Additional local therapy before disease progression for EGFR-mutated advanced lung cancer: a systematic review and meta-analysis.

Background: International guidelines recommend the use of local therapy (LT) to limited progression in patients with epidermal growth factor receptor (EGFR)-mutated advanced non-small cell lung cancer (NSCLC). However, the use of LT before disease progression has not been extensively analyzed. This meta-analysis evaluates the efficacy and safety of administering additional LT in conjunction with first-line EGFR-tyrosine kinase inhibitors (TKIs) before disease progression in patients with EGFR-mutated advanced NSCLC. Methods: We systematically searched PubMed, Embase, and the Cochrane Library for studies published up until May 31, 2023. The LT group consisted of patients who received first-line EGFR-TKIs in conjunction with additional LT, while the TKI group comprised participants treated with first-line EGFR-TKIs alone. Studies comparing the survival outcomes of the LT and TKI groups were included in this analysis. The primary outcomes were progression-free survival (PFS) and overall survival (OS). This review was registered on PROSPERO (registration number CRD42023439913). Results: Among the 11 investigated studies covering 1,313 patients, the LT modalities included radiotherapy, surgery, and ablation therapy, which accounted for 91%, 27%, and 27% of the studies, respectively. The pooled hazard ratios of median PFS and OS were 0.34 [95% confidence interval (CI): 0.22-0.53; P<0.001] and 0.42 (95% CI: 0.36-0.48; P<0.001), respectively, which indicated significant benefits for the LT group compared to the TKI group. There was no significant difference between the LT and TKI groups (P=0.473) regarding the incidence of grade 3 or higher adverse events. Conclusions: This study suggests that the strategic use of additional LT before disease progression is a promising approach for the treatment of EGFR-mutated advanced NSCLC.

Bronchoscopic strategies to improve diagnostic yield in pulmonary tuberculosis patients.

In cases where pulmonary tuberculosis (PTB) is not microbiologically diagnosed via sputum specimens, bronchoscopy has been the conventional method to enhance diagnostic rates. Although the additional benefit of bronchoscopy in diagnosing PTB is well-known, its overall effectiveness remains suboptimal. This review introduces several strategies for improving PTB diagnosis via bronchoscopy. First, it discusses how bronchoalveolar lavage or an increased number of bronchial washings can increase specimen abundance. Second, it explores how thin or ultrathin bronchoscopes can achieve specimen acquisition closer to TB lesions. Third, it highlights the importance of conducting more sensitive TB-polymerase chain reaction tests on bronchoscopic specimens, including the Xpert MTB/RIF assay and the Xpert MTB/RIF Ultra assay. Finally, it surveys the implementation of endobronchial ultrasound with a guide sheath for tuberculomas, collection of post-bronchoscopy sputum, and reduced use of lidocaine for local anesthesia. A strategic combination of these approaches may enhance the diagnostic rates in PTB patients undergoing bronchoscopy.

Durvalumab Consolidation After Chemoradiotherapy in Elderly Patients With Unresectable Stage III NSCLC: A Real-World Multicenter Study.

BACKGROUND: The PACIFIC trial demonstrated survival benefit of durvalumab after concurrent chemoradiotherapy (CCRT) in unresectable stage III non-small-cell lung cancer. Data on the effectiveness and safety of durvalumab in elderly patients is lacking. METHODS: This retrospective study was conducted between September 2017 and September 2022. Progression-free survival (PFS), overall survival (OS), recurrence patterns, first subsequent treatment after recurrence, factors associated with survival outcomes, and adverse events (AEs) were compared. RESULTS: Of the 286 patients, 120 (42.0%) were ≥ 70 years and 166 (58.0%) were < 70 years. The median PFS (17.7 vs. 19.4 months; P = .43) and median OS (35.7 months vs. not reached; P = .13) were similar between 2 groups. Proportion of patients who completed durvalumab was lower in elderly patients (27.5% vs. 39.2%; P = .040). In elderly patients, ECOG PS 0 or 1 was associated with better PFS, and being male and having received a cisplatin-based regimen during CCRT were factors associated with better and worse OS, respectively. In patients aged < 70 years, a PD-L1 ≥ 50% was associated with improved PFS and OS. Elderly patients experienced more treatment-related AEs, grade 3/4 AEs, permanent discontinuation of durvalumab, and treatment-related deaths. Among the AEs leading to permanent discontinuation or death, pulmonary AE was significantly more common in elderly patients. CONCLUSION: Durvalumab demonstrated similar outcomes in elderly compared to younger patients. However, AEs were more common in elderly patients. Thus, judicious selection of patients and chemotherapy regimens, coupled with careful AE monitoring, are important factors for ensuring optimal durvalumab treatment.

Next-generation sequencing using tissue specimen collected with a 1.1 mm-diameter cryoprobe in patients with lung cancer.

BACKGROUND AND OBJECTIVE: Next-generation sequencing (NGS) analysis is considered standard for lung cancer diagnosis in clinical practice. Little is known about the feasibility of NGS using tumour tissue sampled with a 1.1 mm-diameter cryoprobe. We aimed to investigate the suitability of specimens obtained by transbronchial cryobiopsy (TBC) using a 1.1 mm-diameter cryoprobe for NGS analysis. METHODS: Patients with lung cancer who underwent TBC using a 1.1 mm-diameter cryoprobe for NGS testing between October 2020 and April 2023 were enrolled. A 4.0- or 3.0 mm-diameter bronchoscope with radial probe endobronchial ultrasound and virtual bronchoscopic navigation was used to detect peripheral lung lesions. All procedures were performed under fluoroscopic guidance. Data were analysed retrospectively. RESULTS: A total of 56 patients underwent TBC using a 1.1 mm cryoprobe for NGS testing, during the study period. Most patients (98%) were in the advanced stage of lung cancer (recurrent or inoperable disease of stages III or IV). The diagnostic yield of NGS for DNA and RNA sequencing was 95% each (53 of 56). Moderate bleeding was noted in three patients (5%) and none of the study patients developed life-threatening complications, such as pneumothorax or lung infection. CONCLUSION: TBC using a 1.1 mm-diameter cryoprobe is a useful and safe tool for NGS analysis, for both DNA and RNA sequencing.

Ability of the modified NUTRIC score to predict mortality in patients requiring short-term versus prolonged acute mechanical ventilation: a retrospective cohort study.

BACKGROUND: The modified NUTRIC (nutritional risk in the critically ill) score has been reported to predict clinical outcomes in critically ill patients. However, the applicability of this score may differ between patients undergoing short-term mechanical ventilation (STMV, < 96 h) and those undergoing prolonged acute mechanical ventilation (PAMV, ⩾96 h), as PAMV patients typically experience significantly higher morbidity and mortality. OBJECTIVE: This study aimed to investigate the predictive ability of modified NUTRIC score for predicting 28-day mortality in patients receiving STMV and PAMV. DESIGN: Retrospective single-center cohort study. METHODS: We enrolled patients who received mechanical ventilation (MV) on the day of admission to the intensive care unit (ICU) from 1 December 2015 to 30 November 2020. Modified NUTRIC scores were calculated based on the clinical data of each patient at ICU admission. RESULTS: The study population comprised 464 patients, including 319 (68.8%) men with a mean age of 69.7 years. Among these patients, 132 (28.4%) received STMV and 332 (71.6%) received PAMV. The overall 28-day mortality rate was 26.7%, which was significantly higher in STMV patients than in PAMV patients (37.9% versus 22.3%, p < 0.001). Evaluation of the predictive performance of the modified NUTRIC score for 28-day mortality revealed areas under the receiver operating characteristic curves of 0.672 [95% confidence interval (CI): 0.627-0.714] for total patients, 0.819 (95% CI, 0.742-0.880) for STMV patients, and 0.595 (95% CI, 0.540-0.648) for PAMV patients. The best overall cutoff value was 5 in total, STMV, and PAMV patients. This cutoff value was a significant predictor of 28-day mortality based on the Cox proportional hazard model for total [hazards ratio (HR): 2.681; 95% CI: 1.683-4.269] and STMV (HR: 5.725; 95% CI: 2.057-15.931) patients, but not for PAMV patients. CONCLUSION: The modified NUTRIC score is more effective in predicting 28-day mortality in patients undergoing STMV than in those undergoing PAMV.

Predicting survival: Modified NUTRIC score in short-term vs. prolonged mechanical ventilationIn this study, we examined the scoring system called the Modified NUTRIC (nutritional risk in the critically ill) score to determine whether it could be used to predict 28-day mortality following Intensive Care Unit (ICU) admission. In particular, we wanted to determine whether the score works equally well for patients who need short-term mechanical ventilation (STMV, less than 96 hours) and those who need prolonged acute mechanical ventilation (PAMV, 96 hours or more). PAMV patients tend to have more severe illness and use more medical resources.Here's what we did: We studied 464 patients who were put on a breathing machine (mechanical ventilation) on the same day they were admitted to the ICU between December 1, 2015, and November 30, 2020.We calculated the Modified NUTRIC (m-NUTRIC) scores based on their medical information when they entered the ICU.We found that the overall 28-day mortality was 26.7%, and that it was higher for STMV patients (37.9%) than for PAMV patients (22.3%).When we checked how well the m-NUTRIC score predicted survival, we discovered that it worked better for STMV patients (with an accuracy of 81.9%) than for PAMV patients (with an accuracy of 59.5%).We also found that a m-NUTRIC score of 5 or more points was indicative of a higher mortality in STMV patientsIn conclusion, the m-NUTRIC score is a more reliable predictor of 28-day survival in patients who need short-term mechanical ventilation than in those who need prolonged acute mechanical ventilation.

Development of a Prognostic Scoring System for Tracheostomized Patients Requiring Prolonged Ventilator Care: A Ten-Year Experience in a University-Affiliated Tertiary Hospital.

Background and Objectives: This study aimed to assess the value of a novel prognostic model, based on clinical variables, comorbidities, and demographic characteristics, to predict long-term prognosis in patients who received mechanical ventilation (MV) for over 14 days and who underwent a tracheostomy during the first 14 days of MV. Materials and Methods: Data were obtained from 278 patients (66.2% male; median age: 71 years) who underwent a tracheostomy within the first 14 days of MV from February 2011 to February 2021. Factors predicting 1-year mortality after the initiation of MV were identified by binary logistic regression analysis. The resulting prognostic model, known as the tracheostomy-ProVent score, was computed by assigning points to variables based on their respective ß-coefficients. Results: The overall 1-year mortality rate was 64.7%. Six factors were identified as prognostic indicators: platelet count < 150 × 103/µL, PaO2/FiO2 < 200 mmHg, body mass index (BMI) < 23.0 kg/m2, albumin concentration < 2.8 g/dL on day 14 of MV, chronic cardiovascular diseases, and immunocompromised status at admission. The tracheostomy-ProVent score exhibited acceptable discrimination, with an area under the receiver operating characteristic curve (AUC) of 0.786 (95% confidence interval: 0.733-0.833, p < 0.001) and acceptable calibration (Hosmer-Lemeshow chi-square: 2.753, df: 8, p = 0.949). Based on the maximum Youden index, the cut-off value for predicting mortality was set at ≥2, with a sensitivity of 67.4% and a specificity of 76.3%. Conclusions: The tracheostomy-ProVent score is a good predictive tool for estimating 1-year mortality in tracheostomized patients undergoing MV for >14 days. This comprehensive model integrates clinical variables and comorbidities, enhancing the precision of long-term prognosis in these patients.

Recent Advances in Adjuvant Therapy for Non-Small-Cell Lung Cancer.

After the successful development of targeted therapy and immunotherapy for the treatment of advanced-stage non-small cell lung cancer (NSCLC), these innovative treatment options are rapidly being applied in the adjuvant setting for early-stage NSCLC. Some adjuvants that have recently been approved include osimertinib for epidermal growth factor receptor-mutated tumors and atezolizumab and pembrolizumab for selected patients with resectable NSCLC. Numerous studies on various targeted therapies and immunotherapy with or without chemotherapy are currently ongoing in the adjuvant setting. However, several questions regarding optimal strategies for adjuvant treatment remain unanswered. The present review summarizes the available literature, focusing on recent advances and ongoing trials with targeted therapy and immunotherapy in the adjuvant treatment of early-stage NSCLC.

Development of the Korean Association for Lung Cancer Clinical Practice Guidelines: Recommendations on Radial Probe Endobronchial Ultrasound for Diagnosing Lung Cancer - An Updated Meta-Analysis.

Purpose: Radial probe endobronchial ultrasound (RP-EBUS) accurately locates peripheral lung lesions (PLLs) during transbronchial biopsy (TBB). We performed an updated meta-analysis of the diagnostic yield of TBB for PLLs using RP-EBUS to generate recommendations for the development of the Korean Association of Lung Cancer guidelines. Materials and Methods: We systematically searched MEDLINE and EMBASE (from Jan 2013 to Dec 2022), and performed a meta-analysis using R software. The diagnostic yield was evaluated by dividing the number of successful diagnoses by the total lesion number. Subgroup analysis was performed to identify related factors. Results: Forty-one studies with a total of 13,133 PLLs were included. The pooled diagnostic yield of RP-EBUS was 0.72 (95% confidence interval [CI], 0.70-0.75). Significant heterogeneity was observed among studies (χ2, 292.38; p<0.01; I2, 86.4%). In a subgroup analysis, there was a significant difference in diagnostic yield based on RP-EBUS findings (within, adjacent to, invisible), with a risk ratio of 1.45 (95%CI, 1.23-1.72) between within and adjacent to, 4.20 (95% CI, 1.89-9.32) between within and invisible, and 2.59 (95% CI, 1.32-5.01) between adjacent to and invisible. There was a significant difference in diagnostic yield based on lesion size, histologic diagnosis, computed tomography (CT) bronchus sign, lesion character, and location from the hilum. The overall complication rate of TBB with RP-EBUS was 6.8% (bleeding, 4.5%; pneumothorax, 1.4%). Conclusion: Our study showed that TBB with RP-EBUS is an accurate diagnostic tool for PLLs with good safety profiles, especially for PLLs with within orientation on RP-EBUS or positive CT bronchus sign.

BRAF V600E Mutation of Non-Small Cell Lung Cancer in Korean Patients.

Background and Objectives: BRAF mutational status in resected non-small cell lung cancer (NSCLC) in the Korean population is poorly understood. We explored BRAF (particularly BRAF V600E) mutational status among Korean patients with NSCLC. Materials and Methods: This study included 378 patients with resected primary NSCLC who were enrolled from January 2015 to December 2017. The authors obtained formalin-fixed paraffin-embedded (FFPE) tissue blocks and performed peptide nucleic acid (PNA)-clamping polymerase chain reaction (PCR) for detecting BRAF V600, real-time PCR for detecting BRAF V600E, and immunohistochemical analyses using the mutation-specific Ventana VE1 monoclonal antibody. For positive cases in any methods mentioned above, direct Sanger sequencing was additionally performed. Results: The PNA-clamping method revealed the BRAF V600 mutation in 5 (1.3%) of the 378 patients. Among these five patients, real-time PCR, direct Sanger sequencing detected BRAF V600E mutations in three (0.8%) patients. Thus, two cases showed differences in their PNA-clamping and the others. Direct Sanger sequencing of PNA-clamping PCR product was performed for two cases showing negative results on direct Sanger sequencing; both contained BRAF mutations other than V600E. All patients harboring BRAF mutations had adenocarcinomas, and all patients with V600E mutation exhibited minor micropapillary components. Conclusions: Despite the low incidence of the BRAF mutation among Korean patients with NSCLC, lung adenocarcinoma patients with micropapillary components should be prioritized in terms of BRAF mutation testing. Immunohistochemical staining using Ventana VE1 antibody may serve as a screening examination for BRAF V600E.

Clinical outcomes of transbronchial cryobiopsy using a 1.1-mm diameter cryoprobe for peripheral lung lesions - A prospective pilot study.

OBJECTIVES: Transbronchial cryobiopsy (TBCB) is a novel technique for the diagnosis of peripheral lung lesions (PLLs). We aim to evaluate the clinical outcomes of TBCB using a new 1.1-mm diameter cryoprobe for the diagnosis of PLLs. MATERIALS AND METHODS: We performed a prospective observational pilot study on the diagnosis of PLLs (diameter ≤30 mm) by TBCB, using a 1.1-mm diameter cryoprobe with radial endobronchial ultrasound (RP-EBUS), virtual bronchoscopic navigation and fluoroscopy from December 2021 to July 2022. Primary outcome was the pathological diagnostic yield of TBCB, and secondary outcome was adverse event. RESULTS: A total of 50 patients were enrolled (mean lesion size, 21 mm). TBCB was performed in 49 patients up to three times except for the one with "invisible" finding on RP-EBUS. The overall diagnostic yield of TBCB was 90% (45/50). There was no difference in the diagnostic yield between size (20 mm vs. 20-30 mm; 88% [22/25] vs. 92% [23/25]; P = 1.000), RP-EBUS findings (concentric vs. others; 97% [28/29] vs. 81% [17/21]; P = 0.148), and acute angle location (apical segment of both upper lobes vs. others; 92% [12/13] vs. 89% [33/37]; P = 1.000). The cumulative diagnostic yields of the first, second, and third TBCB were 82% (41/50), 88% (44/50), and 90% (45/50), respectively. Mild bleeding was developed in 56% (28/50), and moderate bleeding was found in 26% (13/50). CONCLUSION: TBCB using a 1.1-mm diameter cryoprobe is an effective, reasonable method for the diagnosis of PLLs regardless of its size, RP-EBUS finding, and anatomical location without serious complication. TRIAL REGISTRATION: Clinical Trials.Gov (NCT05046093).

Problems in the Pathologic Diagnosis of Suspected Lung Cancer.

Since the introduction of low-dose computed tomography (CT) screening for patients at high risk of lung cancer, the detection rate of suspicious lung cancer has increased. In addition, there have been many advances in therapeutics targeting oncogenic drivers in non-small cell lung cancer. Therefore, accurate pathological diagnosis of lung cancer, including molecular diagnosis, is increasingly important. This review examines the problems in the pathological diagnosis of suspected lung cancer. For successful pathological diagnosis of lung cancer, clinicians should determine the appropriate modality of the diagnostic procedure, considering individual patient characteristics, CT findings, and the possibility of complications. Furthermore, clinicians should make efforts to obtain a sufficient amount of tissue sample using non- or less-invasive procedures for pathological diagnosis and biomarker analysis.

Association between Participation in a Rehabilitation Program and 1-Year Survival in Patients Requiring Prolonged Mechanical Ventilation.

BACKGROUND: The present study evaluated the association between participation in a rehabilitation program during a hospital stay and 1-year survival of patients requiring at least 21 days of mechanical ventilation (prolonged mechanical ventilation [PMV]) with various respiratory diseases as their main diagnoses that led to mechanical ventilation. METHODS: Retrospective data of 105 patients (71.4% male, mean age 70.1±11.3 years) who received PMV in the past 5 years were analyzed. Rehabilitation included physiotherapy, physical rehabilitation, and dysphagia treatment program that was individually provided by physiatrists. RESULTS: The main diagnosis leading to mechanical ventilation was pneumonia (n=101, 96.2%) and the 1-year survival rate was 33.3% (n=35). One-year survivors had lower Acute Physiology and Chronic Health Evaluation (APACHE) II score (20.2±5.8 vs. 24.2±7.5, p=0.006) and Sequential Organ Failure Assessment score (6.7±5.6 vs. 8.5±2.7, p=0.001) on the day of intubation than non-survivors. More survivors participated in a rehabilitation program during their hospital stays (88.6% vs. 57.1%, p=0.001). The rehabilitation program was an independent factor for 1-year survival based on the Cox proportional hazard model (hazard ratio, 3.513; 95% confidence interval, 1.785 to 6.930; p<0.001) in patients with APACHE II scores ≤23 (a cutoff value based on Youden's index). CONCLUSION: Our study showed that participation in a rehabilitation program during hospital stay was associated with an improvement of 1-year survival of PMV patients who had less severe illness on the day of intubation.

Should We Perform Repeated Re-biopsy for the Detection of T790M Mutation?

PURPOSE: Epidermal growth factor receptor (EGFR) T790M mutations have been detected in the second or third rebiopsy, even if the T790M mutation was not identified in the first rebiopsy. This meta-analysis investigated the EGFR T790M mutation detection rates and its additional advantages with repeated rebiopsies. MATERIALS AND METHODS: We searched through the PubMed and EMBASE databases up to June 2022. Studies reporting rebiopsy to identify the EGFR T790M mutation in case of disease progression among patients with advanced non-small cell lung cancer and multiple rebiopsies were included. The quality of the included studies was checked using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. RESULTS: Eight studies meeting the eligibility criteria, reporting 1,031 EGFR mutation-positive patients were selected. The pooled EGFR T790M mutation detection rate of the first and repeated rebiopsies were 0.442 (95% confidence interval [CI], 0.411 to 0.473; I2=84%; p < 0.01) and 0.465 (95% CI, 0.400 to 0.530; I2=69%; p < 0.01), respectively. Overall, the pooled detection rate of EGFR T790M mutation was 0.545 (95% CI, 0.513 to 0.576), which increased by 10.3% with repeated rebiopsies. CONCLUSION: This meta-analysis identified that repeated rebiopsy increases the detection rate of EGFR T790M mutation by 10.3%, even if EGFR T790M mutation is not detected in the first rebiopsy. Our results indicate that the spatiotemporal T790M heterogeneity can be overcome with repeated rebiopsy.

Favorable Conditions for the Detection of EGFR T790M Mutation Using Plasma Sample in Patients with Non-Small-Cell Lung Cancer.

BACKGROUND: Detection of the epidermal growth factor receptor (EGFR) T790M mutation using plasma samples has been considered simple and non-invasive, but the relatively high false negative results lead to additional tissue sampling in some patients. Until now, the characteristics of patients who prefer liquid biopsy have not yet been established. METHODS: To evaluate the favorable conditions for the detection of T790M mutations using plasma samples, a multicenter retrospective study was performed between May 2018 and December 2021. Patients whose T790M mutation was detected in a plasma sample were classified as the plasma positive group. Study subjects with a T790M mutation not detected in a plasma sample but only in a tissue sample were grouped as the plasma false negative group. RESULTS: Plasma positive and plasma false negative groups were found in 74 and 32 patients, respectively. As a result, 40% of patients with one or two metastatic organs at the time of re-biopsy had false negative plasma sample results, and 69% of patients with three or more metastatic organs at the time of re-biopsy had positive plasma results. In multivariate analysis, three or more metastatic organs at initial diagnosis were independently associated with the detection of a T790M mutation using plasma samples. CONCLUSION: Our results demonstrated that the detection rate of a T790M mutation using plasma samples was related to the tumor burden, particularly to the number of metastatic organs.

Stability and safety of transbronchial dye mixture for preoperative localization in a porcine model.

OBJECTIVE: For thoracoscopy, the usefulness of a dye mixture of indigo carmine and Lipiodol for localizing lung lesions has been reported. However, little is known about the stability and safety of this dye mixture injected on the visceral pleura through a bronchoscope. METHODS: Porcine models were divided into three groups according to the detection time of the dye mixture: group A with a detection time of 4 h; group B, 8 h; and group C, 24 h. A dye mixture of indigo carmine and Lipiodol (0.5 mL each) was sprayed onto the visceral pleura both in the ventral and dorsal regions via a spray catheter. RESULTS: Twelve markings were created on the visceral pleura of the porcine lung (six ventral and six dorsal) in the six porcine models. At predetermined detection times, all 12 dye markings (100%) were visible on the visceral pleura. The mean longest diameter of the dye marking in the ventral and dorsal regions was 18.8 mm and 24.3 mm, respectively. In groups B and C, pathological changes in the lymphatic system, such as lymphatic dilatations, were found; minimal changes were found in group B, however, these changes with oval-shaped lymphatic cysts and Lipiodol accumulation, were more evident in group C. CONCLUSIONS: The dye mixture of indigo carmine and Lipiodol had reliable stability and visibility. In terms of safety, it may be necessary to check the dye mixture on the lung surface within 8 h.

Real-world evaluation of atezolizumab and etoposide-carboplatin as a first-line treatment for extensive-stage small cell lung cancer.

BACKGROUND/AIMS: Despite the obvious benefits of adding immune checkpoint inhibitors to platinum-etoposide chemotherapy in patients with extensive-stage small-cell lung cancer (ES-SCLC), real-world data remain scarce. METHODS: This retrospective study included 89 patients with ES-SCLC treated with platinum-etoposide chemotherapy alone (chemo-only group; n = 48) or in combination with atezolizumab (atezolizumab group; n = 41) and compared the survival outcomes between these two groups. RESULTS: Overall survival (OS) was significantly longer in the atezolizumab group than in the chemo-only group (15.2 months vs. 8.5 months; p = 0.047), whereas the median progression-free survival was almost the same (5.1 months vs. 5.0 months) in both groups (p = 0.754). Subsequent multivariate analysis revealed that thoracic radiation (hazard ratio [HR], 0.223; 95% confidence interval [CI], 0.092-0.537; p = 0.001) and atezolizumab administration (HR, 0.350; 95% CI, 0.184-0.668; p = 0.001) were favorable prognostic factors for OS. In the thoracic radiation subgroup, patients who received atezolizumab demonstrated favorable survival outcomes and no grade 3-4 adverse events (AEs). CONCLUSION: The addition of atezolizumab to platinum-etoposide resulted in favorable outcomes in this real-world study. Thoracic radiation was associated with improved OS and acceptable AE risk in combination with immunotherapy in patients with ES-SCLC.

Trends and an Online Survey on the Use of Rigid Bronchoscopy in Korea.

BACKGROUND: Although almost all interventional pulmonologists agree that rigid bronchoscopy is irreplaceable in the field of interventional pulmonology, less is known about the types of diseases that the procedure is used for and what difficulties the operators face during the procedure. The purpose of this study is to evaluate what diseases rigid bronchoscopy is used for, whether it is widely used, and what challenges the operators face in Korea. METHODS: We enrolled 14 hospitals in this retrospective cohort of patients who underwent rigid bronchoscopy between 2003 and 2020. An online survey was conducted with 14 operators to investigate the difficulties associated with the procedure. RESULTS: While the number of new patients at Samsung Medical Center (SMC) increased from 189 in 2003-2005 to 468 in 2018-2020, that of other institutions increased from 0 to 238. The proportion of SMC patients in the total started at 100% and steadily decreased to 59.2%. The proportion of malignancy as the indication for the procedure steadily increased from 29.1% to 43.0%, whereas post-tuberculous stenosis (25.4% to 12.9%) and post-intubation stenosis (19.0% to 10.9%) steadily decreased (all P for trends < 0.001). In the online survey, half of the respondents stated that over the past year they performed less than one procedure per month. The fewer the procedures performed within the last year, the more likely collaboration with other departments was viewed as a recent obstacle (Spearman correlation coefficient, rs = -0.740, P = 0.003) and recent administrative difficulties were encountered (rs = -0.616, P = 0.019). CONCLUSION: This study demonstrated that the number of patients undergoing rigid bronchoscopy has been increasing, especially among cancer patients. For this procedure to be used more widely, it will be important for beginners to systematically learn about the procedure itself as well as to achieve multidisciplinary consultation.

The Additive Impact of Transbronchial Cryobiopsy Using a 1.1-mm Diameter Cryoprobe on Conventional Biopsy for Peripheral Lung Nodules.

PURPOSE: The diagnostic yield of transbronchial biopsy (TBB) using radial probe endobronchial ultrasound (RP-EBUS) is 71%, which is lower than that of transthoracic needle biopsy. We investigated the performance and safety of sequential transbronchial cryobiopsy (TBC) using a novel 1.1-mm diameter cryoprobe, after conventional TBB using RP-EBUS for the diagnosis of peripheral lung lesions (PLLs). Materials and Methods: From April 2021 to November 2021, 110 patients who underwent bronchoscopy using RP-EBUS for the diagnosis of PLL ≤ 30 mm were retrospectively included in our study. All records were followed until June 2022. RESULTS: The overall diagnostic yield of combined TBB and TBC was 79.1%, which was higher than 60.9% of TBB alone (p=0.005). The diagnostic yield of sequential TBC was 65.5%, which increased the overall diagnostic yield by 18.2%. The surface area of tissues by TBC (mean area, 18.5 mm2) was significantly larger than those of TBB by 1.5-mm forceps (3.4 mm2, p < 0.001) and 1.9-mm forceps (3.7 mm2, p=0.011). In the multivariate analysis, PLLs with the longest diameter of ≤ 22 mm were found to be related to additional diagnostic benefits from sequential TBC (odds ratio, 3.51; 95% confidence interval, 1.043 to 11.775; p=0.042). Complications were found in 10.5% of the patients: pneumothorax (1.0%), infection (1.0%), and significant bleeding (8.6%). None of the patients developed any life-threatening complications. CONCLUSION: Sequential TBC with a 1.1-mm cryoprobe improved the performance of conventional TBB using RP-EBUS without serious complications.

Bronchial Washing Using a Thin Versus a Thick Bronchoscope to Diagnose Pulmonary Tuberculosis: A Randomized Trial.

BACKGROUND: This study was performed to evaluate the efficacy of using a thin bronchoscope for the diagnosis of pulmonary tuberculosis (PTB). METHODS: Between March 2019 and November 2021, we prospectively enrolled participants with suspected PTB whose sputum acid-fast bacilli (AFB) smear and tuberculosis (TB) polymerase chain reaction (PCR) tests were negative or who could not produce self-expectorated sputum. Participants were randomized to a control group (bronchial washing [BW] using a 5.9-mm conventional bronchoscope guided by chest computed tomography) or an investigational group (BW using a 4.0-mm thin bronchoscope under virtual bronchoscopic navigation guidance). The primary outcome was detection of TB in BW fluid, defined as a positive result in the Xpert MTB/RIF assay. The secondary outcomes included AFB smear and Mycobacterium tuberculosis culture positivity, time to treatment initiation, and bronchoscopy-related complications. RESULTS: In total, 85 participants were included in the final analysis (43 in the control group and 42 in the investigational group). Twenty-three and 29, respectively, were finally diagnosed with PTB. The TB detection rate in BW fluid was higher in the investigational group (72.4% vs 43.5%, P = .035). Mycobacterium tuberculosis culture positivity was also higher in the investigational group (79.3% vs 52.2%, P = .038). No participants required premature bronchoscopy termination because of complications. Of the participants with PTB, the time to treatment initiation was shorter in the investigational group (median, 2.0 days vs 4.0 days, P = .001). CONCLUSIONS: BW using a thin bronchoscope increases the TB detection rate in patients with PTB compared to conventional bronchoscopy. Clinical Trials Registration.ȃNCT03802812.

Ultrathin Bronchoscopy for the Diagnosis of Peripheral Pulmonary Lesions: A Meta-Analysis.

BACKGROUND: Ultrathin bronchoscopy (external diameter, ≤3.5 mm) is useful for the diagnosis of peripheral pulmonary lesions because of its good accessibility. OBJECTIVES: We performed a meta-analysis to investigate the diagnostic yield of ultrathin bronchoscopy for peripheral pulmonary lesions. METHODS: We performed a systematic search of MEDLINE and EMBASE (from inception to May 2021), and meta-analysis was performed using R software. The diagnostic yield was evaluated by dividing the number of successful diagnoses by the total number of lesions, and subgroup analysis was performed to identify related factors. RESULTS: Nineteen studies with a total of 1,977 peripheral pulmonary lesions were included. The pooled diagnostic yield of ultrathin bronchoscopy was 0.65 (95% confidence interval, 0.60-0.70). Significant heterogeneity was observed among studies (χ2, 87.75; p < 0.01; I2, 79.5%). In a subgroup analysis, ultrathin bronchoscopy with 1.2 mm channel size showed a diagnostic yield of 0.61 (95% confidence interval, 0.53-0.68), whereas ultrathin bronchoscopy with 1.7 mm channel size showed 0.70 (95% confidence interval, 0.66-0.74) (χ2, 5.35; p = 0.02). In addition, there was a significant difference in diagnostic yield based on lesion size, histologic diagnosis (malignant vs. benign), bronchus sign, and lesion location from the hilum, whereas no significant difference was found based on lobar location. The overall complication rate of ultrathin bronchoscopy was 2.7% (pneumothorax, 1.1%). CONCLUSIONS: Ultrathin bronchoscopy is an excellent tool for peripheral pulmonary lesion diagnosis with a low complication rate. The diagnostic yield of ultrathin bronchoscopy was significantly higher with larger channel size, which might be attributed to the availability of radial endobronchial ultrasound.