].

BACKGROUND: Lymphangitis carcinomatosa of the lung is intractable and associated with a poor prognosis. CASE: A 53-year-old woman was admitted to our hospital due to an uncomfortable feeling on deep inspiration. She was diagnosed with left lung adenocarcinoma with lymphangitis carcinomatosa and bone metastases to the frontal bone of the skull and thoracic vertebrae. The lung carcinoma was positive for an EGFR mutation. Because the patient's performance status (PS) was 0, carboplatin plus paclitaxel plus bevacizumab therapy was initiated and she received zoledronic acid and concurrent radiation therapy of 40 Gy for the metastasis to the thoracic vertebrae. After 2 courses of treatment, the respiratory symptoms had improved. After 6 courses of treatment, a chest CT indicated that the lymphangitis carcinomatosa had disappeared. The serum CEA level, which was 126.2 ng/mL (normal<5.0) before treatment, reduced to 5.0 ng/mL. She was administered 10 courses of bevacizumab as a maintenance therapy; however, the CEA level rose again to 11.7 ng/mL, the lung tumor volume increased, and the metastasis of the frontal bone deteriorated. As second-line chemotherapy, EGFR-TKI was started. However, after 11 months, because of grade 4 liver dysfunction, EGFR-TKI was stopped. She then received fourth-line chemotherapy in our outpatient hospital. This patient has survived 52 months since the initial diagnosis. CONCLUSION: Chemotherapy including bevacizumab facilitated long-term survival (52 months) of a patient with lung adenocarcinoma accompanied by lymphangitis carcinomatosa and multiple bone metastases.

Analysis of the contributing factors to airway hyperresponsiveness by a forced oscillation technique in patients with asthma.

BACKGROUND: Forced oscillation technique (FOT) is increasingly used to obtain much information on the state of the respiratory system. However, there are little data about FOT parameters on methacholine provocation test in adult asthma. This study was designed to determine the physiological implications of FOT parameters during methacholine provocation and analyze the major contributing factors to airway hyperresponsiveness (AHR) in asthma. METHODS: Spirometry and FOT were performed in 22 asthmatic patients and 21 normal control subjects before and after provocation with a maximal dose of methacholine. RESULTS: In asthmatic patients, the percent increase in resistance at 5 Hz (R5) and resistance at 20 Hz (R20) after the methacholine provocation was 70 [45-93] % and 16 [5-23] %. The percent change in R20 was not significantly correlated with the percent change in FVC or FEV1. Similarly, the percent change in R5 was not significantly correlated with the percent change in FEV1, but was significantly correlated with the percent change in FVC. Moreover, the percent change in R5 was significantly correlated with the closing index (r = 0.55, p = 0.01). In addition, AHR to methacholine was closely correlated with the percent change in R5 (r = -0.71, p = 0.001). CONCLUSIONS: Simultaneous measurement of FOT and bronchial challenge test provide meaningful information, and greater change in R5 may represent exaggerated response of small airways in asthmatic patients. This study will provide new insights into the physiological implications of each FOT parameter in asthmatic patients.

Uniportal Video-Assisted Thoracoscopic Segmentectomy for Early-Stage Non-Small Cell Lung Cancer: Overview, Indications, and Techniques.

Twenty years have passed since uniportal video-assisted thoracoscopic surgery (VATS) was first reported. Several reports have already proven the minimal invasiveness of uniportal VATS. In addition, two large clinical trials recently demonstrated the benefits of segmentectomy for small peripheral early-stage non-small cell lung cancer. Uniportal VATS segmentectomy is considered the most beneficial minimally invasive surgery for patients with early-stage lung cancer. However, a high level of skill and experience are required to achieve this goal. Only a few reports have discussed specific techniques, particularly for complex segmentectomies. In this Special Issue, we reviewed previous reports on uniportal VATS segmentectomy regarding the indications, instrument selection, marking of the tumor location, methods of intersegmental plane identification, and lymph node dissection, including our own techniques with video content.

Airway stent intervention in a high-volume center: safe procedures and educational perspectives.

Background: Airway intervention, including stenting, can rapidly improve a patient's respiratory condition, but the procedure requires highly specialized techniques and expertise. Therefore, educating young endoscopists and passing on the techniques are major issues. However, the best way to educate new doctors on these techniques remains unclear. This study analyzed our educational system for airway intervention and its outcomes. Methods: Patients who underwent airway intervention regarding airway stents under general anesthesia in our department between January 2010 and September 2023 were included. The outcomes of interventions related to airway stents in our hospital were evaluated retrospectively, including from an educational perspective. Results: A total of 96 patients (76 undergoing stenting for airway stenosis, 8 stenting for airway-esophageal fistula, and 12 stent removal) were analyzed. The median experience level of the main physician was 5 (range, 1-17) years, and that of the supervising physician was 18 (range, 5-23) years. The median number of physicians who participated in the interventions was four. A rigid bronchoscope was used in 86.5% of cases. The procedure success rate was 95.8%. Intraoperative complications occurred in 8.3% and postoperative complications in 10.5% of cases, and there was 1 procedure-related death (1.3%). In the analysis of factors related to the development of complications, the years of experience of the main physician had no influence. Conclusions: These findings indicate that our method of airway intervention is safe. Young endoscopists were able to master the technique by gaining experience under the supervision of experts.

Pathologically noninvasive cancer predictors and surgical procedure for peripheral lung cancer.

BACKGROUND: In this retrospective study, based on recent studies reporting the superiority of sublobar resection to lobectomy for peripheral small size non-small cell lung cancer (NSCLC), we investigated the optimal pathological factors for predicting noninvasive cancer and the selection of operative procedure. METHODS: Patients with peripheral NSCLC of ≤2 cm who underwent surgery at our hospital between January 2010 and June 2020 were included in this study. We evaluated the relationship between pathologically noninvasive cancer and predictive factors according to the area under the curve (AUC) and accuracy, and the cutoff value was set to investigate indications for sublobar resection. RESULTS: The comparison of the AUCs revealed that the maximum standardized uptake value and consolidation to tumor (C/T) volume ratio were better predictors than the C/T ratio. Among the three factors, the C/T volume ratio showed the best accuracy. The patients were divided into two groups (low and high) using the cutoff value of the C/T volume ratio and compared according to the surgical procedure (lobectomy vs. segmentectomy). In the low-group, there was no significant difference in the prognosis. In the high-group, the 5-year recurrence-free survival rate of the patients who received lobectomy was 87.8%, while that of patients who received segmentectomy was 75.8% (p = 0.08). CONCLUSIONS: The C/T volume ratio was the best preoperative pathologically noninvasive predictive factor. Sublobar resection should be performed with caution in cases with significant solid components on three-dimensional images.

Preoperative detection of pleural adhesions using dynamic chest radiography: prospective analysis.

Background: To plan a surgical approach and predict the operative time or bleeding volume, it is important to determine the presence of pleural adhesions before surgery. Dynamic chest radiography (DCR) is a new modality that can dynamically capture X-rays, and we assessed the utility of DCR for detecting pleural adhesions preoperatively. Methods: The subjects of this study were those who underwent DCR before surgery from January 2020 to May 2022. The preoperative evaluation was performed by three imaging analysis modes, and pleural adhesion was defined as the that spreading to more than 20% of the thoracic cavity and/or taking more than 5 minutes to dissect. Results: Of the 120 total patients, DCR was performed properly for 119 (99.2%). Accurate preoperative evaluations of pleural adhesions were confirmed in 101 patients (84.9%), with a sensitivity of 64.5%, specificity of 91.0%, positive predictive value of 74.1%, and negative predictive value of 88.0%. Conclusions: DCR was very easy to perform in all preoperative patients with all manner of thoracic disease. We demonstrated the utility of DCR, showing its high specificity and negative predictive value. DCR has the potential to become a common preoperative examination for detecting pleural adhesions with further improvements in software programs.

Impact of ground glass opacity in a three-dimensional analysis for pathological findings and prognosis in stage IA pure solid lung cancer.

Background: We investigated whether a three-dimensional (3D) analysis could correct the discrepancy between conventional computed tomography findings and pathological findings and contribute to prognostic stratification in early pure solid lung cancer. Methods: A total of 370 patients with two-dimensional (2D) pure solid, clinical stage IA non-small cell lung cancer (NSCLC) who underwent complete resection at our hospital between January 2010 and March 2021 were included in the present study. We classified the patients into the 3D solid group and the 3D ground glass opacity (GGO) group according to the consolidation volume/tumor volume ratio (C/T volume ratio) measured using a Synapse Vincent 3D analysis workstation, and compared the pathological findings and prognosis between the two groups. Results: There were 142 (38.4%) patients in the 3D GGO group. Lepidic lesions were significantly more frequent in the 3D GGO group (27.6% vs. 59.2%, P<0.001). Lymphatic invasion, vascular invasion and lymph node metastasis were significantly more frequent in the 3D solid group (52.2% vs. 27.5%, P<0.001; 67.5% vs. 43.0%, P<0.001; 22.3% vs. 11.2%, P=0.04). A Cox proportional hazards multivariate analysis for overall survival (OS) and recurrence-free survival (RFS) showed that 3D solid was an independent poor prognostic factor [hazard ratio (HR): 1.981, P=0.02; HR: 1.815, P=0.02]. Kaplan-Meier curves for 5-year OS (74.1% vs. 87.8%, P<0.001) and 5-year RFS (65.6% vs. 84.9%, P<0.001) showed significant differences between the two groups. Conclusions: The C/T volume ratio determined by a 3D analysis detects GGO and reflects the pathological findings, and further prognostic stratification is possible in early 2D pure solid lung cancer.

Multiple solitary fibrous tumors of the pleura with multicentric and unilateral involvement: a case report.

BACKGROUND: Solitary fibrous tumor of the pleura (SFTP) is a mesenchymal tumor. Patients with SFTP generally have only one lesion. We herein report an extremely rare case of multiple SFTPs that were multicentric and unilateral. CASE PRESENTATION: The patient was a 21-year-old asymptomatic young man who was referred to our hospital due to abnormal shadows on a chest X-ray. Computed tomography showed 6 tumors of heterogeneous sizes in the left thoracic cavity. The tumors were suspected to be multiple benign or low-grade malignant thoracic tumors, and tumor resection was performed. The tumors had almost the same appearance, with uniform fibroblastic spindle cell proliferation, and arose from the pleura in microscopy. Immunohistochemical staining revealed that the tumor cells were positive for CD34, CD99, Bcl-2, and STAT6. Based on these findings, the tumors were diagnosed as multiple SFTPs with multicentricity. At 1 year and 6 months after the first surgery, 2 new lesions were found above the diaphragm, and these were resected. These tumors were arose from the pleura with a fibrous capsule structure. Their pathological findings were identical to the initial tumor without evidence of malignant transformation. CONCLUSION: We experienced an extremely rare case of multiple SFTPs with multicentric and unilateral lesions.

Bronchiolar adenoma/ciliated muconodular papillary tumor mixed with adenocarcinoma in situ in the same tumor.

Bronchiolar adenoma (BA)/ciliated muconodular papillary tumor (CMPT) is defined as a benign tumor composed of epithelial and basal cells. Recently, some cases with driver mutations or malignant transformation have been observed. Thus, whether BA/CMPT is benign or malignant remains controversial. We herein report an extremely rare case of a 68-year-old woman with a CMPT accompanied by adenocarcinoma in situ (AIS). BA/CMPT existed inside the AIS. The BA/CMPT component did not show any driver mutations; however, the AIS component had an EGFR driver mutation in exon 19. The accumulation of cases and further studies are needed to discuss the malignant potential of BA/CMPT.

COVID-19 vaccination benefits in preventing severe disease in mild-to-moderate cases: An analysis in the first specialized hospital for COVID-19 in Japan.

BACKGROUND: In Japan, the fourth round of coronavirus disease (COVID-19) vaccination is ongoing and is targeted at medical staff and nursing home workers, individuals aged ≥60 years, and those with comorbidities or other high-risk factors, including body mass index (BMI) ≥30 kg/m2. The incidence of severe COVID-19 decreased markedly after widespread COVID-19 vaccination drives, and our hospital experienced a similar trend. We, therefore, examined the characteristics of our patients to clarify who benefited the most from vaccination. METHODS: We retrospectively investigated all patients hospitalized for COVID-19 in Osaka City Juso Hospital between March 1, 2021, and June 30, 2022. Using multivariable logistic analysis, we calculated the adjusted odds ratios (aORs) for severe disease after vaccination in the whole dataset and in subsets stratified by age, sex, BMI, smoking history, pre-hospitalization location, and comorbidities. RESULTS: The analysis included 1041 patients. Multivariable logistic analysis showed that vaccination was associated with a low risk of severe disease, with an aOR of 0.21 (95% confidence interval: 0.12-0.36, p < 0.001). On stratifying the analysis according to background characteristics, lower aORs for severe COVID-19 were found for patients aged ≥60 years and for those with diabetes or hypertension. Notably, patients with BMI >30 kg/m2 and those with BMI ≥18 kg/m2 and ≤30 kg/m2 benefited from vaccination. CONCLUSIONS: Individuals with diabetes or hypertension and those of age ≥60 years benefited more from vaccination than did their counterparts. We recommend extending the fourth round of vaccinations to individuals with a BMI of 18-30 kg/m2.

Role of fluorodeoxyglucose-positron emission tomography in predicting the pathological response and prognosis after neoadjuvant chemoradiotherapy for locally advanced non-small-cell lung cancer.

OBJECTIVES: The present study compared the utility of fluorodeoxyglucose-positron emission tomography (FDG-PET) and computed tomography (CT) for predicting the pathological response and prognosis following neoadjuvant therapy for locally advanced non-small-cell lung cancer (NSCLC). METHODS: This retrospective analysis included 72 patients in whom adjacent structures showed involvement and/or cN2 NSCLC who received induction chemoradiotherapy (ICRT) and subsequent surgery at our hospital from 2008 to 2019. FDG-PET and CT were performed in all patients before and after ICRT using the same scanner with similar techniques. We calculated the reduction in the maximum standardized uptake value in FDG-PET (ΔSUVmax) and tumour size on CT (ΔCT-size) before and after ICRT and investigated the relationship between the pathological response and prognosis. RESULTS: The disease response was classified as a major pathological response in 43 patients, and a minor response in 29 patients. ΔSUVmax 60% and ΔCT-size 30% were identified as the optimal cut-off values for predicting a major pathological response. ΔSUVmax was superior to ΔCT-size in terms of sensitivity, specificity, positive predictive value and negative predictive value. Furthermore, ΔSUVmax was superior to ΔCT-size for predicting the prognosis. CONCLUSIONS: Based on the results of the present study, FDG-PET appeared to have greater utility than CT in predicting the pathological response following ICRT and the postoperative prognosis in patients with locally advanced NSCLC.

Treatment of secondary pneumothorax with interstitial lung disease: the surgical indications at the start of treatment is important.

Background: Secondary pneumothorax with interstitial lung disease (ILD) is often difficult to treat in comparison to primary pneumothorax. The purpose of this study was to analyze the actual management and outcome, and to find the most effective treatment. Methods: Among 180 patients with pneumothorax caused by ILD, who were managed between January 2000 and April 2021, 129 patients were included. Fifty-one patients with observation only were excluded. In the present study, a patient was considered to be cured if their chest tube could be removed. Results: The managements included chest tube drainage alone (n=41), pleurodesis (n=67), bronchoscopic treatment (n=14), and surgery (include overlapping cases) (n=25). The mean number of pleurodesis treatments was 2.4 (range, 1-9), and the most frequently used agent was blood-patch. All patients who received bronchoscopic treatment underwent bronchial occlusion with silicon spigots. The surgical procedures included bullectomy (n=20), lung cyst ligation (n=3), pleural covering with oxidized cellulose sheet (n=1), and spraying of fibrin glue alone (n=1). One hundred patients (77.5%) were curatively treated, 27 patients (20.9%) died, and 2 patients were transferred without chest tube removal. Among 25 patients who received surgery [including 6 patients with performance status (PS) ≥2], 24 patients (96.0%) were cured, and 1 patient died due to an acute exacerbation of ILD after surgery. The univariate analysis revealed that PS ≥2 and >3 pleurodesis treatments were significant non-curative factors, while steroid treatment before the development of pneumothorax was not. Conclusions: The outcomes of surgery for pneumothorax in patients with ILD were good, and it is desirable to consider the surgical indications.

Idiopathic Obliterative Bronchiolitis in a Young Woman: A Rare Case of a Transbronchial Lung Biopsy Contributing to the Diagnosis.

Idiopathic obliterative bronchiolitis (OB) is a rare disease that usually requires a surgical lung biopsy. A 25-year-old woman with progressive exertional dyspnea for several months showed a severe mixed restrictive and obstructive pattern on spirometry. Chest computed tomography showed a mosaic pattern, and pulmonary ventilation-perfusion scintigraphy showed a matched defect. The bronchoscopic specimens obtained from both the alveolar and bronchiolar regions of the predicted lesion area contributed to the diagnosis of OB. She had no underlying causes of secondary OB, and she was diagnosed with idiopathic OB. Since lung transplantation was indicated, she was referred to a lung transplantation-certified hospital.