Potential role of pre-treatment bone marrow SUVmean to liver SUVmean ratio (BM/L) and comparison of primary tumour FDG uptake with brain FDG uptake in predicting survival in limited-stage lung cancers.

INTRODUCTION: The survival rates of patients with limited-stage small-cell lung cancer are low despite curative treatment. Accordingly, we investigated the disease prognosis by comparing the pre-treatment bone marrow mean standardised uptake values (SUVmean) / liver SUVmean ratio (BM/L) and primary tumour FDG uptake and brain FDG uptake to prognosis. MATERIALS AND METHODS: This was an observational, retrospective, single-centre study of patients with limited-stage small-cell lung cancer. Maximum standardised uptake values before treatment SUVmax, mean SUV (SUVmean), metabolic tumor volume (MTV), total lesion glycolysis (TLG), liver (KC) SUVmean, bone marrow SUVmean, BM/L ratio (grouped as BM/L <1 and BM/L<1), FDG uptake level of the primary tumour are higher than brain FDG uptake. The association of low prevalence with overall survival (OS) and progression-free survival (PFS) was evaluated. DISCUSSION: A total of 125 patients were included in the study. The risk of death was found to be two times higher in patients with primary tumour FDG uptake higher than brain FDG uptake compared to those with less brain involvement. The risk of death in patients with BM/L>1 was found to be 1.6 times higher than in patients with BM/L<1. CONCLUSION: Comparison of BM/L, FDG uptake of the primary tumour and brain FDG uptake as new prognostic parameters can be guiding in the classification of patients with LD-SCLC with a higher risk of death or progression and in planning new treatment strategies.

An unusual, life-threatening complication of EBUS-TBNA: Pneumoperitoneum.

Endobronchial ultrasound-guided with transbronchial needle aspiration (EBUS-TBNA) is a safe procedure. We present an unusual life-threatening complication after EBUS-TBNA in a 43-year-old female. She underwent EBUS-TBNA for enlarged lymph nodes evaluation. After EBUS-TBNA, a progressively worsening abdominal distension was observed. In computed tomography, subcutaneous emphysema, bilateral pneumothorax, pneumomediastinum and pneumoperitoneum were detected. This complication was successfully treated with chest tube insertion and bedside abdominal decompression. Even though EBUS-TBNA is considered to bear a low risk, the possibility of complication occurrence must be taken into account and clinicians must be more cautious about pulmonary barotrauma, especially when EBUS-TBNA is performed.

The efficacy of 18F-FDG PET/CT in monitoring disease progression in malignant pleural mesothelioma.

OBJECTIVE: In the event of suspicion of malignant pleural mesothelioma (MPM) progression, imaging plays an important role. We aimed to evaluate the efficacy of 18F-FDG PET/CT in monitoring disease progression by comparing it with CT, and estimate median overall survival (OS) according to progression status with CT and 18F-FDG PET/CT. MATERIALS AND METHODS: This was an observational, retrospective, single-institution study with MPM patients who had both 18F-FDG PET/CT and CT for monitoring disease progression from March 2009 to February 2020. Clinical features, radiological findings, and progression status according to CT [radiologic progression negative (RPN), radiologic progression positive (RPP)] and 18F-FDG PET/CT [metabolic progression negative (MPN), metabolic progression positive (MPP)] were recorded. The discrepancies and concordance between two methods were evaluated. The OS was estimated using the Kaplan-Meier method. RESULTS: A total of 56 patients were included. There were thirty-one (55.3%) RPN and 25 (44.7%) RPP, while there were 26 (46.5%) MPN and 30 (53.5%) MPP. All RPP patients were also found to be MPP, however, among RPN, 5 patients (8.9% of all patients) were evaluated as MPP. The concordance between two methods in monitoring disease progression was very good (K = 0.423; p < 0.01). The OS was 26 ±â€¯2.6 months in all patients. Kaplan-Meier curves between RPN and RPP, and between MPN and MPP did not show statistically significant differences (p = 0.56 and p = 0.25, respectively). CONCLUSIONS: Both methods are equally acceptable in monitoring disease progression in MPM, even though 18F-FDG PET/CT detected more progression than CT did.

Could PD-L1 positivity be associated with venous thrombosis in patients with non-small cell lung cancer?

The risk of venous thromboembolism (VTE) is increased in non-small cell lung cancer (NSCLC), and defining at-risk patients is important. Thus, we aimed to assess the association between programmed cell death ligand 1 (PD-L1) expression and VTE [pulmonary embolism (PE), deep venous thrombosis (DVT)] in NSCLC. In this retrospective, observational multicentre study, 369 patients with NSCLC who had PD-L1 immunohistochemistry based on biopsies taken between January 2017 and December 2019, were divided as PD-L1-positive (n = 181) and -negative (n = 188) groups, and low-positive (n = 99) and high-positive (n = 82) PD-L1 groups. Among all population, 12.5% of them developed a VTE during a median follow-up of 474 days. The rates of DVT, PE, and PE + DVT were 5.7%, 6% and 0.8%, respectively. VTE (15.5% vs. 9.5%) and DVT (3.8% vs. 7.4%) were similar between two groups, while PE was significantly higher in PD­L1-positive group than those in PD-L1-negative group (11.1% vs 1%, p < 0.001). There were no significant differences between low- and high-positive groups in terms of VTE (14.1% vs. 17%), PE (12.1% vs. 9.8%), and DVT (2% vs. 6.1%). In the multivariate analysis, multiple metastases (Hazard ratio [HR] 4.02; 95% confidence interval [Cl] 1.18-13.63; p = 0.07) and PD-L1 positivity was associated with an increased PE risk (HR 8.39; 95% Cl 2.07-34.07; p = 0.003). In conclusion, PD-L1 positivity may be of important role in predicting the increased risk of PE in patients with NSCLC and thereby may be used to define patients likely to benefit from thromboprophylaxis.

The clinical utility of the LENT score in patients with malignant pleural mesothelioma.

Introduction: In malignant pleural mesothelioma (MPM), useful tools are needed to predict survival. Thus, we aimed to evaluate the LENT score, and demonstrate the performance of the LENT score in predicting survival in patients with MPM. Materials and Methods: This was a retrospective, observational single-center study. Sixty-nine patients diagnosed with MPM who had pleural effusion (March 2009-December 2020) were divided into groups according to their LENT score and compared. Median survivals were estimated and compared according to the LENT score and parameters of the LENT score. Result: Fifty-four patients were in the low-LENT score group, 15 patients were in the moderate-LENT score group, and there were no patients in the highLENT score group. The two groups had similar characteristics in terms of age, gender, and histological subtype distribution. There were no patients with ECOG-PS 0 in the moderate-LENT score group. Serum neutrophil-tolymphocyte ratio (NLR), pleural lactate dehydrogenase (LDH), patients with serum NLR> 9, and patients with pleural LDH> 1500 were significantly higher in the moderate-LENT score group (p= 0.002, 0.001, <0.01, <0.01, respectively). Fifty patients had died during a median follow-up of 38.6 ± 6.5 (95% CI= 25.84-51.41) months. The median survival for all patients was 28.63 ± 3.2 (95% CI= 22.33-34.92) months, higher than the original study. It was 30.97 ± 2 months in the low-LENT score group, and 20.7 ± 3.4 months in the moderate-LENT score group (p= 0.98). The median survival for patients with pleural LDH<1500 was significantly higher than for patients with pleural LDH> 1500 (p= 0.006) (30.97 vs. 16.73 months), while ECOG-PS (0 vs. 1) and NLR (<9 vs. >9) showed no differences. Conclusions: The survival in our resultant groups was higher than those reported in the original study, and the LENT score had no discriminatory ability for predicting survival in patients with MPM. We nevertheless believe that before reaching more definite conclusions, further large-scale multicenter prospective studies are needed to better define the clinical utility of the LENT score.

Evaluation of Exudative Pleural Effusions: A Multicenter, Prospective, Observational Study.

PURPOSE: The aim of this study is to determine the diagnostic performances of pleural procedures in undiagnosed exudative pleural effusions and to evaluate factors suggestive of benign or malignant pleural effusions in tertiary care centers. METHODS: This was a multicenter prospective observational study conducted between January 1 and December 31, 2018. A total of 777 patients with undiagnosed exudative pleural effusion after the initial work-up were evaluated. The results of diagnostic procedures and the patients' diagnoses were prospectively recorded. Sensitivity, specificity, and accuracy estimates with 95% confidence intervals were used to examine the performance of pleural procedures to detect malignancy. RESULTS: The mean age ± SD of the 777 patients was 62.0 ± 16.0 years, and 68.3% of them were male. The most common cause was malignancy (38.3%). Lung cancer was the leading cause of malignant pleural effusions (20.2%). The diagnostic sensitivity and accuracy of cytology were 59.5% and 84.3%, respectively. The diagnostic sensitivity of image-guided pleural biopsy was 86.4%. The addition of image-guided pleural biopsy to cytology increased diagnostic sensitivity to more than 90%. Thoracoscopic biopsy provided the highest diagnostic sensitivity (94.3%). The highest diagnostic sensitivity of cytology was determined in metastatic pleural effusion from breast cancer (86.7%). CONCLUSION: The diagnostic performance increases considerably when cytology is combined with image-guided pleural biopsy in malignant pleural effusions. However, to avoid unnecessary interventions and complications, the development of criteria to distinguish patients with benign pleural effusions is as important as the identification of patients with malignant pleural effusions.

Characteristics of our hypoxemic COVID-19 pneumonia patients receiving corticosteroids and mortality-associated factors.

BACKGROUND: COVID-19 is a disease associated with diffuse lung injury that has no proven effective treatment yet. It is thought that glucocorticoids may reduce inflammation-mediated lung injury, disease progression, and mortality. We aimed to evaluate our patient's characteristics and treatment outcomes who received corticosteroids for COVID-19 pneumonia. METHODS: We conducted a multicenter retrospective study and reviewed 517 patients admitted due to COVID-19 pneumonia who were hypoxemic and administered steroids regarding demographic, laboratory, and radiological characteristics, treatment response, and mortality-associated factors. RESULTS: Of our 517 patients with COVID-19 pneumonia who were hypoxemic and received corticosteroids, the mortality rate was 24.4% (n = 126). The evaluation of mortality-associated factors revealed that age, comorbidities, a CURB-65 score of ≥ 2, higher SOFA scores, presence of MAS, high doses of steroids, type of steroids, COVID-19 treatment, stay in the intensive care unit, high levels of d-dimer, CRP, ferritin, and troponin, and renal dysfunction were associated with mortality. CONCLUSION: Due to high starting and average steroid doses are more associated with mortality, high-dose steroid administration should be avoided. We believe that knowing the factors associated with mortality in these cases is essential for close follow-up. The use of CURB-65 and SOFA scores can predict prognosis in COVID-19 pneumonia.

Comparing effectiveness of intelligent volume-assured pressure support (iVAPS) vs bi-level positive airway pressure spontaneous/timed (BPAP S/T) for hypercapnic respiratory failure in chronic obstructive pulmonary disease.

BACKGROUND AND AIM: Intelligent volume-assured pressure support (iVAPS) is a relatively new hybrid mode of non-invasive ventilation (NIV). There is still limited evidence for iVAPS. The aim of this study was to compare the effectiveness of iVAPS to that of bi-level positive airway pressure spontaneous/timed (BPAP S/T) in patients with acute hypercapnic respiratory failure or acute-on-chronic hypercapnic respiratory failure caused by acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the emergency department. MATERIAL AND METHODS: This was an observational, retrospective study. Eighty-two patients with hypercapnic respiratory failure caused by AECOPD, who were admitted to our emergency department, were analysed. Arterial blood gas (ABG) parameters, length of hospital stay and rate of intensive care unit (ICU) admission were compared between iVAPS and BPAP S/T. RESULTS: A total of 82 patients (26 females, 56 males, mean age 68.26 ± 11.63 years) who were treated with iVAPS (N = 26) or BPAP S/T (N = 56) were enrolled. There were no significant differences between two modes with respect to demographics such as age, gender, presence of comorbidity, usage of long-term oxygen therapy or NIV, and the baseline ABG parameters. The presence of pneumonia was significantly higher in BPAP S/T (P = .01). The rate of ICU admission was 26.9% in iVAPS vs 25% in BPAP S/T. The mean length of hospital stay was 11.5 ± 12.3 days in iVAPS and 9.7 ± 7.4 days in BPAP S/T (P = .53). The mean values of ABG parameters at the 1st and 24th hours of NIV therapy did not differ in both groups. CONCLUSION: Both modes were similarly effective in the management of appropriately selected patients with hypercapnic respiratory failure caused by AECOPD. Hence, we underline that NIV mode selection in the emergency department should be performed in line with experiences of clinicians/institutions and accessibility of ventilator devices/modes.

Levels of YKL-40 in pleural effusion and blood from patients with pleuritis.

INTRODUCTION: In recent years, there have been a significant increase in the tests and biomarkers available for pleural fluid analysis. YKL-40 is one of the inflammatory biomarkers that is used for this purpose. The aim of our study is to assess the levels and diagnostic values of YKL-40 in patients with different types of pleural effusions (PE). MATERIALS AND METHODS: This was a prospective, observational and crosssectional study. Pleural and serum YKL-40 levels were measured using enzyme-linked immunosorbent assay in 119 patients with PEs, including 23 transudates PE, 47 malignant PE, 26 parapneumonic PE (PPPE), 17 paramalignant PE (PME) and 6 tuberculous PE (TBPE). RESULT: Median pleural YKL-40 level was higher in exudates (390.3 ng/mL) than in transudates (369.5 ng/mL) (p<0.02). For a cut-off level of 378 ng/mL, it was found to predict exudates with 70% sensitivity and 64% specificity. [area under the curve (AUC)= 0.660, p= 0.01]. Median pleural YKL-40 level was highest in PMEs (407.1 ng/mL) and the lowest in transudates (369.5 ng/ mL) and high levels, with a cut-off value of 396 ng/mL, differentiated PMEs from other subgroups with 65% sensitivity and 68% specificity. (AUC= 0.680, p= 0.02). Median serum YKL-40 level was the highest in PPPEs (351.4 ng/mL) and the lowest in TBPEs (114.2 ng/mL) (p= 0.01). For a cut-off level of 284 ng/mL, it differentiated PPPEs from TBPEs with 61% sensitivity and 100% specificity (AUC= 0.830, p= 0.01). In TBPEs, pleural/serum YKL-40 ratio was strongly related with pleural ADA (r= 1, p= 0.04). CONCLUSIONS: Pleural YKL-40 may be useful for differentiating exudates and detecting PMEs. Serum YKL-40 may be good diagnostic biomarker for differentiating PPPEs and TBPEs. Additionally, measuring serum and pleural YKL-40 and pleural ADA may be reliable way to diagnose TBPEs.