[Thymoma with Partial Anomalous Pulmonary Venous Drainage from the Left Upper Lobe:Report of a Case].

A 73-year-old woman presented with left anterior chest pain and back pain. Computed tomography (CT) scan showed an anterior mediastinal tumor. It also showed partial anomalous pulmonary venous drainage (left superior pulmonary vein draining into the left brachiocephalic vein), and the tumor was located near the left brachiocephalic vein. The operation was performed through a median sternotomy to resect the thymus and tumor with partial resection of the left upper lobe due to the tumor's adhesion to the left upper lobe. One of the vascular anomalies encountered in adult thoracic surgery is partial anomalous pulmonary venous drainage. It is important to recognize the presence of such an anomaly on imaging and to anticipate the surgical procedure with a preoperative surgical technique.

[Pulmonary Epithelioid Hemangioendothelioma Requiring Differentiation from Metastatic Lung Tumor:Report of a Case].

BACKGROUND: Pulmonary epithelioid hemangioendothelioma is a rare malignant disease, and most cases are found as multiple lung nodules, rarely as a single nodule. CASE: Computed tomography( CT) in a 71-year-old man revealed a growing 3-mm lung nodule in the left S6 after rectal cancer operation. Wedge resection was performed. A pathological examination resulted in a diagnosis of pulmonary epithelioid hemangioendothelioma based on CD31 and CD34 positivity in immunohistochemistry. CONCLUSION: When new nodules are noted on routine CT scans of other malignancies, it is essencial to make a pathological diagnosis, bearing in mind that pulmonary nodules can arise from a variety of causes.

Theory and application of growth delay analysis of colony formation for evaluation of injured population of the stressed fungal conidia.

A new concept of injured population assessment is proposed, in which the size of the injured population in stressed mold spores is evaluated by analyzing the colony formation process on a solid agar medium. In this method, a small paper disc containing mold spores is placed on a subculture agar plate, and the linear increase in the radius of the colony formed by development from the spore is measured over time. Then, the principle of the previously reported growth delay analysis (GDA) method originally using a liquid medium is applied to obtain the integrated viable ratio (IV) of the stressed population from the delay time relative to the growth of the unstressed population. On the other hand, the viable ratio (V) to the initial value as the colony count obtained with the stressed culture is obtained; the difference between the logarithms of V and IV is determined as the log number of the injured population. Applying this analysis method to heated spores of Cladosporium sphaerospermum, we determined the size of the injured population that occurred. This method was considered to be effective as a new method for quantifying injured populations using a solid medium.

Different patterns of germination inhibition by carvacrol and thymol in Bacillus subtilis spores.

This study aimed to clarify how the phenolic monoterpene carvacrol and its structural isomer thymol both as essential oil components (EOCs) inhibit the germination of Bacillus subtilis spore. Germination was evaluated by the OD600 reduction rate in a growth medium and phosphate buffer containing either l-alanine (l-Ala) system or l-asparagine, d-glucose, d-fructose plus KCl (AGFK) system. The germination of the wild-type spores in the Trypticase Soy broth (TSB) was found to be greatly inhibited by thymol than by carvacrol. Such a difference in the germination inhibition was confirmed by the dipicolinic acid (DPA) release from germinating spores in the AGFK buffer system, but not in the l-Ala system. Similar to the wild-type spores, no difference in the inhibitory activity between the EOCs was also indicated with the gerB, gerK-deletion mutant spores in the l-Ala buffer system and the above substantial difference was also done with the gerA-deleted mutant spores in the AGFK. Fructose was found to release spores from the EOC inhibition and inversely even stimulated. Increased concentrations of glucose and fructose partially suppressed the germination inhibition by carvacrol. The results obtained should contribute to the elucidation of the control effects of these EOCs on bacterial spores in foods.

Real-World Data Analysis of Pembrolizumab Monotherapy for NSCLC Using Japanese Postmarketing All-Case Surveillance Data.

Introduction: Pembrolizumab is a programmed death-ligand 1 inhibitor that was initially indicated for monotherapy in patients with advanced lung cancer. The Japanese Lung Cancer Society conducted an observational study on pembrolizumab using confirmative data obtained through postmarketing all-case surveillance (PMACS), which was performed by a pharmaceutical company under the Japanese law in 2017. Methods: This multicenter observational study was conducted by the Japanese Lung Cancer Society using PMACS data with the newly created central registration system regarding patients with NSCLC who received pembrolizumab monotherapy between February 1, 2017 and June 30, 2017; a new database was created by adding the clinical information regarding prognosis for 3 years after therapy to the existing data collected by PMACS. Results: A total of 300 patients from 43 facilities were enrolled in this study. The median overall survival and progression-free survival after pembrolizumab initiation were 558 and 188 days, respectively. Moreover, the 1- and 3-year survival rates were 58.9% and 33.7%, respectively. Results of multivariate analysis revealed performance status (p < 0.0001), histology (p = 0.0118), previous chemotherapy (p = 0.0007), programmed death-ligand 1 expression status (p = 0.0195), and previous steroid use (p = 0.0460) as significant factors that affected overall survival. The toxicity profile was similar to that previously reported. Conclusions: In this first attempt to use PMACS data, we successfully collected clinical information and found the real-world efficacy and safety of pembrolizumab.

Theoretical Base for the Application of the DiVSaL Method to Bacterial Spores to Evaluate Injured Populations Occurring After Exposure to Lethal Stress.

To assess injury in bacterial spore populations exposed to lethal stress, we proposed a theoretical basis for applying the DiVSaL method, which has already been reported for general microorganisms as a double subculture method. We constructed a mathematical model in which both injuries to the germination system and the spore body were taken into the theory. In this theory, we reasonably assumed that the viable and germinable spore count is constant before the subsequent vegetative growth and that the delay of germination and outgrowth can be included in the concept of λ injury previously reported as the growth-independent injury. By introducing these assumptions, the double subculture method can be considered to apply to spores as well. As examples of the application of this theory, the growth delays of Bacillus subtilis spores treated with heat and UV irradiation were analyzed and the numbers of injured spores were evaluated. Based on the results obtained, heat is indicated to have a higher injury generation ability than UV irradiation. The applicability of the DiVSaL method as a tool for food preservation and sanitation designs is presented.

[Primary Myelolipoma of the Posterior Mediastinum:Report of a Case].

The patient was a 66-year-old male. Computed tomography( CT) scan revealed a tumor of the posterior mediastinum 2 years before and grew slowly 49.0 to 51.4 mm in the longest diameter of the coronal slice. Thoracoscopic surgery was performed to resect it. The pathological examination revealed a predominantly mature adipose tissue with hematopoietic tissue in hematoxylin and eosin( HE) staining and the hematopoietic tissue was comprised of mature erythroblasts, megakaryocytes, and granulocytes in immune staining, which diagnosed it as myelolipoma. Incidence of myelolipoma which originates from besides adrenal glands is reported 0.08 to 0.2%. As far as we can search, 40 cases of myelolipoma of the posterior mediastinum are in the literatures.

Low Temperature Heating-Induced Death and Vacuole Injury in Cladosporium sphaerospermum Conidia.

The mechanism of thermal death of mold conidia has not been understood in detail. The purpose of this study is to analyze the death kinetics of heated conidia of Cladosporium sphaerospermum and to ascertain the expectant cell injury responsible for the death. The death of the dormant (resting) conidia of Cladosporium sphaerospermum was examined at temperatures of between 43 and 54℃ with the conventional colony count method. The death reaction apparently followed the first order kinetics, but the Arrhenius plot of the death rate constant demonstrated seemingly a break. The linearity at temperatures higher than that at the break was lost at lower temperatures, suggesting the involvement of an unusual mechanism in the latter temperatures. In the cell morphology, we observed with quinacrine staining the vacuole rupture at a lower temperature but not at a high temperature. Interestingly, the vacuole rupture by low-temperature heating was found to correlate with the viability loss. Furthermore, active protease originally locating in vacuoles was detected in the cytoplasm of the conidia after heated at a low temperature. The results obtained suggest the involvement of potent autophagic cell death induced by low temperature heating of C. sphaerospermum conidia.

Evaluation of distinct modes of oxidative secondary injury generated in heat-treated cells of Escherichia coli with solid/liquid and complex/semi-synthetic media sets.

AIMS: To characterize and evaluate oxidative secondary injury generated in heat-treated Escherichia coli cells during recovery cultivation either on agar or in a broth of a semi-synthetic enriched M9 (EM9) medium and a complex Luria broth (LB) medium with different types of antioxidants. METHODS AND RESULTS: E. coli cells grown in the EM9 and LB broth were heated at 50°C in a buffer (pH 7.0). Heated cells were recovered on the same kind of agar medium as that used for growth, with or without different antioxidants. Although these antioxidants mostly protected the cells from oxidative secondary injury on the recovery media, sodium thiosulphate and sodium pyruvate were most protective on EM9 and LB agars, respectively. Determination of viability using the most probable number and growth delay analysis methods showed significant reductions in the protective effects of antioxidants in the EM9 and LB media. CONCLUSION: Oxidative secondary injury generated in heated E. coli cells was found to be qualitatively and quantitatively diverse under cellular and environmental conditions. SIGNIFICANCE AND IMPACT OF THE STUDY: Our results suggest that different modes of oxidation should be considered in viability determination and injured cell enumeration of heat-treated cells.

Acute Exacerbation of Tracheal Obstruction and Severe Respiratory Failure after a Single Dose of 2-Gy Irradiation for Squamous Cell Lung Carcinoma: A Case Report.

The patient, a 62-year-old woman, complained chiefly of cough. We planned chemoradiotherapy for squamous nonsmall cell lung cancer. A single dose of 2-Gy irradiation and no anticancer agent administration exacerbated the airway stenosis with severe respiratory failure. Urgent tracheal intubation was performed, and a tracheal stent was implanted under extracorporeal membrane oxygenation (ECMO). Because her performance status (PS) worsened from 1 to 2, we administered radiotherapy. The tumor size decreased. There was no recurrence for the next 3 months, and her PS improved to 1. Emergency tracheal intubation and tracheal stent placement under ECMO can be effective for exacerbated airway obstruction after radiotherapy.

The role of virtual-assisted lung mapping 2.0 combining microcoils and dye marks in deep lung resection.

OBJECTIVES: Virtual-assisted lung mapping 2.0 is a novel preoperative bronchoscopic lung mapping technique combining the multiple dye marks of conventional virtual-assisted lung mapping with intrabronchial microcoils to navigate thoracoscopic deep lung resection. This study's purpose was to evaluate the feasibility of virtual-assisted lung mapping 2.0 in resecting deeply located pulmonary nodules with adequate margins. METHODS: A multicenter, prospective single-arm study was performed from 2019 to 2020 in 8 institutions. The selection criteria were barely identifiable nodules requiring sublobar lung resections, nodules requiring resection lines reaching the inner 2/3 of the pulmonary lobe on computed tomography images in wedge resection, or the nodule center located in the inner 2/3 of the pulmonary lobe in wedge resection or segmentectomy. Resection margins larger than 2 cm or the nodule diameter were considered successful resection. Bronchoscopic placement of multiple dye marks and microcoil(s) was conducted 0 to 2 days before surgery. RESULTS: We analyzed 65 lesions in 64 patients. The diameter and depth of the targeted nodules and the minimum required resection depth reported as median (interquartile range) were 9 (7-13) mm, 11 (5-15) mm, and 30 (25-35) mm, respectively. Among 60 wedge resections and 5 segmentectomies, successful resection was achieved in 64 of 65 resections (98.5%; 95% confidence interval, 91.7-100). Among 75 microcoils placed, 3 showed major displacement after bronchoscopic placement. There were no severe adverse events associated with the virtual-assisted lung mapping procedure. CONCLUSIONS: This study demonstrated that virtual-assisted lung mapping 2.0 can facilitate successful resections for deep pulmonary nodules, overcoming the limitations of conventional virtual-assisted lung mapping.

Virtual-assisted lung mapping in sublobar resection of small pulmonary nodules, long-term results.

OBJECTIVES: The short-term efficacy of virtual-assisted lung mapping (VAL-MAP), a preoperative bronchoscopic multi-spot lung-marking technique, has been confirmed in 2 prospective multicentre studies. The objectives of this study were to analyse the local recurrence and survival of patients enrolled in these studies, long-term. METHODS: Of the 663 patients enrolled in the 2 studies, 559 patients' follow-up data were collected. After excluding those who did not undergo VAL-MAP, whose resection was not for curative intent, who underwent concurrent resection without VAL-MAP, or who eventually underwent lobectomy instead of sublobar resection (i.e. wedge resection or segmentectomy), 422 patients were further analysed. RESULTS: Among 264 patients with primary lung cancer, the 5-year local recurrence-free rate was 98.4%, and the 5-year overall survival (OS) rate was 94.5%. Limited to stage IA2 or less (≤2 cm in diameter; n = 238, 90.1%), the 5-year local recurrence-free and OS rates were 98.7% and 94.8%, respectively. Among 102 patients with metastatic lung tumours, the 5-year local recurrence-free rate was 93.8% and the 5-year OS rate was 81.8%. Limited to the most common (colorectal) cancer (n = 53), the 5-year local recurrence-free and OS rates were 94.9% and 82.3%, respectively. CONCLUSIONS: VAL-MAP, which is beneficial in localizing small barely palpable pulmonary lesions and determining the appropriate resection lines, was associated with reasonable long-term outcomes. SUBJ COLLECTION: 152, 1542.

Multicentre, prospective, observational study investigating the most appropriate surgical option that can prevent the recurrence of primary spontaneous pneumothorax after surgery: the PATCH study, protocol.

INTRODUCTION: Thoracoscopic surgery is performed for refractory or recurrent primary spontaneous pneumothorax (PSP). To reduce postoperative recurrence, additional treatment is occasionally adopted during surgery after bulla resection. However, the most effective method has not been fully elucidated. Furthermore, the preference for additional treatment varies among countries, and its efficacy in preventing recurrence must be evaluated based on settings tailored for the conditions of a specific country. The number of registries collecting detailed data about PSP surgery is limited. Therefore, to address this issue, a prospective multicentre observational study was performed. METHODS AND ANALYSIS: This multicentre, prospective, observational study will enrol 450 participants aged between 16 and 40 years who initially underwent PSP surgery. Data about demographic characteristics, disease and family history, surgical details, and CT scan findings will be collected. Follow-up must be conducted until 3 years after surgery or in the event of recurrence, whichever came first. Patients without recurrence will undergo annual follow-up until 3 years after surgery. The primary outcome is the rate of recurrence within 2 years after surgery. A multivariate analysis will be performed to compare the efficacy of different surgical options. Then, adverse outcomes correlated with various treatments and the feasibility of treatment methods will be compared. ETHICS AND DISSEMINATION: This study was approved by the local ethics committee of all participating centres. The findings will be available in 2025, and they can be used as a basis for clinical decision-making regarding appropriate options for the initial PSP surgery. TRIAL REGISTRATION NUMBER: NCT04758143.

Detection Time Distribution of Microcolonies Formed by Individual Heat-Injured Cells of Escherichia coli.

The microcolony formation at 30℃ on an enriched minimal salts agar plates by individual Escherichia coli cells heated at 50℃ was monitored with a time-lapse shadow image analysis system, MicroBio µ3DTM AutoScanner. While the time course of microcolony count detected every half an hour for the unheated cells seemingly demonstrated a normal distribution, that for the heated cell population demonstrated totally the growth delay probably resulting from cell injury and also interestingly distributed in its rather deformed pattern with a tailing. Those patterns of the cumulative counts of appearing microcolonies during the post-heating cultivation period were expressed in three different mathematical models. This approach may be proposed as a rapid cultivation method predictable for enumeration of viable and repairable injured cells in practical use.

Long agonal period deteriorates cardiac death donor lung function in a rat EVLP model.

PURPOSE: We investigated the impact of the duration of agonal period on donor lung function after reperfusion in an ex vivo rat lung perfusion model. METHODS: Three mechanical hypoventilation conditions were used for three agonal periods, which were defined as the interval between the start of hypoventilation and the time when systolic arterial blood pressure reached < 50 mmHg, i.e., < 10, 30-60, and 150-200 min for very short (VS), short (S), and long (L) groups (n = 5 rats/group). After flushing the lung, heart-lung blocks were reperfused ex vivo for 120 min; physiological data were obtained throughout the reperfusion process. RESULTS: Pulmonary vascular resistance was significantly higher throughout reperfusion in group L than in the other two groups (p < 0.05). After reperfusion, oxygenation was worse and pulmonary edema was more severe in group L than in group S (p < 0.05). Potassium concentrations in the perfusates were significantly higher in group L than in group VS. Histological analysis revealed more severe injury in group L than in the other two groups. CONCLUSIONS: Long agonal periods may lead to deterioration of donor lung function; short intervals may not significantly affect donor lung function.

Effects of Warm Versus Cold Ischemic Donor Lung Preservation on the Underlying Mechanisms of Injuries During Ischemia and Reperfusion.

BACKGROUND: Ischemia-reperfusion injury related to lung transplantation is a major contributor to early postoperative morbidity and mortality. We hypothesized that donation after cardiac death donor lungs experience warm ischemic conditions that activate different injurious mechanisms compared with donor lungs that undergo prolonged cold ischemic conditions. METHODS: Rat donor lungs were preserved under different cold ischemic times (CIT) (12 hours or 18 hours), or under warm ischemia time (WIT) (3 hours) after cardiac death, followed by single left lung transplantation. Lung function was analyzed during the 2-hour reperfusion period. Microscopic injury, cell death, energy status, and inflammatory responses were assessed. RESULTS: Pulmonary oxygenation function was significantly worse in both 18hCIT and WIT groups, accompanied by higher peak airway pressure, acute lung injury scores, and expression of cell death markers compared with the 12hCIT control group. In lung tissue, reperfusion induced increased expression levels of interleukin (IL)-1α, IL-1ß, IL-6, and chemokines CCL2, CCL3, CXCL1, and CXCL2 in CIT lungs. Notably, these changes were much lower in the WIT group. Additionally, plasma levels of IL-6, IL-18, CCL2, and vascular endothelial growth factor were significantly higher, and adenosine triphosphate levels were significantly reduced in warm versus cold ischemic lungs. CONCLUSIONS: Compared with 12hCIT, posttransplant pathophysiology deteriorated similarly in both 18hCIT and WIT groups. However, tissue adenosine triphosphate levels and inflammatory profiling differed between warm versus cold ischemic donor lungs. These differences should be carefully considered when developing specific therapeutic strategies to reduce ischemia-reperfusion injury in lung transplantation.

Bronchodilator Inhalation During Ex Vivo Lung Perfusion Improves Posttransplant Graft Function After Warm Ischemia.

BACKGROUND: We hypothesized that an injured lung graft from donation after cardiac death donors could be reconditioned before transplantation using an ex vivo lung perfusion (EVLP) system and ventilation with high-dose short-acting ß2-adrenergic receptor agonists. METHODS: Cardiac arrest was induced in a canine model by intravenous potassium chloride injection. Lungs were randomly assigned to two groups after 150 minutes of warm ischemia: inhalation of 1,400 µg of procaterol (BETA group, n = 5) or control group receiving solvent (CON group, n = 5) during EVLP. Left lungs were transplanted after 120 minutes of EVLP. Functional variables, tissue adenosine 5'-triphosphate levels, and tissue cyclic adenosine monophosphate levels were measured 240 minutes after transplantation. RESULTS: Physiologic pulmonary function was similar at the end of EVLP in both groups. However, significantly better graft oxygenation, dynamic pulmonary compliance, and reduced pulmonary vascular resistance were observed in the BETA group than in the CON group 240 minutes after transplantation. No severe adverse effects were observed after lung transplantation in the BETA group. Lung tissue adenosine 5'-triphosphate levels and cyclic adenosine monophosphate levels were significantly higher in the BETA group than in the CON group at the end of EVLP and at 240 minutes after transplantation. CONCLUSIONS: High-dose nebulized procaterol during EVLP ameliorated lung graft dysfunction at the early posttransplantation period without severe adverse effects. These data suggest that lung reconditioning with procaterol ventilation during EVLP improves lung graft function after transplantation.

Antifungal Activity of Diglycerin Ester of Fatty Acids against Yeasts and Its Comparison with Those of Sucrose Monopalmitate and Sodium Benzoate.

The antifungal activities of diglycerin monoester of fatty acids (DGCs), which have been employed as food emulsifiers, were examined against three yeasts, Saccharomyces cerevisiae, Candida albicans and Candida utilis and were compared with those of sucrose monoester of palmitic acid (SC16) as another type of emulsifier and sodium benzoate (SB) as a weak acid food preservative. When the minimum growth inhibitory concentrations (MICs) of diglycerin monolaurate (DGC12) against these yeasts were determined 2 d after incubation in YM broth at pH5.0, they were relatively low, being 0.01% (w/v), for both S. cerevisiae and C. utilis, whereas was high, being 4.0% (w/v), for C. albicans. On the contrary, the MICs of sucrose monopalmitate (SC16) were high, being 3.0 and 4.0% (w/v), for the former two yeasts, respectively, but 0.6% (w/v) for the last yeast. In contrast to these emulsifiers, the MICs of sodium benzoate (SB) were similar independently upon the yeast strain, being in order 0.4, 0.3 and 0.5% (w/v), for the above yeasts, respectively. The anti-yeast activities of DGC12 and SC16 were gradually increased with a decrease in pH, in a manner similar to that of SB, except for the action of SC16 on C. albicans, for which the activity was more effective at pHs 5.0 and 6.0 than at pHs 4.0 and 7.0. Among DGCs tested having different fatty acid moieties in the molecule, lauroyl ester (DGC12) was more effective than myristoyl and palmitoyl esters against S. cerevisiae and C. utilis. The inhibitory effect of DGC12 on the yeast growth depended upon both the cell density and the strength of aeration during the treatment. Further, DGC12 was found to kill S. cerevisiae and C. utilis cells at a rather low concentration of 0.005% (w/v) in 50mM acetate buffer at pH5.0, although, against C. albicans cells, only slight fungicidal activity was demonstrated at a high concentration of 0.5% (w/v). The results obtained support the effectiveness of practical application of DGC12 to acidic foods for the control of growth and survival of general yeasts such as S. cerevisiae and C. utilis.

Human α1-antitrypsin improves early post-transplant lung function: Pre-clinical studies in a pig lung transplant model.

BACKGROUND: The translation of novel drugs in lung transplantation is challenged by different physiologic conditions between small animals and humans. Large-animal models provide important pre-clinical evidence and the next step that best informs clinical trials. In the present study, we used a pig lung transplant model to determine whether human α1-antitrypsin (A1AT), a medication shown to prevent pulmonary ischemia-reperfusion injury in rats, could attenuate reperfusion injury after prolonged hypothermic preservation in a large-animal lung transplant model. METHODS: Donor lungs were preserved for 24 hours at 4°C, followed by lung transplantation. In a randomized and blinded fashion, intravenous A1AT (240 mg/kg; n = 5) or human albumin (n = 5) was administered to the recipient before reperfusion. Allograft gas exchange function and lung mechanics were monitored during a 4-hour reperfusion period. Microscopic lung injury, inflammatory response, coagulation activity, and cell death were assessed. RESULTS: Pulmonary gas exchange was significantly better during the 4-hour reperfusion period in the A1AT group. Treatment with A1AT improved static pulmonary compliance and significantly reduced pulmonary edema and lung permeability. A1AT treatment inhibited inflammatory mediators in the circulation, with reduced activation of nuclear factor-κB and inflammasome, reduced formation of thrombin-antithrombin complex in plasma, and reduced apoptosis in the allografts. CONCLUSIONS: Administration of human A1AT before reperfusion in recipients improved immediate post-transplant lung function in pigs. A large-animal survival model should be considered to support further advancement toward a clinical trial of A1AT to prevent primary graft dysfunction in lung transplantation.

Modified In Vivo Lung Perfusion for Local Chemotherapy: A Preclinical Study With Doxorubicin.

BACKGROUND: In vivo lung perfusion (IVLP) is a promising adjuvant treatment of lung metastases, allowing the localized delivery of drugs to the lungs without systemic exposure. Previous experimental and clinical data resulted in variable efficacy and frequent toxicity. Our objectives were to demonstrate the feasibility and safety of a novel protective IVLP technique coupled with the delivery of sarcoma-based chemotherapy to the lung. METHODS: The left pulmonary artery and veins in pigs were cannulated and clamped. Left lung IVLP was performed for 4 hours. Doxorubicin (Dox) at a standard clinical dose of 75 mg/m(2) was used, followed by 150 and 225 mg/m(2). Dox 75 mg/m(2) combined with ifosfamide (Ifos) 6 g/m(2) was also tested. After IVLP, blood reperfusion was allowed for 4 hours. Lung physiology was assessed and biopsy samples were obtained for histologic assessment of acute lung injury (ALI), inflammatory profile, and cell death. Lung tissue levels, perfusate, and plasma levels of Dox were measured during the procedure. RESULTS: Lungs treated with Dox 75 mg/m(2) alone or combined with Ifos showed stable function throughout the procedure, without evidence of ALI (p = 0.12 and p = 0.36, respectively). Tissue levels of Dox were 70.3 µg/g homogeneously distributed in the lung (p = 0.12). No drug was detected systemically. Dox 150 mg/m(2) and 225 mg/m(2) showed incremental ALI. CONCLUSIONS: IVLP for 4 hours with Dox 75 mg/m(2) alone or combined with Ifos was well tolerated, without measurable ALI. High drug levels in perfusate and lung tissue were found without systemic leakage. A dose-related toxicity was observed with increases in Dox doses.