Serum galactomannan antigen test for the diagnosis of chronic pulmonary aspergillosis

BACKGROUND

A serum galactomannan (GM) antigen test has been widely used to diagnose invasive pulmonary aspergillosis. However, there are limited data on the use of the serum GM antigen test for the serologic diagnosis of chronic pulmonary aspergillosis (CPA).

METHODS

Data were collected from all consecutive patients with a clinical suspicion of CPA who underwent a serum GM antigen test.

RESULTS

In total, 334 patients who were suspected to have CPA were eligible for this study and 168 (50%) patients were finally diagnosed with CPA. The serum GM antigen test was positive in 38 (23%) patients with CPA and in 25 (15%) patients without CPA. The sensitivity of the serum GM antigen test was 23% (95% confidence interval [CI], 17-30%), and its specificity was 85% (95% CI, 79-90%), with positive and negative predictive values of 60% (95% CI, 47-72%) and 52% (95% CI, 46-58%), respectively. The accuracy of the test was 54%. The area under the receiver operating characteristic curve was 0.538 (95% CI, 0.496-0.580).

CONCLUSION

The serum GM antigen test could not be used for the serologic diagnosis of CPA.

The clinical, radiological, and bronchoscopic findings and outcomes in patients with benign tracheobronchial tumors

PURPOSE

We evaluated the characteristics of and treatment outcomes in patients with benign tracheobronchial tumors.

MATERIALS AND METHODS

We reviewed the records of patients with benign tracheobronchial tumors who underwent bronchoscopic intervention with mechanical removal and Nd: YAG laser cauterization, and evaluated the characteristics and treatment outcomes of 55 patients with hamartomas, leiomyomas, papillomas, typical carcinoids, or schwannomas seen between April 1999 and July 2012.

RESULTS

The most common tumors were hamartoma (n=24), leiomyoma (n=16), papilloma (n=7), typical carcinoid (n=5), and schwannoma (n=3). Forty-one patients (75%) had symptoms. On chest computed tomography, 35 patients (64%) had round or ovoid lesions, accompanied by atelectasis (n=26, 47%) or obstructive pneumonia (n=17, 31%). Fatty components (n=9, 16%) and calcifications (n=7, 13%) were observed only in hamartomas, leiomyomas, and typical carcinoids. At bronchoscopy, the typical findings were categorized according to tumor shape, surface, color, and visible vessels. Fifty (91%) patients underwent complete resection. Forty patients (73%) achieved successful bronchoscopic removal defined as complete resection without complications or recurrence. Recurrences occurred in four papillomas, one leiomyoma, and one typical carcinoid. The proportions of tumor types (p=0.029) differed between the successful and unsuccessful removal groups, and a pedunculated base (p<0.001) and no spontaneous bleeding (p=0.037) were more frequent in the successful removal group.

CONCLUSION

We described clinical, radiological, and typical bronchoscopic findings in patients with benign tracheobronchial tumors; these findings might help to differentiate such tumors. Bronchoscopic intervention was a useful treatment modality, and tumor type, pedunculated base, and vascularity may influence successful tumor removal.

Outcomes of Pneumocystis pneumonia with respiratory failure in HIV-negative patients

PURPOSE

The outcomes and predictors of mortality from Pneumocystis pneumonia (PCP) in HIV-negative patients requiring mechanical ventilation (MV) for respiratory failure were evaluated.

MATERIALS AND METHODS

This retrospective observational study enrolled 48 patients with PCP requiring MV in the medical intensive care unit (ICU). Multiple logistic regression analysis was used to identify independent predictors of in-hospital mortality.

RESULTS

The main conditions underlying the PCP were malignancies (60%) or post solid organ transplant (35%). Excluding four patients whose initial treatment was changed due to adverse reactions, 21 (44%) of 44 patients did not respond to the initial treatment. During the ICU stay, additional complications developed: shock in 22 (46%), ventilator-associated pneumonia in 16 (33%), and acute kidney injury in 15 (31%). Ultimately, 31 (65%) patients died while hospitalised. In multivariate analysis, hospital mortality was independently associated with severity of illness on ICU admission, failure of initial antimicrobial treatment for PCP, and newly developed shock during ICU stay.

CONCLUSIONS

PCP in HIV-negative patients requiring MV for respiratory failure remains a serious illness with high mortality. Failure of the initial antimicrobial treatment for PCP as well as severity of illness was independent predictors of poor outcomes.

Classification of broncholiths and clinical outcomes

BACKGROUND AND OBJECTIVE

We evaluated effective treatments of broncholithiasis based on its radiographical and bronchoscopic features.

METHODS

This retrospective study conducted at Samsung Medical Center, Korea enrolled patients who were suspected of having broncholithiasis based on chest computed tomography (CT). The broncholiths were classified as intraluminal, mixed (both intraluminal and extraluminal) and extraluminal based on chest CT and bronchoscopic findings.

RESULTS

The study enrolled 46 patients between 1995 and 2009. Symptoms included cough (n = 21, 45.7%), hemoptysis (n = 19, 41.3%) and purulent sputum (n = 11, 23.9%). Cough was more common in intraluminal boncholiths than in other type of broncholiths (P = 0.03). Based on chest CT, there were 15 (32.6%) intraluminal, 15 (32.6%) mixed and 16 (34.8%) extraluminal broncholiths. All 15 intraluminal broncholiths were removed completely via flexible (n = 2) or rigid (n = 13) bronchoscopy. For the 15 mixed broncholiths, seven (46.7%) bronchoscopic interventions were performed, but complete removal of the broncholiths was not accomplished. Six (40%) mixed and four (25%) extraluminal broncholiths were treated by surgical resection for symptom control. None of the patients who underwent surgical resection suffered morbidity or postoperative mortality.

CONCLUSIONS

The treatment of broncholithiasis should be based on chest CT and bronchoscopic findings. Intraluminal broncholiths can be removed via bronchoscopy, while surgery should be considered for symptomatic mixed or extraluminal broncholiths.

Comparison of severe healthcare-associated pneumonia with severe community-acquired pneumonia

BACKGROUND

We compared the demographic characteristics and outcomes of patients with severe healthcare-associated pneumonia (HCAP) to those with severe community-acquired pneumonia (CAP).

METHODS

This was a retrospective study of prospectively collected data from all consecutive patients with severe pneumonia who were admitted to the hospital through the emergency department between January 2008 and December 2010.

RESULTS

During the study period, 247 patients had severe pneumonia; of these, 107 had severe CAP and 140 had severe HCAP. There was no significant difference in demographic characteristics between the two groups, except for comorbidities. Although the incidence of potentially drug-resistant pathogens was higher in patients with severe HCAP than in those with severe CAP (34 vs. 6 %, P = 0.004), there was no statistically significant difference in the rate of inappropriate antibiotic treatment (16 vs. 3 %, P = 0.143). Finally, clinical outcomes, such as intensive care unit admission, length of hospital stay, and in-hospital mortality, were not different between the two groups. In a multiple logistic regression analysis, a higher PSI score (adjusted OR 1.01; 95 % CI 1.00-1.02; P = 0.024) and the need for mechanical ventilation (adjusted OR 2.62; 95 % CI 1.37-5.00; P = 0.004) were independently associated with in-hospital mortality. However, the type of pneumonia was not associated with in-hospital mortality after adjusting for potential confounding factors.

CONCLUSIONS

The severity of illness rather than the type of pneumonia might be associated with in-hospital mortality in patients with severe pneumonia.

Increasing Recovery of Nontuberculous Mycobacteria from Respiratory Specimens over a 10-Year Period in a Tertiary Referral Hospital in South Korea

Background

The number of patients with pulmonary disease caused by nontuberculous mycobacteria (NTM) has been increasing worldwide. The aim of this study was to evaluate long-term trends in the NTM recovery rate from respiratory specimens over a 10-year period in a tertiary referral hospital in South Korea.

Methods

We retrospectively reviewed the records of mycobacterial cultures of respiratory specimens at Samsung Medical Center from January 2001 to December 2011.

Results

During the study period, 32,841 respiratory specimens from 10,563 patients were found to be culture-positive for mycobacteria. These included 12,619 (38%) Mycobacterium tuberculosis and 20,222 (62%) NTM isolates. The proportion of NTM among all positive mycobacterial cultures increased from 43% (548/1,283) in 2001 to 70% (3,341/4,800) in 2011 (p<0.001, test for trend). The recovery rate of NTM isolates from acid-fast bacilli smear-positive specimens increased from 9% (38/417) in 2001 to 64% (1,284/1,997) in 2011 (p<0.001, test for trend). The proportion of positive liquid cultures was higher for NTM than for M. tuberculosis (p<0.001). The most frequently isolated NTM were Mycobacterium avium-intracellulare complex (53%) and Mycobacterium abscessus-massiliense complex (25%).

Conclusion

The recovery rate of NTM from respiratory specimens in South Korea has increased steadily.

Timing of silicone stent removal in patients with post-tuberculosis bronchial stenosis

CONTEXT:

In patients with post-tuberculosis bronchial stenosis (PTBS), the severity of bronchial stenosis affects the restenosis rate after the silicone stent is removed. In PTBS patients with incomplete bronchial obstruction, who had a favorable prognosis, the timing of stent removal to ensure airway patency is not clear.

AIMS:

We evaluated the time for silicone stent removal in patients with incomplete PTBS.

SETTINGS AND DESIGN:

A retrospective study examined PTBS patients who underwent stenting and removal of a silicone stent.

METHODS:

Incomplete bronchial stenosis was defined as PTBS other than total bronchial obstruction, which had a luminal opening at the stenotic segment on bronchoscopic intervention. The duration of stenting was defined as the interval from stent insertion to removal. The study included 44 PTBS patients and the patients were grouped at intervals of 6 months according to the duration of stenting.

RESULTS:

Patients stented for more than 12 months had a significantly lower restenosis rate than those stented for less than 12 months (4% vs. 35%, P = 0.009). Multiple logistic regression revealed an association between stenting for more than 12 months and a low restenosis rate (odds ratio 12.095; 95% confidence interval 1.097-133.377). Moreover, no restenosis was observed in PTBS patients when the stent was placed more than 14 months previously.

CONCLUSIONS:

In patients with incomplete PTBS, stent placement for longer than 12 months reduced restenosis after stent removal.

High-throughput molecular genotyping for small biopsy samples in advanced non-small cell lung cancer patients

BACKGROUND

Despite the key role of mutational analysis in targeted therapy, the difficulty in acquisition of adequate tumor tissues for molecular genotyping in advanced non-small cell lung cancer (NSCLC) has led to the need for a fast and efficient method for detecting genetic alterations for targeted therapy.

PATIENTS AND METHODS

We analyzed tissue specimens of advanced NSCLC. A mass spectrometry-based assay was used to investigate 471 oncogenic mutations. All tumor specimens were prepared from fresh-frozen tissues.

RESULTS

In total, there were 59 hotspot mutations in 67% of the entire patient group (41 out of 61 patients). The most frequent mutation was in TP53 (n=24, 39.3%), followed by EFGR (n=19, 31.1%). Others included MLH1, KRAS, PIK3CA, ERBB2, ABL1 and HRAS.

CONCLUSION

Our results suggest that molecular genotyping using high-throughput technology such as OncoMap v4 is feasible, even with small biopsied specimens from patients with advanced NSCLC.

Usefulness of endobronchial ultrasound-guided transbronchial needle aspiration for diagnosis of sarcoidosis

PURPOSE

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an accurate and minimally invasive technique used routinely for investigation of mediastinal and hilar lymphadenopathy. However, few studies have addressed its role in comparison to the traditional diagnostic approaches of transbronchial lung biopsy (TBLB), endobronchial biopsy (EBB), and bronchoalveolar lavage (BAL) in the diagnosis of sarcoidosis. We evaluated the usefulness of EBUS-TBNA in the diagnosis of sarcoidosis compared to TBLB, EBB, and BAL.

MATERIALS AND METHODS

Consecutive patients with suspected sarcoidosis (stage I and II) on chest radiography and chest computed tomography were included. All 33 patients underwent EBUS-TBNA, TBLB, EBB, and BAL during the same session between July 2009 and June 2011. EBUS-TBNA was performed at 71 lymph node stations.

RESULTS

Twenty-nine of 33 patients, were diagnosed with histologically proven sarcoidosis; two patients were compatible with a clinical diagnosis of sarcoidosis during follow-up; and two patients were diagnosed with metastatic carcinoma and reactive lymphadenopathy, respectively. Among 29 patients with histologically proven sarcoidosis in combination with EBUS-TBNA, TBLB, and EBB, only EBUS-TBNA and TBLB revealed noncaseating granuloma in 18 patients and one patient, respectively. The overall diagnostic sensitivities of EBUS-TBNA, TBLB, EBB, and BAL (CD4/CD8 ≥3.5) were 90%, 35%, 6%, and 71%, respectively (p<0.001). The combined diagnostic sensitivity of EBUS-TBNA, TBLB, and EBB was 94%.

CONCLUSION

EBUS-TBNA was the most sensitive method for diagnosing stage I and II sarcoidosis compared with conventional bronchoscopic procedures. EBUS-TBNA should be considered first for the histopathologic diagnosis of stage I and II sarcoidosis.

Additional role of second washing specimen obtained during single bronchoscopy session in diagnosis of pulmonary tuberculosis

Background

Flexible bronchoscopy with bronchial washing is a useful procedure for diagnosis of pulmonary tuberculosis (TB), when a patient cannot produce sputum spontaneously or when sputum smears are negative. However, the benefit of gaining serial bronchial washing specimens for diagnosis of TB has not yet been studied. Therefore, we conducted a retrospective study to determine the diagnostic utility of additional bronchial washing specimens for the diagnosis of pulmonary TB in suspected patients.

Methods

A retrospective analysis was performed on 174 patients [sputum smear-negative, n = 95 (55%); lack of sputum specimen, n = 79 (45%)] who received flexible bronchoscopy with two bronchial washing specimens with microbiological confirmation of pulmonary TB in Samsung Medical Center, between January, 2010 and December, 2011.

Results

Pulmonary TB was diagnosed by first bronchial washing specimen in 141 patients (81%) out of 174 enrolled patients, and an additional bronchial washing specimen established diagnosis exclusively in 22 (13%) patients. Smear for acid-fast bacilli (AFB) was positive in 46 patients (26%) for the first bronchial washing specimen. Thirteen patients (7%) were positive only on smear of an additional bronchial washing specimen. Combined smear positivity of the first and second bronchial washing specimens was significantly higher compared to first bronchial washing specimen alone [Total cases: 59 (34%) vs. 46 (26%), p < 0.001; cases for smear negative sputum: 25 (26%) vs. 18 (19%), p = 0.016; cases for poor expectoration: 34 (43%) vs. 28 (35%), p = 0.031]. The diagnostic yield determined by culture was also significantly higher in combination of the first and second bronchial washing specimens compared to the first bronchial washing. [Total cases: 163 (94%) vs. 141 (81%), p < 0.001; cases for smear negative sputum: 86 (91%) vs. 73 (77%), p < 0.001; cases for poor expectoration: 77 (98%) vs. 68 (86%), p = 0.004].

Conclusions

Obtaining an additional bronchial washing specimen could be a beneficial and considerable option for diagnosis of TB in patients with smear-negative sputum or who cannot produce sputum samples.

The relationships between tracheal index and lung volume parameters in mild-to-moderate COPD

BACKGROUND

Although elongated morphological changes in the trachea are known to be related to lung function in chronic obstructive pulmonary disease (COPD), whether the tracheal morphological changes are associated with airflow limitations or overinflation of the lung in the early stages of COPD has not yet been determined. Thus, our aim was to investigate the association of tracheal index (TI) with lung function parameters, including lung volume parameters, in COPD patients with mild-to-moderate airflow limitations.

MATERIALS AND METHODS

A retrospective study was conducted in 193 COPD patients with GOLD grades 1-2 (post-bronchodilator forced expiratory volume in 1s [FEV1] ≥ 50% predicted with FEV1/forced vital capacity ratio ≤ 70%; age range, 40-81) and 193 age- and gender-matched subjects with normal lung function as a control group (age range, 40-82). Two independent observers measured TI at three anatomical levels on chest radiographs and CT scans.

RESULTS

Compared with the control group, TI was reduced significantly and "saber-sheath trachea" was observed more frequently in COPD patients. Patients with GOLD grade 2 disease had a lower TI than those with GOLD grade 1. TI had apparent inverse correlations with total lung capacity, functional residual capacity, and residual volume, regardless of the anatomical level of the trachea. Even after adjustments for covariates, this association persisted.

CONCLUSIONS

TI is reduced even in mild-to-moderate COPD patients, and TI measured on chest CT shows significant inverse relationships with all lung volume parameters assessed, suggesting that tracheal morphology may change during the early stages of COPD.

Toxocariasis as a cause of new pulmonary infiltrates

SETTING

Patients with new pulmonary infiltrates on chest computed tomography (CT) scans at a tertiary centre in South Korea.

OBJECTIVE

To demonstrate associations among radiological changes, blood eosinophilia (E) and Toxocara (T) seropositivity.

DESIGN

We retrospectively reviewed blood eosinophilia, Toxocara seropositivity, history of raw meat intake and radiological features, and divided study patients into four groups according to blood eosinophilia and Toxocara seropositivity.

RESULTS

Among 150 patients, 62 were E- and T-positive (E+T+), 45 were E-negative and T-positive (E-T+), 7 were E-positive and T-negative (E+T-), and 36 were E- and T-negative (E-T-). History of raw meat intake was found in 95 (63%) patients. The type and number of lesions on CT did not show any significant differences among the four groups. Among 119 patients who were not diagnosed with a specific disease, transient or migrating lesions were seen in 93% of E+T+, 93% of E-T+, 80% of E+T- and 52% of E-T- patients (P < 0.0001). Furthermore, the frequencies of migrating or new lesions and improvement were significantly higher in the Toxocara-positive group (88/95, 93%) than in the Toxocara-negative group (14/24, 58%; P = 0.002).

CONCLUSION

Transient and migratory pulmonary infiltrates on chest CT scans were associated with blood eosinophilia and Toxocara seropositivity. Clinicians should consider asymptomatic toxocariasis as a cause of unexplained new pulmonary infiltrates in countries with dietary habits of raw meat intake.

EGFR and KRAS mutation analyses from specimens obtained by bronchoscopy and EBUS-TBNA

BACKGROUD

Procurement of tumor tissue is mandatory for a mutation analysis in patients with non-small cell lung cancer. The purpose of this study was to evaluate the usefulness of bronchoscopic biopsy and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy for detecting epidermal growth factor receptor (EGFR) and KRAS mutations in routine practice.

METHODS

Tumor DNA was extracted from formalin-fixed paraffin-embedded tissues, and amplifications of exons 18-21 of EGFR and codons 12, 13 and 61 of KRAS were performed using polymerase chain reaction (PCR). PCR products were subjected to direct sequencing in both directions.

RESULTS

Of 211 consecutive specimens, 201 (95.3%) were available for EGFR mutation analysis, and 196 (92.9%) were adequate for KRAS mutation analysis. EGFR and KRAS mutations were detected in 14.9% and 5.4%, respectively. A median of 16 days was spent from biopsy to the final report for either EGFR or KRAS mutation status. The detection rates for both mutations were similar between bronchoscopic biopsy and EBUS-TBNA (P > 0.05). Female gender (53.3%), never smoker (63.3%), and adenocarcinoma (96.7%) were predominant in patients with EGFR mutations. Among patients with adenocarcinoma (n = 104), the frequencies of EGFR and KRAS mutations were 27.9% and 10.6%, respectively.

CONCLUSIONS

Small tissue samples obtained by bronchoscopic biopsy and EBUS-TBNA are sufficient for detecting EGFR and KRAS mutations in routine practice. Therefore, concurrent mutational analyses of small tissue samples should be considered at the time of initial diagnosis.

Etiologies, diagnostic strategies, and outcomes of diffuse pulmonary infiltrates causing acute respiratory failure in cancer patients: a retrospective observational study

Introduction

Although previous studies have reported etiologies, diagnostic strategies, and outcomes of acute respiratory failure (ARF) in cancer patients, few studies investigated ARF in cancer patients presenting with diffuse pulmonary infiltrates.

Methods

This was a retrospective observational study of 214 consecutive cancer patients with diffuse pulmonary infiltrates on chest radiography admitted to the oncology medical intensive care unit for acute respiratory failure between July 2009 and June 2011.

Results

After diagnostic investigations including bronchoalveolar lavage in 160 (75%) patients, transbronchial lung biopsy in 75 (35%), and surgical lung biopsy in 6 (3%), the etiologies of diffuse pulmonary infiltrates causing ARF were identified in 187 (87%) patients. The most common etiology was infection (138, 64%), followed by drug-induced pneumonitis (13, 6%) and metastasis (12, 6%). Based on the etiologic diagnoses, therapies for diffuse pulmonary infiltrates were subsequently modified in 99 (46%) patients. Diagnostic yield (46%, 62%, 85%, and 100%; P for trend < 0.001) and frequency of therapeutic modifications (14%, 37%, 52%, and 100%; P for trend < 0.001) were significantly increased with additional invasive tests. Patients with therapeutic modification had a 34% lower in-hospital mortality rate than patients without therapeutic modification (38% versus 58%, P = 0.004) and a similar difference in mortality rate was observed up to 90 days (55% versus 73%, Log-rank P = 0.004). After adjusting for potential confounding factors, therapeutic modification was still significantly associated with reduced in-hospital mortality (adjusted OR 0.509, 95% CI 0.281-0.920).

Conclusions

Invasive diagnostic tests, including lung biopsy, increased diagnostic yield and caused therapeutic modification that was significantly associated with better outcomes for diffuse pulmonary infiltrates causing ARF in cancer patients.

Clinical characteristics and treatment outcomes of chronic pulmonary aspergillosis

Chronic pulmonary aspergillosis (CPA) is a relatively uncommon disease that has been poorly characterized. This study investigated the clinical features and treatment outcomes of CPA through a retrospective review of records of patients with newly diagnosed CPA between January 2008 and January 2012. A total of 70 CPA patients, which included 51 (73%) males, had a median age of 55 years. Fifty-seven patients (81%) had a history of pulmonary tuberculosis and pulmonary disease caused by nontuberculous mycobacteria (NTM) was a primary underlying condition in 32 patients (46%). Most patients (n = 66; 99%) were treated with oral itraconazole, for a median of 6.4 months. Treatment response of 73% of patients was based on alleviation of symptoms and in 44% on computed tomography. Laboratory tests improved for more than 60% of patients and overall favorable responses were achieved in 44 patients (62%). Five of the latter (11%) had to restart antifungal therapy after a median of 9.2 months after therapy. Death occurred in 10 patients (14%). This study suggested that NTM lung disease was an important risk factor for CPA development. While treatment with oral itraconazole for approximately 6 months was moderately effective in treating CPA, a more effective treatment is required.

Tracheal wall thickening is associated with the granulation tissue formation around silicone stents in patients with post-tuberculosis tracheal stenosis

PURPOSE

Tracheal restenosis due to excessive granulation tissue around a silicone stent requires repeated bronchoscopic interventions in patients with post-tuberculosis tracheal stenosis (PTTS). The current study was conducted to identify the risk factors for granulation tissue formation after silicone stenting in PTTS patients.

MATERIALS AND METHODS

A retrospective study was conducted between January 1998 and December 2010. Forty-two PTTS patients with silicone stenting were selected. Clinical and radiological variables were retrospectively collected and analyzed.

RESULTS

Tracheal restenosis due to granulation tissue formation were found in 20 patients (47.6%), and repeated bronchoscopic interventions were conducted. In multivariate analysis, tracheal wall thickness, measured on axial computed tomography scan, was independently associated with granulation tissue formation after silicone stenting. Furthermore, the degree of tracheal wall thickness was well correlated with the degree of granulation tissue formation.

CONCLUSION

Tracheal wall thickening was associated with granulation tissue formation around silicone stents in patients with post-tuberculosis tracheal stenosis.

Prognostic factors for bronchoscopic intervention in advanced lung or esophageal cancer patients with malignant airway obstruction

CONTEXT

Bronchoscopic intervention can provide immediate relief from suffocation and an opportunity for additional treatment in patients with malignant airway obstruction. However, few studies have specifically identified prognostic factors affecting the survival of advanced lung or esophageal cancer patients receiving bronchoscopic intervention.

AIMS

We aimed to investigate prognostic factors influencing survival in these patients.

STUDY DESIGN

We conducted retrospective study.

METHODS

The clinical parameters were retrospectively reviewed in 51 patients (lung cancer: n = 35; esophageal cancer: n = 16) who underwent palliative bronchoscopic interventions due to malignant airway.

RESULTS

Bronchoscopic interventions, such as mechanical removal (n = 26), stenting (n = 31), laser cauterization (n = 19), and ballooning (n = 16), were performed on intraluminal (n = 21, 41%), extrinsic (n = 8, 16%), and combined lesions (n = 22, 43%). Tracheal invasion was found in 24 patients (47%). Successful palliation was achieved in 49 patients (96%). After the intervention, additional anti-cancer treatment was followed in 24 patients (47%). The median survival time and overall survival rate were 3.4 months and 4%. Survival was increased with selected conditions, including a treatment-naïve status (hazard ratio [HR], 0.359; confidence interval [CI], 0.158-0.815; P = 0.01), an intact proximal airway (HR, 0.265; CI, 0.095-0.738; P = 0.01), and post-procedural additional treatment (HR, 0.330; CI, 0.166-0.657; P < 0.01).

CONCLUSIONS

Brochoscopic intervention could provide immediate relief and survival improvement in advanced lung or esophageal cancer patients with selected conditions such as a treatment-naïve status, an intact proximal airway, and available post-procedural additional treatment.

The impact of post-transplant hemoglobin level on renal allograft outcome

BACKGROUND

Anemia is a common complication of chronic renal disease and renal transplantation. Early post-transplant anemia is the consequence of blood loss, immunosuppressant therapy, and failure to produce sufficient erythropoietin. Late post-transplant anemia has been attributed to drug therapy, renal dysfunction, and infection. The effect of post-transplant anemia on renal allograft survival and acute rejection rates is not established. The aim of this study was to examine the impact of post-transplant anemia on renal function and allograft outcomes.

MATERIALS AND METHODS

We included 411 patients who underwent living or deceased donor renal transplantations in our center from April 1990 to March 2010. The patients were divided into 2 groups according to their postoperative hemoglobin level at 1 month: anemic group (<12.0 g/dL in men, <11.0 g/dL in women) and nonanemic group (≥ 12.0 g/dL in men, ≥ 11.0 g/dL in women). The outcome measures included postoperative serum creatinine levels at 12 and 36 months, acute and chronic rejection rates, as well as long-term graft survival.

RESULTS

The acute and chronic rejection rates were significantly higher in the anemic group: 28.1% versus 19.7% (P = .000) and 24.1% versus 19.7% (P = .027), respectively. Postoperative serum creatinine levels at 12 and 36 months were not significantly different in patients with functioning grafts regardless of their anemia status (P = .530 and P = .430, respectively). Graft survival was lower with anemia: 85.4% versus 93.8% at 5 years, and 74.8% versus 83.5% at 10 years (P = .040).

CONCLUSIONS

Post-transplant anemia was associated with poorer renal function at 12 months, higher acute rejection rates, and worse long-term renal allograft outcomes compared with subjects displaying normal hemoglobin levels.

Endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of central lung parenchymal lesions

PURPOSE

The purpose of this study was to evaluate the usefulness of convex probe endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for detecting malignancy in parenchymal pulmonary lesions located adjacent to the central airways.

MATERIALS AND METHODS

We retrospectively reviewed the diagnostic performance of EBUS-TBNA in consecutive patients with high clinical suspicion of a centrally located primary lung cancer who had undergone EBUS-TBNA at the Samsung Medical Center between May 2009 and June 2011.

RESULTS

Thirty-seven patients underwent EBUS-TBNA for intrapulmonary lesions adjacent to the central airways. Seven lesions were located adjacent to the trachea and 30 lesions were located adjacent to the bronchi. Cytologic and histologic samples obtained via EBUS-TBNA were diagnostic in 32 of 37 (86.4%) of patients. The final diagnosis was lung cancer in 30 patients (7 small cell lung cancer, 23 non-small cell lung cancer), lymphoma in one and malignant fibrous histiocytoma in one patient. The diagnostic sensitivity of EBUS-TBNA in detecting malignancy and detecting both malignancy and benignity was 91.4% and 86.5%, respectively. Two patients experienced minor complications.

CONCLUSION

EBUS-TBNA is an effective and safe method for tissue diagnosis of parenchymal lesions that lie centrally close to the airways. EBUS-TBNA should be considered the procedure of choice for patients with centrally located lesions without endobronchial involvement.

Bronchogenic cyst rupture and pneumonia after endobronchial ultrasound-guided transbronchial needle aspiration: a case report

We report a 54-year-old woman who presented with a well-defined, homogeneous, and non-enhancing mass in the retrobronchial region of the bronchus intermedius. The patient underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for histological confirmation. Serous fluid was aspirated by EBUS-TBNA. Cytological examination identified an acellular smear with negative microbiological cultures. The patient was finally diagnosed with bronchogenic cysts by chest computed tomography (CT) and EBUS-TBNA findings. However, 1 week after EBUS-TBNA, the patient developed bronchogenic cyst rupture and pneumonia. Empirical antibiotics were administered, and pneumonia from the bronchogenic cyst rupture had resolved on follow-up chest CT. To our knowledge, this is the first reported case of pneumonia from bronchogenic cyst rupture after EBUS-TBNA.

Clinical significance of the differentiation between Mycobacterium avium and Mycobacterium intracellulare in M avium complex lung disease

BACKGROUND

Mycobacterium avium and Mycobacterium intracellulare are grouped together as the M avium complex; however, little is known about the clinical impact of this species differentiation. This study compared the clinical features and prognoses of patients with M avium and M intracellulare lung disease.

METHODS

From 2000 to 2009, 590 patients were given a new diagnosis of M avium complex lung disease; 323 (55%) had M avium lung disease, and 267 (45%) had M intracellulare lung disease.

RESULTS

Compared with the patients with M avium lung disease, the patients with M intracellulare lung disease were more likely to have the following characteristics: older age (64 vs 59 years, P = .002), a lower BMI (19.5 kg/m² vs 20.6 kg/m², P < .001), respiratory symptoms such as cough (84% vs 74%, P = .005), a history of previous treatment for TB (51% vs 31%, P < .001), the fibrocavitary form of the disease (26% vs 13%, P < .001), smear-positive sputum (56% vs 38%, P < .001), antibiotic therapy during the 24 months of follow-up (58% vs 42%, P < .001), and an unfavorable microbiologic response after combination antibiotic treatment (56% vs 74%, P = .001).

CONCLUSIONS

Patients with M intracellulare lung disease exhibited a more severe presentation and had a worse prognosis than patients with M avium lung disease in terms of disease progression and treatment response. Therefore, species differentiation between M avium and M intracellulare may have prognostic and therapeutic implications.

Clinical applicability of staging small cell lung cancer according to the seventh edition of the TNM staging system

The two-stage system of limited and extensive disease has been widely employed for small cell lung cancer (SCLC). However, the International Association for the Study of Lung Cancer has proposed that the TNM classification should be incorporated into clinical practice. The purpose of this study was to evaluate the applicability of the Union for International Cancer Control (UICC) 7th TNM staging system to SCLC. We retrospectively reviewed the medical records of consecutive patients with newly diagnosed histologically proven SCLC between March 2005 and January 2010. Patients who had other concurrent malignancies or had combined-type SCLC were excluded. We assessed overall survival (OS) according to the T descriptor, N descriptor, M descriptor, and TNM stage grouping. In total, 320 SCLC patients were included. Median age was 65 years and 286 patients (89.4%) were male. Median OS was 12.7 months. There were no significant differences in OS according to the T descriptor (P = 0.880). However, there were significant differences in OS according to the N (P < 0.001) and M (P < 0.001) descriptors and TNM stage grouping (P < 0.001). Hazard ratios for OS, adjusted for known prognostic factors, differed significantly according to the N and M descriptor, and TNM stage grouping, but not according to the T descriptors. The UICC 7th TNM staging system may contribute to a more precise prognosis in SCLC patients. Further studies are required to evaluate the applicability of the TNM staging system to SCLC.

Antifactor Xa levels in critically ill Korean patients receiving enoxaparin for thromboprophylaxis: a prospective observational study

The aim of this study was to investigate antifactor Xa (aFXa) levels after once daily dose of 40 mg of enoxaparin and to evaluate factors influencing aFXa levels among Korean intensive care unit (ICU) patients. This prospective observational study was conducted between August and December 2011 in medical ICUs at Samsung Medical Center. AFXa levels between 0.1 and 0.3 U/mL were considered to be effective for antithrombotic activity. Fifty-five patients were included. The median aFXa levels were 0.22 (IQR 0.17-0.26) at 4 hr, 0.06 (IQR 0.02-0.1) at 12 hr, and 0 U/mL (IQR 0-0.03) at 24 hr. The numbers of patients showing effective antithrombotic aFXa levels were 48 (87.3%), 18 (32.7%), and 0 (0%) at 4, 12 and 24 hr, respectively. At 12 hr, higher sequential organ failure assessment (SOFA) scores and hyperbilirubinemia were significantly associated with low aFXa levels (OR, 0.58; 95% CI, 0.36-0.93; P = 0.02 and 0.06; 0.003-0.87; 0.04, respectively). Once daily dose of 40 mg of enoxaparin is inadequate for maintaining effective antithrombotic aFXa levels, and the inadequacy is more salient for patients with high SOFA scores and hyperbilirubinemia.