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Yu C, Li T, Yang X, Xin L, Zhao Z, Yang Z, Zhang R. The maximal contrast-enhanced range of CT for differentiating the WHO pathological subtypes and risk subgroups of thymic epithelial tumors. Br J Radiol 2023; 96:20221076. [PMID: 37486626 PMCID: PMC10546431 DOI: 10.1259/bjr.20221076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 07/01/2023] [Accepted: 07/11/2023] [Indexed: 07/25/2023] Open
Abstract
OBJECTIVE To explore the value of maximal contrast-enhanced (CEmax) range using contrast-enhanced CT (CECT) imaging in differentiating the pathological subtypes and risk subgroups of thymic epithelial tumors (TETs). METHODS The pre-treatment-CECT images of 319 TET patients from May 2012 to November 2021 were analyzed retrospectively. The CEmax was defined as the maximum difference between the CT value of the solid tumor on pre-contrast and contrast-enhanced images. The mean CEmax value was calculated at three different tumor levels. RESULTS There was a significant difference in the CEmax among the eight main pathological subtypes [types A, AB, B1, B2, and B3 thymoma, thymic carcinoma (TC), low-grade neuroendocrine tumor (NET) and high-grade NET] (p < 0.001). Among the eight subtypes, the CEmax values of types A, AB, and low-risk NET were higher than those of the other subtypes (all p < 0.001), and there was no difference among types B1-B3 and high-risk NET (all p > 0.05). There was no difference for CEmax values between NET and TC (p = 0.491). For the risk subgroups, the CEmax of TC (including NET) was 35.35 ± 11.41 HU, which was lower than that of low-risk thymoma (A and AB) (57.73±21.24 HU) (P < 0.001) and was higher than that of high-risk thymoma (B1-B3) (27.37±8.27 HU) (P < 0.001). The CEmax cut-off values were 38.5 HU and 30.5 HU respectively (AUC: 0.829 and 0.712; accuracy, 72.4% and 67.7%). CONCLUSION The tumor CEmax on CECT helps differentiate the pathological subtypes and risk subgroups of TETs. ADVANCES IN KNOWLEDGE In this study, an improved simplified risk grouping method was proposed based on the traditional (2004 edition) simplified risk grouping method for TETs. If Type B1 thymoma is classified as high-risk, radiologists using this improved method may improve the accuracy in differentiating risk level of TETs compared with the traditional method.
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Affiliation(s)
- Chunhai Yu
- Department of Radiology, Cancer Hospital Affiliated to Shanxi Medical University, Shanxi Province Cancer Hospital, Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Taiyuan, China
| | - Ting Li
- Department of Nephrology, Taiyuan People's Hospital, Taiyuan, China
| | - Xiaotang Yang
- Department of Radiology, Cancer Hospital Affiliated to Shanxi Medical University, Shanxi Province Cancer Hospital, Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Taiyuan, China
| | - Lei Xin
- Department of Radiology, Cancer Hospital Affiliated to Shanxi Medical University, Shanxi Province Cancer Hospital, Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Taiyuan, China
| | - Zhikai Zhao
- Department of Radiology, Cancer Hospital Affiliated to Shanxi Medical University, Shanxi Province Cancer Hospital, Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Taiyuan, China
| | - Zhao Yang
- Department of Radiology, Cancer Hospital Affiliated to Shanxi Medical University, Shanxi Province Cancer Hospital, Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Taiyuan, China
| | - Ruiping Zhang
- First Hospital of Shanxi Medical University, Taiyuan, China
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Huang YY, Liu X, Liang SH, Hu Y, Ma GW. Prognostic value of preoperative C-reactive protein to albumin ratio in patients with thymic epithelial tumors: a retrospective study. BMC Cancer 2022; 22:1183. [PMCID: PMC9670652 DOI: 10.1186/s12885-022-10234-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 10/25/2022] [Indexed: 11/18/2022] Open
Abstract
Background The C-reactive protein to albumin ratio (CAR) is associated with poor prognosis in various cancers. However, its value in thymic epithelial tumors remains to be elucidated, we aimed to evaluate the prognostic significance of preoperative CAR in patients with surgically resected thymic epithelial tumors (TETs). Methods We retrospectively collected data from 125 patients with TETs who underwent thymoma resection at our center. The best cutoff values for the continuous variable, CAR, were obtained using X-tile software. Univariate and multivariate Cox regression analyses were used to evaluate CAR as an independent predictor of overall survival (OS) and recurrence-free survival (RFS). Kaplan–Meier analysis and log-rank tests were used to present risk stratification of patients based on CAR and the Glasgow-prognostic-score (GPS). The prognostic effect of CAR was assessed using a receiver operating characteristic curve. Results Patients were categorized into high (≥ 0.17) and low (< 0.17) CAR groups according to the optimal cutoff value of 0.17. Univariate and multivariate analyses showed that CAR was an independent predictor of prognosis. World health organization stage, CAR level, GPS score, and drinking history were important independent prognostic factors for OS (p < 0.05). T stage, CAR level, and drinking history were important independent prognostic factors for RFS (p < 0.05). The area under the curve value of CAR to predict prognosis was 0.734 for OS and 0.680 for RFS. Conclusions Elevated preoperative CAR was independently associated with poor OS and RFS after thymectomy. Therefore, CAR may be a valuable biomarker for the postoperative prognosis of TETs. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-10234-x.
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Affiliation(s)
- Yang-Yu Huang
- grid.12981.330000 0001 2360 039XState Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China ,grid.5379.80000000121662407Faculty of Biology, Medicine and Health, School of Biological Sciences, The University of Manchester, Manchester, UK
| | - Xuan Liu
- grid.12981.330000 0001 2360 039XState Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Shen-Hua Liang
- grid.12981.330000 0001 2360 039XState Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yu Hu
- grid.12981.330000 0001 2360 039XState Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Guo-Wei Ma
- grid.12981.330000 0001 2360 039XState Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
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Ruan GT, Ge YZ, Xie HL, Hu CL, Zhang Q, Zhang X, Tang M, Song MM, Zhang XW, Liu T, Li XR, Zhang KP, Yang M, Li QQ, Chen YB, Yu KY, Braga M, Cong MH, Wang KH, Barazzoni R, Shi HP. Association Between Systemic Inflammation and Malnutrition With Survival in Patients With Cancer Sarcopenia-A Prospective Multicenter Study. Front Nutr 2022; 8:811288. [PMID: 35198586 PMCID: PMC8859438 DOI: 10.3389/fnut.2021.811288] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 12/31/2021] [Indexed: 12/21/2022] Open
Abstract
Objective Systemic inflammation and malnutrition are correlated with cancer sarcopenia and have deleterious effects on oncological outcomes. However, the combined effect of inflammation and malnutrition in patients with cancer sarcopenia remains unclear. Methods We prospectively collected information on 1,204 patients diagnosed with cancer sarcopenia. the mean (SD) age was 64.5 (11.4%) years, and 705 (58.60%) of the patients were male. The patients were categorized into the high advanced lung cancer inflammation index (ALI) group (≥18.39) and the low ALI group (<18.39) according to the optimal survival cut-off curve. We selected the optimal inflammation marker using the C-index, decision curve analysis (DCA), and a prognostic receiver operating characteristic curve. Univariate and multivariate survival analyses were performed to determine the prognostic value of the optimal inflammation indicator. We also analyzed the association between inflammation and malnutrition in patients with cancer. Results The C-index, DCA, and prognostic area under the curve of ALI in patients with cancer sarcopenia were higher or better than those of neutrophil-lymphocyte ratio (NLR), prognostic nutritional index (PNI), systemic immune-inflammation index (SII), and platelet-lymphocyte ratio (PLR). The prognosis for patients in the low ALI group was worse than that of patients in the high ALI group [HR (95%CI) = 1.584 (1.280–1.959), P < 0.001]. When the ALI was divided into quartiles, we observed that decreased ALI scores strongly correlated with decreased overall survival (OS). Patients with both a low ALI and severe malnutrition (vs. patients with high ALI and well-nourished) had a 2.262-fold death risk (P < 0.001). Subgroup analysis showed a significant interactive association between the ALI and death risk in terms of TNM stage (P for interaction = 0.030). Conclusions The inflammation indicator of the ALI was better than those of the NLR, PNI, SII, and PLR in patients with cancer sarcopenia. Inflammation combined with severe malnutrition has a nearly 3-fold death risk in patients with cancer sarcopenia, suggesting that reducing systemic inflammation, strengthening nutritional intervention, and improving skeletal muscle mass are necessary.
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Affiliation(s)
- Guo-Tian Ruan
- Department of Gastrointestinal Surgery/Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Cancer Food for Special Medical Purposes (FSMP) for State Market Regulation, Beijing, China
| | - Yi-Zhong Ge
- Department of Gastrointestinal Surgery/Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Cancer Food for Special Medical Purposes (FSMP) for State Market Regulation, Beijing, China
| | - Hai-Lun Xie
- Department of Gastrointestinal Surgery/Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Cancer Food for Special Medical Purposes (FSMP) for State Market Regulation, Beijing, China
| | - Chun-Lei Hu
- Department of Gastrointestinal Surgery/Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Cancer Food for Special Medical Purposes (FSMP) for State Market Regulation, Beijing, China
| | - Qi Zhang
- Department of Gastrointestinal Surgery/Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Cancer Food for Special Medical Purposes (FSMP) for State Market Regulation, Beijing, China
| | - Xi Zhang
- Department of Gastrointestinal Surgery/Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Cancer Food for Special Medical Purposes (FSMP) for State Market Regulation, Beijing, China
| | - Meng Tang
- Department of Gastrointestinal Surgery/Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Cancer Food for Special Medical Purposes (FSMP) for State Market Regulation, Beijing, China
| | - Meng-Meng Song
- Department of Gastrointestinal Surgery/Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Cancer Food for Special Medical Purposes (FSMP) for State Market Regulation, Beijing, China
| | - Xiao-Wei Zhang
- Department of Gastrointestinal Surgery/Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Cancer Food for Special Medical Purposes (FSMP) for State Market Regulation, Beijing, China
| | - Tong Liu
- Department of Gastrointestinal Surgery/Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Cancer Food for Special Medical Purposes (FSMP) for State Market Regulation, Beijing, China
| | - Xiang-Rui Li
- Department of Gastrointestinal Surgery/Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Cancer Food for Special Medical Purposes (FSMP) for State Market Regulation, Beijing, China
| | - Kang-Ping Zhang
- Department of Gastrointestinal Surgery/Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Cancer Food for Special Medical Purposes (FSMP) for State Market Regulation, Beijing, China
| | - Ming Yang
- Department of Gastrointestinal Surgery/Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Cancer Food for Special Medical Purposes (FSMP) for State Market Regulation, Beijing, China
| | - Qin-Qin Li
- Department of Gastrointestinal Surgery/Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Cancer Food for Special Medical Purposes (FSMP) for State Market Regulation, Beijing, China
| | - Yong-Bing Chen
- Department of Gastrointestinal Surgery/Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Cancer Food for Special Medical Purposes (FSMP) for State Market Regulation, Beijing, China
| | - Kai-Ying Yu
- Department of Gastrointestinal Surgery/Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Cancer Food for Special Medical Purposes (FSMP) for State Market Regulation, Beijing, China
| | - Marco Braga
- Department of Surgery, San Raffaele Hospital, Milan, Italy
| | - Ming-Hua Cong
- Comprehensive Oncology Department, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kun-Hua Wang
- Department of Surgery, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Rocco Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Han-Ping Shi
- Department of Gastrointestinal Surgery/Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.,Key Laboratory of Cancer Food for Special Medical Purposes (FSMP) for State Market Regulation, Beijing, China
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Valdivia D, Cheufou D, Fels B, Puhlvers S, Mardanzai K, Zaatar M, Weinreich G, Taube C, Theegarten D, Stuschke M, Schuler M, Stamatis G, Hegedus B, Aigner C. Potential Prognostic Value of Preoperative Leukocyte Count, Lactate Dehydrogenase and C-Reactive Protein in Thymic Epithelial Tumors. Pathol Oncol Res 2021; 27:629993. [PMID: 34257595 PMCID: PMC8262211 DOI: 10.3389/pore.2021.629993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 03/25/2021] [Indexed: 11/18/2022]
Abstract
Thymic epithelial tumors are the most common mediastinal tumors. Surgery is the mainstay of treatment and complete resection provides the best survival rate. However, advanced tumors often require multimodality treatment and thus we analyzed the prognostic potential of routine circulating biomarkers that might help to risk-stratify patients beyond tumor stage and histology. Preoperative values for white blood cell count (WBC), C-reactive protein (CRP) and lactate dehydrogenase (LDH) were analyzed in 220 thymic epithelial tumor patients operated between 1999 and 2018. Increased CRP levels (>1 mg/dl) were significantly more often measured in thymic carcinoma and neuroendocrine tumors when compared to thymoma. LDH serum activity was higher in thymic neuroendocrine tumors when compared to thymoma or thymic carcinoma. The median disease specific survival was significantly longer in thymoma cases than in thymic carcinoma and neuroendocrine tumors. Increased preoperative LDH level (>240 U/L) associated with shorter survival in thymus carcinoma (HR 4.76, p = 0.0299). In summary, higher CRP associated with carcinoma and neuroendocrine tumors, while LDH increased primarily in neuroendocrine tumors suggesting that biomarker analysis should be performed in a histology specific manner. Importantly, preoperative serum LDH might be a prognosticator in thymic carcinoma and may help to risk stratify surgically treated patients in multimodal treatment regimens.
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Affiliation(s)
- Daniel Valdivia
- Department of Thoracic Surgery, University Medicine Essen-Ruhrlandklinik, University Duisburg-Essen, Essen, Germany
| | - Danjouma Cheufou
- Department of Thoracic Surgery, University Medicine Essen-Ruhrlandklinik, University Duisburg-Essen, Essen, Germany
| | - Benjamin Fels
- Department of Thoracic Surgery, University Medicine Essen-Ruhrlandklinik, University Duisburg-Essen, Essen, Germany
| | - Stephan Puhlvers
- Department of Thoracic Surgery, University Medicine Essen-Ruhrlandklinik, University Duisburg-Essen, Essen, Germany
| | - Khaled Mardanzai
- Department of Thoracic Surgery, University Medicine Essen-Ruhrlandklinik, University Duisburg-Essen, Essen, Germany
| | - Mohamed Zaatar
- Department of Thoracic Surgery, University Medicine Essen-Ruhrlandklinik, University Duisburg-Essen, Essen, Germany
| | - Gerhard Weinreich
- Department of Pulmonology, University Medicine Essen-Ruhrlandklinik, University Duisburg-Essen, Essen, Germany
| | - Christian Taube
- Department of Pulmonology, University Medicine Essen-Ruhrlandklinik, University Duisburg-Essen, Essen, Germany
| | - Dirk Theegarten
- Department of Pathology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Martin Stuschke
- Department of Radiation Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - Martin Schuler
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - Georgios Stamatis
- Department of Thoracic Surgery, University Medicine Essen-Ruhrlandklinik, University Duisburg-Essen, Essen, Germany.,German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - Balazs Hegedus
- Department of Thoracic Surgery, University Medicine Essen-Ruhrlandklinik, University Duisburg-Essen, Essen, Germany
| | - Clemens Aigner
- Department of Thoracic Surgery, University Medicine Essen-Ruhrlandklinik, University Duisburg-Essen, Essen, Germany.,German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
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5
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Okuma Y, Ko R, Shukuya T, Tateishi K, Imai H, Iwasawa S, Miyauchi E, Kojima T, Fujita Y, Hino T, Yamanda S, Suzuki T, Fukuizumi A, Sakakibara T, Harada T, Morita S, Kobayashi K, Nukiwa T, Takahashi K. Prognostic factors for patients with metastatic or recurrent thymic carcinoma receiving palliative-intent chemotherapy. Lung Cancer 2020; 148:122-128. [PMID: 32890794 DOI: 10.1016/j.lungcan.2020.08.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/25/2020] [Accepted: 08/16/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Thymic malignancies are a model of rare cancer. However, little clinical data is available based on the large database. We aimed to clarify the prognostic factors, particularly the metastatic sites, for thymic malignancies using one of the largest, representative, multi-institutional databases, the NEJ023 database. PATIENTS AND METHODS Patients with Stage IVA/IVB or recurrent thymic carcinoma were enrolled between 1995 and 2014. Clinicopathologic information was evaluated, and the patients were subdivided according to the metastatic organs of involvement (serosal dissemination, liver, lymph node, pulmonary, and bone metastasis). A Kaplan-Meier analysis and multivariate Cox regression were used to evaluate survival. RESULTS Two hundred and seventy-nine patients with metastases and a predominantly squamous histology (66.7%) were included. Most patients (53.0%) had serosal dissemination, whereas 26.5%, 21.9%, 19.7%, and 15.8% had pulmonary, lymph node, bone and liver metastases, respectively. Over a median follow-up time of 21.5 months, the median overall survival (mOS) was 30.7 months. When the subjects were grouped according to involved metastatic sites, patients with more than 3 involved metastatic organs had the worst survival outcome. Among patients with isolated involvement, those with bone metastasis had the poorest survival, followed by patients with liver metastasis. Subjects with hypoalbuminemia also had poor survival outcomes. When patients treated with platinum and anthracycline-containing pharmacotherapy were compared with those treated with platinum and non-anthracycline-containing pharmacotherapy, no significant difference was observed. Bone metastasis (P = 0.0005), liver metastasis (P = 0.047), and hypoalbuminemia (P = 0.0021) were identified as prognostic factors in a multivariate analysis. CONCLUSION The site of metastatic involvement affects the survival outcomes of patients with thymic carcinoma, and this result may reflect the sensitivity of metastatic sites to pharmacotherapy. As a next step, controlling liver metastasis with pharmacotherapy could help to improve the prognosis of patients with thymic carcinoma.
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Affiliation(s)
- Yusuke Okuma
- Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo, Japan; Department of Thoracic Oncology and Respiratory Medicine, Tokyo Metropolitan Cancer and Infectious disease Center Komagome Hospital, Tokyo, Japan.
| | - Ryo Ko
- Department of Respiratory Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Takehito Shukuya
- Department of Respiratory Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Kazunari Tateishi
- First department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hisao Imai
- Division of Respiratory Medicine, Gunma Prefectural Cancer Center, Ohta, Japan; Department of Respiratory Medicine, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Shunichiro Iwasawa
- Department of Respirology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Eisaku Miyauchi
- Department of Respiratory Medicine, Tohoku University Hospital, Sendai, Japan
| | - Tetsuya Kojima
- Department of Respiratory Medicine, KKR Sapporo Medical Center, Sapporo, Japan
| | - Yuka Fujita
- Department of Respiratory Medicine, Asahikawa Medical Center, Asahikawa, Japan
| | - Toshihiko Hino
- Department of Respiratory Medicine, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Shinsuke Yamanda
- Department of Thoracic Surgery, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Japan
| | - Toshiro Suzuki
- Department of Respiratory Medicine, Iwate Prefectural Isawa Hospital, Oshu, Japan
| | - Aya Fukuizumi
- Department of Thoracic Oncology, Saitama Cancer Center, Saitama, Japan .; Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | | | - Toshiyuki Harada
- Center for Respiratory Diseases, JCHO Hokkaido Hospital, Sapporo, Japan
| | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kunihiko Kobayashi
- Department of Respiratory Medicine, Saitama Medical University International Medical Center, Hidaka, Japan
| | | | - Kazuhisa Takahashi
- Department of Respiratory Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
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