Performance of the galactomannan test for the diagnosis of invasive pulmonary aspergillosis using non-invasive proximal airway samples

OBJECTIVE

To diagnose invasive pulmonary aspergillosis (IPA), galactomannan (GM) detection in serum or bronchoalveolar lavage fluid (BALF) is widely used. However, the utility of proximal airway GM test (from induced sputum or tracheal aspirate) has not been well elucidated.

METHODS

In this retrospective cohort study, we evaluated the diagnostic performance of proximal airway GM in diagnosis of IPA including COVID-19 associated pulmonary aspergillosis (CAPA). Between January 2022 and January 2023, patients who had been tested for GM with clinical suspicion or for surveillance from any specimen (serum, induced sputum, tracheal aspirate, and BALF) were screened. IPA was diagnosed using EORTC/MSGERC criteria, and CAPA was diagnosed following the 2020 ECMM/ISHAM consensus criteria.

RESULTS

Of 624 patients with GM results, 70 met the criteria for proven/probable IPA and 427 had no IPA. The others included possible IPA and chronic form of aspergillosis. The sensitivities and specificities of serum, proximal airway, and BALF GM for proven/probable IPA versus no IPA were 78.9% and 70.6%, 93.1% and 78.7%, and 78.6% and 91.0%, respectively. Areas under the receiver operating characteristic curve (AUCs) were 0.742 for serum GM, 0.935 for proximal airway GM, and 0.849 for BALF GM (serum GM vs proximal airway GM, p = 0.014; proximal airway GM vs BALF GM, p = 0.334; serum GM vs BALF GM, p = 0.286).

CONCLUSION

This study demonstrates that the performance of GM test from non-invasive proximal airway samples is comparable or even better than those from serum and distal airway sample (BALF).

Prevalence of pre-existing lung diseases and their association with income level among patients with lung cancer: a nationwide population-based case-control study in South Korea

BACKGROUND

This study aimed to estimate the prevalence of pre-existing lung diseases in patients with lung cancer compared to people without lung cancer and examine the association between income levels and pre-existing lung diseases.

METHODS

Data on patients with lung cancer (case) and the general population without lung cancer (non-cancer controls) matched by age, sex and region were obtained from the Korea National Health Insurance Service-National Health Information Database (n=51 586). Insurance premiums were divided into quintiles and medicaid patients. Conditional logistic regression models were used to examine the association between pre-existing lung diseases and the risk of lung cancer. The relationship between income level and the prevalence of pre-existing lung disease among patients with lung cancer was analysed using logistic regression models.

RESULTS

The prevalence of asthma (17.3%), chronic obstructive lung disease (COPD) (9.3%), pneumonia (9.1%) and pulmonary tuberculosis (1.6%) in patients with lung cancer were approximately 1.6-3.2 times higher compared with the general population without lung cancer. A significantly higher risk for lung cancer was observed in individuals with pre-existing lung diseases (asthma: OR=1.36, 95% CI 1.29 to 1.44; COPD: 2.11, 95% CI 1.94 to 2.31; pneumonia: 1.49, 95% CI 1.38 to 1.61; pulmonary tuberculosis: 2.16, 95% CI 1.75 to 2.66). Patients with lung cancer enrolled in medicaid exhibited higher odds of having pre-existing lung diseases compared with those in the top 20% income level (asthma: OR=1.75, 95% CI 1.56 to 1.96; COPD: 1.91, 95% CI 1.65 to 2.21; pneumonia: 1.73, 95% CI 1.50 to 2.01; pulmonary tuberculosis: 2.45, 95% CI 1.78 to 3.36).

CONCLUSIONS

Pre-existing lung diseases were substantially higher in patients with lung cancer than in the general population. The high prevalence odds of pre-existing lung diseases in medicaid patients suggests the health disparity arising from the lowest income group, underscoring a need for specialised lung cancer surveillance.

Prediction Models for Mediastinal Metastasis and Its Detection by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Potentially Operable Non-Small Cell Lung Cancer: A Prospective Study

BACKGROUND

Prediction models for mediastinal metastasis and its detection by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) have not been developed using a prospective cohort of potentially operable patients with non-small cell lung cancer (NSCLC).

RESEARCH QUESTION

Can mediastinal metastasis and its detection by EBUS-TBNA be predicted with prediction models in NSCLC?

STUDY DESIGN AND METHODS

For the prospective development cohort, 589 potentially operable patients with NSCLC were evaluated (July 2016-June 2019) from five Korean teaching hospitals. Mediastinal staging was performed using EBUS-TBNA (with or without the transesophageal approach). Surgery was performed for patients without clinical N (cN) 2-3 disease by endoscopic staging. The prediction model for lung cancer staging-mediastinal metastasis (PLUS-M) and a model for mediastinal metastasis detection by EBUS-TBNA (PLUS-E) were developed using multivariable logistic regression analyses. Validation was performed using a retrospective cohort (n = 309) from a different period (June 2019-August 2021).

RESULTS

The prevalence of mediastinal metastasis diagnosed by EBUS-TBNA or surgery and the sensitivity of EBUS-TBNA in the development cohort were 35.3% and 87.0%, respectively. In PLUS-M, younger age (< 60 years and 60-70 years compared with ≥ 70 years), nonsquamous histology (adenocarcinoma and others), central tumor location, tumor size (> 3-5 cm), cN1 or cN2-3 stage by CT, and cN1 or cN2-3 stage by PET-CT were significant risk factors for N2-3 disease. Areas under the receiver operating characteristic curve (AUCs) for PLUS-M and PLUS-E were 0.876 (95% CI, 0.845-0.906) and 0.889 (95% CI, 0.859-0.918), respectively. Model fit was good (PLUS-M: Hosmer-Lemeshow P = .658, Brier score = 0.129; PLUS-E: Hosmer-Lemeshow P = .569, Brier score = 0.118). In the validation cohort, PLUS-M (AUC, 0.859 [95% CI, 0.817-0.902], Hosmer-Lemeshow P = .609, Brier score = 0.144) and PLUS-E (AUC, 0.900 [95% CI, 0.865-0.936], Hosmer-Lemeshow P = .361, Brier score = 0.112) showed good discrimination ability and calibration.

INTERPRETATION

PLUS-M and PLUS-E can be used effectively for decision-making for invasive mediastinal staging in NSCLC.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT02991924; URL: www.

CLINICALTRIALS

gov.

Long-Term Survival According to N Stage Diagnosed by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Non-Small Cell Lung Cancer

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the main procedure for mediastinal staging. However, long-term survival analyses according to cN stage diagnosed by EBUS-TBNA (abbreviated to eN stage) have not been reported. The value of EBUS-TBNA has not been assessed through an analysis of survival in false-negative EBUS-TBNA cases.

RESEARCH QUESTIONS

What is the prognostic impact of eN stage in non-small cell lung cancer (NSCLC)? What is the survival rate in false-negative EBUS-TBNA cases?

STUDY DESIGN AND METHODS

We retrospectively (January 2006-December 2011) reviewed the medical records of NSCLC patients who underwent EBUS-TBNA (± transesophageal approach) for initial staging (n=1,089). Mediastinoscopy was not performed for EBUS-TBNA negative cases. We performed 5-year survival analyses according to eN stage and treatment modality. Survival in false-negative EBUS cases was compared with that in pN0-1 patients, including 941 non-EBUS cases, during the same period.

RESULTS

Among 1,089 EBUS patients (eN0-1=681, eN2=314, eN3=94), we observed significant differences in survival between the eN stages [eN0-1 vs eN2; p <0.0001, eN2 vs eN3; p=0.0118, estimated 5-year overall survival (5YOS) rate: eN0-1=57.4%, eN2=23.2%, eN3=12.8%]. Surgery cases had better survival than non-surgery cases among eN0-1 and eN2 patients (eN0-1/surgery vs. eN0-1/no surgery; p<0.0001, eN2/surgery vs. eN2/no surgery; p<0.0001). Among eN0-1 patients, there were 55 false-negative cases (eN0-1/pN2-3, pN2=54, pN3=1). The 5YOS rates of pN0, pN1, and eN0-1/pN2-3 patients were 76.4%, 56.0% and 56.4%, respectively. eN0-1/pN2-3 patients had worse survival than pN0 patients (p=0.0061), whereas there was no significant difference compared with pN1 patients (p=0.9191).

INTERPRETATIONS

Long-term survival significantly differed according to eN stage in NSCLC, highlighting the importance of EBUS-TBNA in NSCLC staging. False-negative EBUS-TBNA cases had favorable survival which was similar to that of pN1 patients, which may provide a rationale for performing surgery after negative EBUS-TBNA results.

Increased Incidence and Associated Risk Factors of Aspergillosis in Patients with Bronchiectasis

There are insufficient data regarding the relationship between non-cystic fibrosis bronchiectasis and incident aspergillosis. We performed a population-based, matched cohort study using data from the Korean National Health Insurance database between 2003 and 2013. The incidence of aspergillosis was 50/100,000 person-years in the bronchiectasis cohort and 11/100,000 person-years in the matched cohort (subdistribution hazard ratio, 4.53; 95% confidence interval (CI), 3.25–6.32). Among the bronchiectasis cohort, chronic obstructive pulmonary disease (adjusted HR, 1.95; 95% CI, 1.07–3.57), previous pulmonary tuberculosis (adjusted HR, 3.67; 95% CI, 2.03–6.64), and non-tuberculous mycobacterial pulmonary disease (adjusted HR, 11.25; 95% CI, 1.49–85.18) increased the risk of incident aspergillosis. The incidence of aspergillosis in patients with bronchiectasis was approximately 4.5-fold that in those without bronchiectasis. Comorbid pulmonary diseases—chronic obstructive pulmonary disease, previous pulmonary tuberculosis, and non-tuberculous mycobacterial pulmonary disease—significantly increased the risk of aspergillosis in patients with bronchiectasis. Our study indicates that close monitoring is warranted for aspergillosis in patients with bronchiectasis.

Incidence of bronchiectasis concerning tuberculosis epidemiology and other ecological factors: A Korean National Cohort Study

In South Korea, the estimated incidences of bronchiectasis were 147-229 cases per 100000 with a decreasing trend. It may follow the concurrent decrease in the TB prevalence and incidence, and favourable personal and socioeconomic conditions. https://bit.ly/32UA8xH.

Lung cancer staging: State of the art in the era of ablative therapies and surgical segmentectomy

Implementation of lung cancer screening and improvements in imaging are expected to increase the proportion of lung cancer diagnosed at an early stage. The standard of care has historically been anatomic lobectomy; however, there is now an array of surgical and non-surgical approaches for management of local disease either in active use or under investigation. By their nature, these new modalities offer a theoretical trade-off of reduced morbidity in exchange for reduced efficacy in the setting of advanced disease. It is therefore critical that patients being considered for these approaches (e.g. surgical segmentectomy and SABR) be accurately staged to maximize the potential for definitive treatment. In this article, we will review current approaches to the staging of patients being considered for segmentectomy or ablation. This will serve as a foundation to highlight important questions deserving further investigation.

Views on Precision Medicine among Health Professionals in Korea: A Mixed Methods Study

This study aimed to investigate awareness, attitudes, and perspectives on precision medicine among health professionals in Korea and to identify issues that need to be addressed before implementing precision medicine. Mixed methods research was applied. For qualitative research, a semi-structured focus group interview was conducted with six health professionals. For quantitative research, a self-reported survey was administered. A total of 542 health professionals participated in the survey, and 526 completed the entire questionnaire. Health professionals showed positive attitudes toward precision medicine. About 95-96% of respondents agreed that precision medicine will be effective in treatment and precise diagnosis, and 69.9% reported that they would participate as study subjects. Meanwhile, they expressed concerns regarding educating patients and health professionals in precision medicine and developing research and data sharing infrastructure. Also, they emphasized the importance of developing precision medicine in an equitable way. Despite varying levels of awareness of precision medicine, the health professionals expressed a willingness to engage in precision medicine research, and recommended that health professionals work closely with policymakers to design precision medicine in a way that can be effectively adopted. Health professionals showed had a positive, but cautious, attitude toward precision medicine. The results of this study suggest areas to be addressed before ushering in precision medicine in Korea.

Pulmonary Tuberculosis is Associated with Elevated Risk of Lung cancer in Korea: The Nationwide Cohort Study

Objective: Although previous studies suggest that previous pulmonary tuberculosis was associated with increased risk of lung cancer. It remains controversial whether pulmonary tuberculosis is a risk factor for lung cancer. Our study was aimed to examine the association between pulmonary tuberculosis and lung cancer risk in Korean.

Methods: The Korean National Health and Nutrition Examination Survey database was linked with the Korean National Cancer Incidence Database to examine the occurrence of pulmonary tuberculosis and lung cancer. The linked databases were also merged with causes of death database of Statistics Korea. The Cox-proportional hazards model was used to estimates the hazard risk of lung cancer for Korean adults aged ≥40 years with pulmonary tuberculosis.

Results: Of 20,252 total participants, 2,640 (13.0%) had old pulmonary tuberculosis (a medical history of pulmonary tuberculosis or radiologically inactive tuberculosis). After adjusting for all covariates, the hazard ratio of lung cancer among patients with old pulmonary tuberculosis was 3.24 (95% CI, 1.87‒5.62) compared to the control group. According to smoking status, the hazard ratios of lung cancer for never smokers, ex-smokers, and current smokers among participants with old pulmonary tuberculosis were 3.52 (95% CI, 1.17‒10.63), 2.16 (95% CI, 0.89‒5.24), and 3.71 (95% CI, 1.49‒9.22) compared to the control group, respectively.

Conclusions: Korean adults with old pulmonary tuberculosis have a higher risk of lung cancer, compared to general population without pulmonary tuberculosis.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Re-biopsy in Previously Treated Lung Cancer

Purpose

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is widely used for the diagnosis and staging of lung cancer. However, evidence of its usefulness for re-biopsy in treated lung cancer, especially according to the previous treatment, is limited. We evaluated the role of EBUS-TBNA for re-biopsy and its diagnostic values in patients with different treatment histories.

Materials and Methods

We reviewed the medical records of patients who underwent EBUS-TBNA for re-biopsy of suspicious recurrent or progressive lesions between January 2006 and December 2016 at the National Cancer Center in South Korea. Patients were categorized into three groups based on the previous treatment modalities: surgery, radiation, and palliation.

Results

Among the 367 patients (surgery, n=192; radiation, n=40; palliation, n=135) who underwent EBUS-TBNA for re-biopsy, the overall sensitivity, negative predictive value (NPV), and diagnostic accuracy of EBUS-TBNA in detecting malignancy were 95.6%, 82.7%, and 96.3%, respectively. The sensitivity was lower in the radiation group (83.3%) when compared with the surgery (95.7%, p=0.042) and palliation (97.7%, p=0.012) groups. The NPV was lower in the palliation group (50.0%) than in the surgery group (88.5%, p=0.042). The sample adequacy of EBUS-TBNA specimens was lower in the radiation group (80.3%) than in the surgery (95.4%, p < 0.001) or palliation (97.8%, p < 0.001) groups. EGFR mutation analysis was feasible in 94.6% of the 92 cases, in which mutation analysis was requested. There were no major complications. Minor complications were reported in 12 patients (3.3%).

Conclusion

EBUS-TBNA showed high diagnostic values and high suitability for EGFR mutation analysis with regard to re-biopsy in patients with previously treated lung cancer. The sensitivity was lower in the radiation group and NPV was lower in the palliation group. The complication rate was low.

WITHDRAWN:The Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Re-biopsy in Previously Treated Lung Cancer

Ahead of Print article withdrawn by publisher.

Lung Cancer Screening with Low-Dose CT in Female Never Smokers: Retrospective Cohort Study with Long-term National Data Follow-up

Purpose

Because of growing concerns about lung cancer in female never smokers, chest low-dose computed tomography (LDCT) screening is often performed although it has never shown clinical benefits. We examinewhether or not female never smokers really need annual LDCT screening when the initial LDCT showed negative findings.

Materials and Methods

This retrospective cohort study included 4,365 female never smokers aged 40 to 79 years who performed initial LDCT from Aug 2002 to Dec 2007. Lung cancer diagnosis was identified from the Korea Central Cancer Registry Database registered until December 31, 2013. We calculated the incidence, cumulative probability, and standardized incidence ratio (SIR) of lung cancer by Lung Imaging Reporting and Data System (Lung-RADS) categories showed on initial LDCT.

Results

After median follow-up of 9.69 years, 22 (0.5%) had lung cancer. Lung cancer incidence for Lung-RADS category 4 was 1,848.4 (95% confidence interval [CI], 1,132.4 to 3,017.2) per 100,000 person-years and 16.4 (95% CI, 7.4 to 36.4) for categories 1, 2, and 3 combined. The cumulative probability of lung cancer for category 4 was 10.6% at 5 years and 14.8% at 10 years while they were 0.07% and 0.17% when categories 1, 2, and 3 were combined. The SIR for subjects with category 4 was 43.80 (95% CI, 25.03 to 71.14), which was much higher than 0.47 (95% CI, 0.17 to 1.02) for categories 1, 2, and 3 combined.

Conclusion

Considering the low risk of lung cancer development in female never smokers, it seems unnecessary to repeat annual LDCT screening for at least 5 years or even longer unless the initial LDCT showed Lung-RADS category 4 findings.

Prognostic Differences in Subgroups of Patients With Surgically Resected T3 Non-Small Cell Lung Cancer

BACKGROUND

This study determined the characteristics and prognosis of each descriptor of T3 non-small cell lung cancer (NSCLC).

METHODS

A total of 3,241 patients underwent an operation for NSCLC between 2001 and 2013, and this study included 461 patients who received complete anatomic resection of T3 NSCLC. The T3 descriptors were coded as follows: tumor invading main bronchus within 2 cm of the carina (T3-cent), tumor invading beyond visceral pleura (T3-inv), tumor larger than 7 cm (T3-size), separate tumor nodules (T3-sep), or tumor with combined T3 descriptors (T3-comb).

RESULTS

The T3 distribution was as follows: T3-cent, 75 patients (16.3%); T3-inv, 157 patients (34.1%); T3-size, 132 patients (28.6%); T3-sep, 34 patients (7.4%); and T3-comb, 63 patients (13.7%). Subgroup analyses revealed a significant survival benefit in the T3-cent group compared with the other groups (all p < 0.05). The 5-year disease-free survival (DFS) values were 55.4%, 36.7%, 40.9%, 30.3%, and 32.0% in the T3-cent, T3-inv, T3-size, T3-sep, and T3-comb subgroups, respectively. Multivariable analyses revealed that age (p = 0.019), N status (p = 0.001), adjuvant chemotherapy (p < 0.001), and T3 descriptors (T3-cent versus others, p < 0.001) were the most important independent prognostic factors for DFS. Additional analyses were performed to evaluate prognostic factors for DFS in the T3-cent group. Multivariable analysis revealed that bronchoplastic procedures (p = 0.004) was an independent prognostic factor for DFS.

CONCLUSIONS

Survival for centrally located T3 NSCLC is better than other types of T3 NSCLC. Lung-preserving operations such as bronchoplastic procedures might result in improved survival of these patients.

Guideline for the acquisition and preparation of conventional and endobronchial ultrasound-guided transbronchial needle aspiration specimens for the diagnosis and molecular testing of patients with known or suspected lung cancer

RATIONALE

Conventional transbronchial needle aspiration (TBNA) and endobronchial ultrasound (EBUS)-TBNA are widely accepted tools for the diagnosis and staging of lung cancer and the initial procedure of choice for staging. Obtaining adequate specimens is key to provide a specific histologic and molecular diagnosis of lung cancer.

OBJECTIVES

To develop practice guidelines on the acquisition and preparation of conventional TBNA and EBUS-TBNA specimens for the diagnosis and molecular testing of (suspected) lung cancer. We hope to improve the global unification of procedure standards, maximize the yield and identify areas for research.

METHODS

Systematic electronic database searches were conducted to identify relevant studies for inclusion in the guideline [PubMed and the Cochrane Library (including the Cochrane Database of Systematic Reviews)].

MAIN RESULTS

The number of needle aspirations with both conventional TBNA and EBUS-TBNA was found to impact the diagnostic yield, with at least 3 passes needed for optimal performance. Neither needle gauge nor the use of miniforceps, the use of suction or the type of sedation/anesthesia has been found to improve the diagnostic yield for lung cancer. The use of rapid on-site cytology examination does not increase the diagnostic yield. Molecular analysis (i.e. EGFR, KRAS and ALK) can be routinely performed on the majority of cytological samples obtained by EBUS-TBNA and conventional TBNA. There does not appear to be a superior method for specimen preparation (i.e. slide staining, cell blocks or core tissue). It is likely that optimal specimen preparation may vary between institutions depending on the expertise of pathology colleagues.

Technical aspects of endobronchial ultrasound-guided transbronchial needle aspiration

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is becoming a standard method for invasive mediastinal staging and for the diagnosis of paratracheal and peribronchial lesions. It is essential to understand the technical aspects of EBUS-TBNA to ensure safe and efficient procedures. In this review, we discuss the practical aspects to be considered during EBUS-TBNA, including anesthesia, manipulation of equipment, understanding mediastinal ultrasound images, target selection, number of aspirations needed per target, sample handling, and complications.

A case of capecitabine-induced sarcoidosis

Sarcoidosis is an inflammatory disease involving multiple-organs with an unknown cause. The new onset of sarcoidosis associated with therapeutic agents has been observed in 3 clinical settings; tumor necrosis factor antagonists in autoimmune rheumatologic diseases, interferon alpha with or without ribavirin in patients with chronic hepatitis C or melanoma, and antineoplastic agent-associated sarcoidosis in patients with hematologic malignancies. Here, we report a female patient who developed sarcoidosis after capecitabine treatment as an adjuvant chemotherapy for sigmoid colon cancer. To our knowledge, this is the first report of a capecitabine-induced sarcoidosis.

Respiratory Review of 2012: Bronchoscopic Innovations and Advances

Recent advances in bronchoscopy have led to changes in clinical diagnostics and therapeutics in pulmonary medicine. In diagnostic bronchoscopy, there have also been new developments in endobronchial ultrasound technology which may be incorporated into clinical practice in the near future. Functional bronchoscopy, which evaluates information such as airway pressure, airflow, or gas exchange, suggests promising clinical advances in the near future. In therapeutic bronchoscopy, bronchoscopic volume reduction is a novel approach for the treatment of severe emphysema. In this review, seven recently published articles representing current advances in bronchoscopy are summarized and discussed.

Transbronchial and transesophageal fine-needle aspiration using an ultrasound bronchoscope in mediastinal staging of potentially operable lung cancer

OBJECTIVE

We performed this study to evaluate the role of transesophageal endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA) following endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the mediastinal staging of lung cancer.

METHODS

In this prospective study, we applied transbronchial and transesophageal ultrasonography using an ultrasound bronchoscope on patients with confirmed or strongly suspected potentially operable non-small cell lung cancer. Following EBUS-TBNA, EUS-B-FNA was used for mediastinal nodes that were inaccessible or difficult to access by EBUS-TBNA. The accessibility by EBUS-TBNA and EUS-B-FNA to mediastinal nodal stations having at least one node ≥ 5 mm was also checked.

RESULTS

In 150 patients, we performed EBUS-TBNA and EUS-B-FNA on 299 and 64 mediastinal nodal stations, respectively. Among 143 evaluable patients, EBUS-TBNA diagnosed mediastinal metastasis in 38 patients. EUS-B-FNA identified mediastinal metastasis in three additional patients. Surgery diagnosed mediastinal metastasis in four more patients. The sensitivity, negative predictive value, and diagnostic accuracy of EBUS-TBNA in the detection of mediastinal metastasis were 84.4%, 93.3%, and 95.1%, respectively. These values for the combined approach of EBUS-TBNA and EUS-B-FNA increased to 91.1%, 96.1%, and 97.2%, respectively, although the differences were not statistically significant (P = .332, P = .379, and P = .360, respectively). Among 473 mediastinal nodal stations having at least one node ≥ 5 mm that were evaluated, the proportion of accessible mediastinal nodal stations by EBUS-TBNA was 78.6%, and the proportion increased to 84.8% by combining EUS-B-FNA with EBUS-TBNA (P = .015).

CONCLUSION

Following EBUS-TBNA in the mediastinal staging of potentially operable lung cancer, the accessibility to mediastinal nodal stations increased by adding EUS-B-FNA and an additional diagnostic gain might be obtained by EUS-B-FNA.

TRIAL REGISTRATION

clinicaltrials.gov, NCT00741247.

Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of lung cancer

PURPOSE

We performed this study to evaluate the role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the pathologic diagnosis of lung cancer including lung masses as well as lymph nodes as targets.

METHODS

We retrospectively reviewed 126 patients who underwent EBUS-TBNA to diagnose radiologically suspected lung cancer. The patients had masses or lymph nodes that were highly suspicious for malignancy and accessible by EBUS-TBNA.

RESULTS

EBUS-TBNA was performed on 195 lesions (lymph nodes, n=151; lung masses, n=44). In 61 cases, other diagnostic methods had failed previous to EBUS-TBNA. In 118 patients, no definite endobronchial mucosal tumor invasion was observed. In eight patients with endobronchial tumor invasion, EBUS-TBNA was chosen due to tumor bleeding, necrosis, or difficult location for endobronchial biopsy. EBUS-TBNA confirmed 105 lung cancers, five other malignancies and six specific benign cases, demonstrating a diagnostic yield of 92.1% (116/126). Nine cases were diagnosed by other methods (lung cancer, n=2; other malignancies, n=2; benign cases, n=5). One case that was not confirmed by any diagnostic method was considered false negative. The sensitivity and diagnostic accuracy of EBUS-TBNA in the diagnosis of lung cancer were 97.2% (105/108) and 97.6% (123/126), respectively.

CONCLUSIONS

EBUS-TBNA targeting lymph nodes or masses highly suspicious for malignancy demonstrated high diagnostic value in the diagnosis of lung cancer. EBUS-TBNA is recommended for these cases, especially when other diagnostic methods have failed or are difficult.

Transoesophageal needle aspiration using a convex probe ultrasonic bronchoscope

BACKGROUND AND OBJECTIVE

Although endoscopic ultrasound-guided fine needle aspiration can be helpful when combined with bronchoscopic procedures, endoscopic ultrasound-guided fine needle aspiration is not available as a conjunctive procedure with bronchoscopy at many institutions. This study evaluated the feasibility and the additional role of transoesophageal fine needle aspiration using a convex probe ultrasonic bronchoscope (EUS-B-FNA).

METHODS

We analysed 84 patients who underwent EUS-B-FNA between Oct 2007 and May 2008. Bronchoscopy and/or endobronchial ultrasound-guided transbronchial needle aspiration was performed on 83 patients prior to EUS-B-FNA.

RESULTS

EUS-B-FNA was performed on 89 lesions (1.7 aspirations/lesion) including three lung masses and 86 lymph nodes (nodal stations 1, 3P, 4L, 5, 7, 8, 9 and 10L) without complication. Sample adequacy was 95.4% for each aspiration and 100% for each lesion. Of the 89 lesions, 39 malignant lesions were confirmed by EUS-B-FNA. EUS-B-FNA provided additional diagnostic gain to bronchoscopic procedures in 16 patients (19.0%): 3 lung cancers were upstaged, 11 lung cancers were pathologically confirmed, and 2 patients were diagnosed with mediastinal metastasis from an extrathoracic malignancy. This gain was obtained by the sampling of inaccessible (n = 4) or difficult lesions by endobronchial ultrasound-guided transbronchial needle aspiration (n = 2) or when bronchoscopy was difficult due to dyspnoea, cough, brain metastasis or other conditions (n = 10).

CONCLUSIONS

EUS-B-FNA is a technically feasible and safe procedure, which may be an alternative to endoscopic ultrasound-guided fine needle aspiration as a procedure that complements bronchoscopy. Additional diagnostic yield can be obtained by combining EUS-B-FNA with bronchoscopic procedures.

Genetic polymorphisms in the Rb-binding zinc finger gene RIZ and the risk of lung cancer

Histone methyltransferase (HMT) enzymes that methylate the lysine of histones are involved in chromatin-mediated gene expression. Previously, we reported that a novel polymorphism of SUV39H2, the HMT that is required for the methylation of H3-K9, was associated with an increased risk of lung cancer in Koreans. The retinoblastoma protein-interacting zinc finger gene RIZ (PRDM2) is also a member of a histone/protein-methyltransferase superfamily, and the inactivation of RIZ in many cancers was detected as frameshift mutations, hypermethylation and missense mutations. In this study, we show the association of RIZ polymorphisms with the risk of lung cancer. In a hospital-based study of 335 lung cancer patients and 335 age- and gender-matched healthy controls, 120 polymorphisms of RIZ were screened. Of the 120 genotyped single nucleotide polymorphisms (SNPs), 42 SNPs were selected for the statistical analysis based on their frequency (>5%) and linkage disequilibrium [LD; only a representative SNP was analyzed if there were absolute LDs (r2 = 1)]; this resulted in three LD blocks. The +92337G>A and +95701C>A polymorphisms showed a statistically significant association with the reduced risk of lung adenocarcinomas after correcting the P values for multiple testing [for carrying one variant allele versus none, adjusted odds ratio (aOR) = 0.55 (95% CI = 0.38-0.78), corrected P = 0.04; aOR = 0.54 (95% CI = 0.38-0.77), corrected P = 0.02, respectively]. One haplotype (Ht5) in LD block 3 of RIZ was significantly associated with the reduced risk of lung adenocarcinomas (aOR = 0.28, 95% CI = 0.13-0.58) as well as overall lung cancer (aOR = 0.50, 95% CI = 0.30-0.82). This study suggested that RIZ polymorphisms may be important predictive markers for lung cancer susceptibility.

Combined effects of genetic polymorphisms in six selected genes on lung cancer susceptibility

Various molecular epidemiological studies have been performed to find genetic etiology for lung cancer. Particularly, genetic polymorphisms in NAD(P)H-quinone oxidoreductase (NQO1), cytochrome P450 (CYP)1A1, myeloperoxidase (MPO), glutathione-S-transferase (GST)P1, GSTT1, and GSTM1, and have been suspected to affect lung cancer risk. However, there was no study that examined the combined effects of these genes on lung cancer risk. We studied the combined genetic effects on lung cancer risk in 671 Korean subjects including 318 lung cancer patients and 353 controls. They filled questionnaires, which included lifestyle and childhood- and current environment data. Based on single nucleotide polymorphisms and gene deletions, genetic polymorphisms of the above six genes were determined with PCR-RFLP and TaqMan methods. As results, genetic polymorphisms in the GSTP1, MPO, and CYP1A1 among the genetic factors showed associations with lung cancer risk. The reference, which is supposed to have the lowest risk for cancer, was subjects who were homozygous wild type of the GSTP1 and CYP1A1 and had the MPO- mutant allele. After combination study of the three gene-polymorphism, the subjects who were most different with the reference, i.e. had the mutant allele of the GSTP1 and CYP1A1 and homozygous wild type of the MPO, showed approximately 5-fold-higher risk for lung cancer than the reference (95% CI, 2.05-12.05). Therefore, our study suggests that the combination of the GSTP1, MPO, and CYP1A1 variations affects susceptibility to lung cancer.

Novel polymorphisms in the SUV39H2 histone methyltransferase and the risk of lung cancer

Histone H3 lysine 9 (H3-K9) methylation and DNA methylation are important features of mammalian heterochromatin. Suppressor of variegation 3-9 homolog 2 (SUV39H2) is the histone methyltransferase that is required to methylate H3-K9, leading to transcriptional repression or silencing of target genes. In this study, we investigated the association of SUV39H2 polymorphisms and the risk of lung cancer. From the results of PCR direct sequencing, eight single nucleotide polymorphisms (SNPs) of SUV39H2 were identified in Korean population. In a hospital-based study of 346 lung cancer patients and 423 healthy controls, a novel SNP in the 3'-UTR of SUV39H2 (1624 G-->C) was associated with a statistically significant increase in lung cancer risk. Compared to the G/G genotype, genotypes with 1624C allele (G/C + C/C) significantly increased the susceptibility to lung cancer with adjusted odds ratio (AOR) of 2.63 (95% confidence interval (CI)= 1.10-6.29) for ever-smokers, especially in the older age group (age >or=55 years). Specifically, the variant genotype of 1624SNP was significantly associated with an increased risk of squamous cell carcinoma (AOR, 3.52; 95% CI = 1.13-9.45) in the older age group, while no significant association was found in patients with other histology. This study provided the first evidence that a novel SUV39H2 polymorphism may be an important predictive marker for lung cancer susceptibility for the smokers.

Low-dose steroid therapy at an early phase of postoperative acute respiratory distress syndrome

BACKGROUND

The acute respiratory distress syndrome (ARDS) that develops after thoracic surgery is usually lethal. The use of corticosteroids to treat ARDS has been the subject of great controversy.

METHODS

Therefore we compared conventional therapy with early low-dose steroid therapy in the treatment of postoperative ARDS. Methylprednisolone was given daily as an intravenous push every 6 hours and was changed to a single oral dose or discontinued, with a loading dose of 2 mg/kg followed by 2 mg/kg per day.

RESULTS

Over 2.5 years, 523 major thoracic operations were performed with postoperative ARDS developing in 20 patients (3.8%), of which 8 were treated with conventional therapy and 12 with early low-dose steroid therapy. Early low-dose steroid therapy significantly reduced postoperative mortality, with 7 patients (58.3%) recovering without mechanical ventilation.

CONCLUSIONS

We believe this is the first clinical study of low-dose methylprednisolone at an early phase of postoperative ARDS. The beneficial effects of the use of early low-dose steroids in ARDS are consistent with the hypothesis that fibroproliferation is an early response to lung injury, which is inhibited by early low-dose steroid therapy without disturbing operative wound healing.

Weekly Docetaxel in Combination With Capecitabine in Patients With Metastatic Gastric Cancer

Docetaxel (T) and capecitabine (X) are active agents against gastric cancer with synergistic antitumor effects. We conducted the current phase II study to assess the response rate and toxicity of combination TX regimen in patients with metastatic gastric cancer. Eligible patients were treated with docetaxel (36 mg/m2 intravenously) on days 1 and 8 and capecitabine (1000 mg/m2 orally twice a day) on days 1-14 of a 3-week schedule until progression occurred. From December 2001 to May 2003, 55 patients with median age of 54 years (range, 22-73 years) were enrolled; 47 patients had measurable lesions. A total of 358 courses of treatment were given, with a median of 5 (range, 1-22+) per patient. Objective responses were documented in 19 of 47 patients with measurable lesions (response rate, 40.4%; 95% confidence interval [CI], 25.9-54.9), with the median response duration of 5.6 months (range, 2.1-13.6+). At a median follow up of 15.9 months for all of 55 study patients, the median time to progression and survival were 4.5 months (95% CI, 3.4-5.6) and 12.0 months (95% CI, 7.5-16.6), respectively. Hematologic toxicities were mild to moderate, and the observed grade 3 nonhematologic toxicities, the most frequent of which was stomatitis, were generally manageable. Four patients experienced pneumonitis, but all of them responded to steroid treatment. The TX regimen was relatively well tolerated and effective against metastatic gastric cancer, with the added advantage of being an outpatient regimen.

Dose-volumetric parameters for predicting severe radiation pneumonitis after three-dimensional conformal radiation therapy for lung cancer

PURPOSE

To retrospectively evaluate dose-volumetric parameters for association with risk of severe (grade >/=3) radiation pneumonitis (RP) in patients after three-dimensional (3D) conformal radiation therapy for lung cancer.

MATERIALS AND METHODS

The study was approved by the institutional review board, which did not require informed consent. Data from 76 patients (66 men, 10 women; median age, 60 years; range, 35-79 years) with histologically proved lung cancer treated curatively with 3D conformal radiation therapy between August 2001 and October 2002 were retrospectively analyzed. Twenty patients underwent surgery before radiation therapy; 57 patients received chemotherapy. Median total radiation dose of 60 Gy (range, 54-66 Gy) was delivered in 30 (range, 27-33) fractions over 6 weeks. RP was scored by using Radiation Therapy Oncology Group criteria. Clinical parameters were analyzed. Dose-volumetric parameters analyzed were percentage of lung volume that received a dose of 20 Gy or more (V20), 30 Gy or more (V30), 40 Gy or more (V40), or 50 Gy or more (V50); mean lung dose (MLD); normal tissue complication probability (NTCP); and total dose. Fisher exact test was performed to compare clinical parameters between patients who developed severe RP and those who did not. Univariate and multivariate logistic regression analyses were performed to evaluate data for association between dose-volumetric parameters and severe RP. Pearson chi(2) test was used to assess data for correlations among dose-volumetric parameters. P < or = .05 was considered to indicate statistically significant difference.

RESULTS

Of 76 patients, 30 (39%) did not develop RP; 23 (30%) developed RP of grade 1; 11 (14%), grade 2; 11 (14%), grade 3; and 1 (1%), grade 4. None had grade 5 RP. Age (< 60 vs > or =60), sex, Karnofsky performance status (< 70 vs > or =70), forced expiratory volume in 1 second, presence of weight loss, preexisting lung disease, history of thoracic surgery, and history of chemotherapy did not significantly differ between patients who developed severe RP and those who did not. In univariate analyses, MLD, V20, V30, V40, V50, and NTCP were associated with severe RP (P < .05). In multivariate analysis, MLD was the only variable associated with severe RP.

CONCLUSION

MLD is a useful indicator of risk for development of severe RP after 3D conformal radiation therapy in patients with lung cancer.

Right heart dysfunction in post-tuberculosis emphysema

SETTING

University-affiliated general hospital.

OBJECTIVE

To evaluate the pump performance of right heart before and after exercise in post-tuberculosis emphysema.

DESIGN

In patients with post-tuberculosis or primary emphysema (similar lung volumes), body plethysmography, arterial blood gas analysis and echocardiography were performed at rest and after exercise. Right heart pump performance was evaluated with the ejection fraction.

RESULTS

At rest, in post-tuberculosis emphysema, diffusing capacity (mean +/- SE 72.7 +/- 3.9 vs. 91.0 +/- 7.1% of reference) and right ventricular ejection fraction (57.5 + 1.4 vs. 61.3 +/- 1.2%) were lower and PaCO2 (42.7 +/- 1.1 vs. 38.6 +/- 0.7 mmHg) was higher, while lung compliance, airway resistance, PaO2, and alveolar-arterial oxygen difference were not different. After exercise, PaO2 (65.6 +/- 2.8 vs. 80.5 +/- 3.5 mmHg) and right ventricular ejection fraction (51.2 +/- 2.4 vs. 59.6 +/- 1.7%) were lower and PaCO2 (47.0 +/- 1.5 vs. 40.9 +/- 1.5 mmHg) was higher in post-tuberculosis emphysema, whereas alveolar-arterial oxygen difference was not different. PaCO2 and alveolar-arterial oxygen difference increased, and PaO2 and right ventricular ejection fraction decreased in post-tuberculosis emphysema, while they did not significantly change in primary emphysema.

CONCLUSION

In post-tuberculosis emphysema, the impairment of gas exchange was more serious. Global assessment should be focused on right heart dysfunction which might be more affected than in primary emphysema.

NF-kappaB activation is related to the resistance of lung cancer cells to TNF-alpha-induced apoptosis

In diverse cell types, NF-kappaB transcription factors have been shown to have a role in regulating the apoptotic program, either as essential for the induction of apoptosis or, perhaps more commonly, as blockers of apoptosis. We investigated the role of NF-kappaB activation in the TNF-alpha-mediated apoptosis in lung cancer cells. TNF-alpha-resistant NCI-H157 cells became sensitized to TNF-alpha by prior treatment with cycloheximide, suggesting the presence of newly synthesized antiapoptotic protein(s). We next evaluated whether the transcription of antiapoptotic protein(s) depends on the activation of NF-kappaB. NF-kappaB activation was blocked by either adenovirus-mediated overexpression of IkappaBalpha superrepressor or pretreatment with proteasome inhibitor, MG132. Both methods of blocking NF-kappaB activation enhanced TNF-alpha-induced apoptosis in NCI-H157 cells. These results suggest that NF-kappaB activation confers resistance to TNF-alpha-mediated apoptosis in lung cancer cells.