Brief communication: body composition and hidden obesity in people living with HIV on antiretroviral therapy

BACKGROUND

Increased incidence of lifestyle diseases as side-effects of antiretroviral therapy (ART) have been reported in people living with HIV (PLWH). Few studies have evaluated obesity and hidden obesity in Japanese PLWH and their association with ART. In order to provide more appropriate drug selection and lifestyle guidance, we investigated the relationship between the effects of HIV infection and ART on the body composition of Japanese PLWH.

METHODS

PLWH who visited the outpatient clinic and had body composition measured using the body composition analyzer InBody 570 were included in this study. Medications, comorbidities, and blood test data were obtained. Body mass index (BMI), body fat percentage, and skeletal muscle mass index (SMI) were measured.

RESULTS

In this study, 543 patients were included. Based on body shape, patients were classified into a thin group (13), normal weight group (14), hidden obesity group (158), apparent obesity group (14), and obesity group (218). Compared with the normal weight group, the hidden obesity group had a higher prevalence of comorbidities and a lower SMI.

CONCLUSIONS

PLWH are more likely to have obesity than the general population, indicating that hidden obesity is common even among those with a normal BMI. It is important to measure body fat percentage along with body weight, as hidden obesity can be missed. Further investigation of the effects of ART on body composition is needed.

Simulation analysis of EGFR mutation detection: Oncomine Dx target test and AmoyDx panel impact on lung cancer treatment decisions

Lung cancer is a leading cause of cancer-related deaths worldwide. Epidermal growth factor receptor (EGFR) driver mutations are crucial for treatment decisions for patients with non-small cell lung cancer (NSCLC). This study aimed to assess the differences in EGFR mutation detection between two companion diagnostic (CDx) tests-the Oncomine Dx Target Test (ODxTT) and the AmoyDx Pan Lung Cancer PCR Panel-and their impact on treatment applicability. To this end, we used an in-house targeted sequencing dataset of 282 samples from 127 EGFR-mutated NSCLC patients to simulate the concordance between the EGFR variants targeted by the ODxTT and AmoyDx panel, the oncogenicity of the variants, and their therapeutic potential. Of the 216 EGFR mutations identified by the in-house panel, 51% were detectable by both CDx tests, 3% were specific to ODxTT, and 46% were not targeted by either test. Most non-targeted mutations did not have oncogenicity and were located outside exons 18-21. Notably, 95% of the mutations detectable by both tests had potential oncogenicity. Furthermore, among the 96 patients harboring actionable EGFR mutations, 97% had mutations detectable by both CDx tests and 1% by ODxTT, while 2% had mutations not covered by either test. These findings suggest that while both CDx tests are effective in detecting almost all actionable EGFR mutations, ODxTT provides slightly broader coverage. These results emphasize the importance of selecting appropriate CDx tests to inform treatment decisions for EGFR-positive NSCLC patients.

Correlation between the Closure Time of Patent Ductus Arteriosus in Preterm Infants and Long-Term Neurodevelopmental Outcome

In patent ductus arteriosus (PDA) in preterm infants, the relationship between treatment timing and long-term developmental prognosis remains unclear. The purpose of this study was to clarify the relationship between the age in days when ductus arteriosus closure occurred and long-term development. Preterm infants with a birth weight of less than 1500 g who were admitted to our NICU over a period of 9 years (2011-2019) and were diagnosed with PDA were included. A new version of the K-type developmental test for corrected ages of 1.5 and 3 years was used as an index of development. The relationship between the duration of PDA and the developmental index was evaluated using Pearson's correlation coefficient, and multiple regression analysis was performed. Development quotient (DQ) at the ages of 1.5 and 3 years showed a correlation with the PDA closure date and the standard deviation (SD) value of the term birth weight. Multiple regression analysis showed a positive correlation of the DQ at 1.5 and 3 years with the SD value of the term birth weight and a negative correlation with the PDA closure date. In addition, a stronger correlation was found in the "posture/motor" sub-item at 3 years. On the other hand, the analysis including preterm infants without PDA showed that preterm infants with PDA closure on the 6th day or later after birth had a significantly lower 3-year-old DQ than preterm infants with a PDA exposure within 5 days. In conclusion, it is suggested that the decrease in cerebral blood flow due to PDA in preterm infants has an adverse effect on long-term neurodevelopment. Appropriate interventions, including surgical treatment for PDA in preterm infants without delay, ideally within 5 days of birth, may be effective in improving the developmental prognosis.

Combination of the platelet-to-lymphocyte ratio and fibrinogen may predict 5-year overall survival of patient in non-small cell lung cancer treated with surgery

Background

Non-small cell lung cancer (NSCLC) is a major type of lung cancer with high incidence and mortality. Systemic inflammatory response (SIR) and an imbalance of the coagulation system are both associated with the tumor progression. However, few studies have investigated the prognostic utility of a combination of inflammation and the coagulation system in NSCLC. The combination of platelet-to-lymphocyte ratio (PLR) and fibrinogen (FIB) (PLR-FIB; defined as PLR × FIB) is an indicator reflecting SIR and coagulation concurrently, which have potentiality to predict prognosis of NSCLC.

Methods

This retrospective, single-center study included 314 NSCLC patients with surgery. According to a cutoff value for the PLR-FIB, we divided participants into a low-PLR-FIB group and a high-PLR-FIB group. We retrospectively collected the data on 314 patients and used univariate and multivariate analyses to investigate the relationship between the PLR-FIB and survival.

Results

Univariate analysis showed that adenosquamous carcinoma (ASC) (P=0.002), high PLR-FIB (P=0.023), and tumor-node-metastasis (TNM) stage III-IV (P<0.001) were associated with a poor outcome. On multivariate analysis, low PLR-FIB [hazard ratio (HR), 0.587; 95% confidence interval (CI): 0.359-0.985; P=0.044], and TNM stage I-II (HR, 0.380; 95% CI: 0.245-0.590; P<0.001) were independent factors of a better prognosis. ASC type was an independent prognostic factor of poor outcome (HR, 5.513; 95% CI: 1.895-16.034; P=0.002). There were no significant differences in patient demographics or clinical characteristics between the two PLR-FIB groups (P>0.05). The 5-year overall survival (OS) rates were 80.8% and 67.9% for the low-PLR-FIB group and high-PLR-FIB group, respectively (P=0.02).

Conclusions

Preoperative PLR-FIB was found to be an independent prognostic factor for 5-year overall survival in patients with NSCLC treated with surgery.

Histiocytic sarcoma of the palate: a case report

Histiocytic sarcoma is a malignant proliferation of cells that exhibit morphological and immunophenotypic features of mature histiocytes. Owing to its rarity, its clinical features and standard treatment have not yet been established. This report describes a case of histiocytic sarcoma of the palate that developed in a 76-year-old man, the first report of an intraoral histiocytic sarcoma. An extended resection was performed; however, establishing the excision line was extremely difficult because assessing the tumour boundary on imaging was challenging and the tumour underwent dynamic gross morphological changes following biopsy. Complete resection is required to obtain a favourable prognosis for high-grade tumours with indistinct borders. In this case, an intraoperative rapid examination with frozen section analysis was performed along the planned excision line to completely resect the tumours exhibiting such behaviour. At 28 months postoperatively, the patient demonstrated no recurrence or metastasis; however, he is under careful monitoring.

International expert consensus on diagnosis and treatment of lung cancer complicated by chronic obstructive pulmonary disease

Background

Lung cancer combined by chronic obstructive pulmonary disease (LC-COPD) is a common comorbidity and their interaction with each other poses significant clinical challenges. However, there is a lack of well-established consensus on the diagnosis and treatment of LC-COPD.

Methods

A panel of experts, comprising specialists in oncology, respiratory medicine, radiology, interventional medicine, and thoracic surgery, was convened. The panel was presented with a comprehensive review of the current evidence pertaining to LC-COPD. After thorough discussions, the panel reached a consensus on 17 recommendations with over 70% agreement in voting to enhance the management of LC-COPD and optimize the care of these patients.

Results

The 17 statements focused on pathogenic mechanisms (n=2), general strategies (n=4), and clinical application in COPD (n=2) and lung cancer (n=9) were developed and modified. These statements provide guidance on early screening and treatment selection of LC-COPD, the interplay of lung cancer and COPD on treatment, and considerations during treatment. This consensus also emphasizes patient-centered and personalized treatment in the management of LC-COPD.

Conclusions

The consensus highlights the need for concurrent treatment for both lung cancer and COPD in LC-COPD patients, while being mindful of the mutual influence of the two conditions on treatment and monitoring for adverse reactions.

Nucleic Acid Quality Assessment is Critical to the Success of the Oncomine Dx Target Test for Lung Cancer

BACKGROUND AND OBJECTIVE

The Oncomine Dx Target Test (ODxTT) has been used as a companion diagnostic test for lung cancer. Here, we evaluated whether the amount of nucleic acid and the degree of RNA degradation are related to the success of the ODxTT.

METHODS

This study included 223 samples from 218 patients with lung cancer. For all samples, DNA and RNA concentrations were quantified using Qubit, and the degree of RNA degradation was evaluated using the Bioanalyzer.

RESULTS

Of the 223 samples, 219 samples were successfully analyzed in the ODxTT and four were not. DNA analysis failed in two samples, which were attributed to low DNA concentrations and both were cytology specimens. Meanwhile, RNA analysis failed in the other two samples. These samples had sufficient amounts of RNA, but it was highly degraded with DV200 (the percentage of RNA fragments > 200 base pairs) less than 30. Compared with RNA samples with DV200 ≥ 30, analysis of RNA with DV200 < 30 yielded significantly fewer reads for the internal control genes. This test showed actionable mutations were identified in 38% (83/218) of all patients and in 46.6% (76/163) of patients with lung adenocarcinoma.

CONCLUSIONS

DNA concentration and degree of RNA degradation are key factors determining the success of diagnostic testing by the ODxTT.

Impact of the FilmArray Rapid Multiplex PCR Assay on Clinical Outcomes of Patients with Bacteremia

Bacteremia is a serious disease with a reported mortality of 30%. Appropriate antibiotic use with a prompt blood culture can improve patient survival. However, when bacterial identification tests based on conventional biochemical properties are used, it takes 2 to 3 days from positive blood culture conversion to reporting the results, which makes early intervention difficult. Recently, FilmArray (FA) multiplex PCR panel for blood culture identification was introduced to the clinical setting. In this study, we investigated the clinical impact of the FA system on decision making for treating septic diseases and its association with patients' survival. Our hospital introduced the FA multiplex PCR panel in July 2018. In this study, blood-culture-positive cases submitted between January and October 2018 were unbiasedly included, and clinical outcomes before and after the introduction of FA were compared. The outcomes included (i) the duration of use of broad-spectrum antibiotics, (ii) the time until the start of anti-MRSA therapy to MRSA bacteremia, and (iii) sixty-day overall survival. In addition, multivariate analysis was used to identify prognostic factors. In the FA group, overall, 122 (87.8%) microorganisms were concordantly retrieved with the FA identification panel. The duration of ABPC/SBT use and the start-up time of anti-MRSA therapy to MRSA bacteremia were significantly shorter in the FA group. Sixty-day overall survival was significantly improved by utilizing FA compared with the control group. In addition, multivariate analysis identified Pitt score, Charlson score, and utilization of FA as prognostic factors. In conclusion, FA can lead to the prompt bacterial identification of bacteremia and its effective treatment, thus significantly improving survival in patients with bacteremia.

A case of breast milk-acquired cytomegalovirus infection in an extremely low birth weight infant

INTRODUCTION

Although breast milk is considered the optimal nutrition for infants, it is also the primary cause of postnatal cytomegalovirus (CMV) infection. Preterm infants with postnatal CMV infections are susceptible to a variety of life-threatening conditions.

CASE SUMMARY

Twin male infants were delivered via emergency caesarian section at 27 weeks' gestation secondary to maternal complete uterine rupture. The Apgar scores at 1 and 5 min were 1 and 1 for the older twin (Twin A) and 0 and 3 for the younger twin (Twin B). Their birth weights were 1203 g (+ 0.65SD) and 495 g (- 3.79SD) respectively. On day 41, laboratory blood test results for Twin B showed a moderate elevation in C-reactive protein (CRP), thrombocytopenia. CMV quantitative polymerase chain reaction (qPCR) tests in Twin B's urine and blood as well as in the mother's breast milk were positive, but stored, dried umbilical cord CMV qPCR tests were negative. Twin B was diagnosed with a postnatal CMV infection secondary to infected breast milk and ganciclovir was commenced on day 52. Treatment was switched to valganciclovir at 74 days of age, but a negative CMV-DNA level in the blood was not achieved. Postnatal CMV infection in this infant led to an exacerbation of pre-existing bronchopulmonary dysplasia (BPD) and he demised at 182 days of age.

CONCLUSION

Postnatal cytomegalovirus infections may lead to exacerbations of BPD. Early use of raw breast milk in preterm infants should be done with careful consideration of this potential complication.

Reduced Autophagy in Aged Trigeminal Neurons Causes Amyloid β Diffusion

The relationship between oral health and the development of Alzheimer's disease (AD) in the elderly is not yet well understood. In this regard, the association between aging or neurodegeneration of the trigeminal nervous system and the accumulation of amyloid-β(1-42) (Aβ₄₂) oligomers in the pathogenesis of AD is unknown. We focused on selective autophagy in the trigeminal mesencephalic nucleus (Vmes) and the diffusion of Aβ₄₂ oligomers with respect to aging of the trigeminal nervous system and whether the degeneration of Vmes neurons affects the diffusion of Aβ₄₂ oligomers. We used female 2- to 8-mo-old transgenic 3xTg-AD mice and App^NL-G-F knock-in mice and immunohistochemically examined aging-related changes in selective autophagy and Aβ₄₂ oligomer processing in the Vmes, which exhibits high amyloid-β (Aβ) expression. We induced degeneration of Vmes neurons by extracting the maxillary molars and examined the changes in Aβ₄₂ oligomer kinetics. Autophagosome-like membranes, which stained positive for Aβ, HO-1, and LC3B, were observed in Vmes neurons of 3xTg-AD mice, while there was weak immunoreactivity of the membranes for intraneuronal Aβ in App^NL-G-F mice. By contrast, there was strong immunopositivity for extracellular Aβ₄₂ oligomers with the formation of Aβ₄₂ oligomer clusters in App^NL-G-F mice. The expression of Rubicon, which indicates age-related deterioration of autophagy, increased the diffusion of Aβ₄₂ oligomer with the age of Vmes neurons. Tooth extraction increased the extracellular immunopositivity for Aβ₄₂ oligomers in App^NL-G-F mice. These results suggest that autophagy maintains homeostasis in Vmes neurons and that deterioration of autophagy due to aging or neurodegeneration leads to the diffusion of Aβ₄₂ oligomers into the extracellular space and possibly the development of AD.

Deep targeted sequencing of cytological tumor cells using whole genome amplification

BACKGROUND

Genomic profiling in lung cancer is essential for precision medicine. Cytological specimens provide an alternative to formalin-fixed paraffin-embedded (FFPE) samples for comprehensive genomic analysis. However, this approach remains challenging when a limited number of tumor cells are available. We applied whole genome amplification (WGA) to cytology specimens to overcome this limitation.

METHODS

Using a lung cancer panel targeting 58 genes, we performed next-generation sequencing of whole genome-amplified DNA extracted from cytological specimens containing 10-20 tumor cells (cyto-WGA) and DNA from corresponding FFPE tumor tissue. We compared sequencing data from cyto-WGA and FFPE samples to examine the detection accuracy of copy number variations and oncogenic and drug-matched variants.

RESULTS

The DNA quality and quantity from cyto-WGA were higher than those from FFPE samples (p < .0005 and p < .05, respectively). Sequencing metrics of cyto-WGA and FFPE tissues showed no difference in the number of mapped reads and mean coverage depth, but there were significant differences in the on-target rate (p < .05) and uniformity (p < .0005). Copy number variations in cyto-WGA samples (n = 211) were higher than in FFPE samples (n = 9) (p < .0001). Fourty nine oncogenic variants were detected in cyto-WGA and 39 in FFPE. Of these variants, 34 (63%) were present in both samples. In addition, all 16 drug-matched variants were detected in FFPE and cyto-WGA samples with 100% concordance.

CONCLUSION

Cyto-WGA can be a feasible and alternative method to detect oncogenic and drug-matched variants.

Safety and efficacy of immunotherapy rechallenge following checkpoint inhibitor-related pneumonitis in advanced lung cancer patients: a retrospective multi-center cohort study

BACKGROUND

Checkpoint inhibitor-related pneumonitis (CIP) induced by immune checkpoint inhibitors (ICIs) is one of the most fatal immune-related adverse events (irAE). However, only limited data are available on rechallenge with ICIs after CIP. We evaluated the efficacy and safety of rechallenge after CIP in patients with advanced lung cancer to identify the potential populations that would benefit.

METHODS

We conducted a multicenter retrospective study of advanced lung cancer patients who received further ICI treatment (rechallenge) or did not undergo re-administration after grade ≥1 CIP between May 2017 and May 2021. Progression-free survival (PFS) and overall survival (OS) were estimated from first or second ICI initiation to disease progression (PFS1 and PFS2, respectively), death, or last follow-up (OS1 and OS2, respectively). The recurrence of CIP and new irAEs in these patients after ICI rechallenge were calculated.

RESULTS

Among 107 patients afflicted with CIP, 45 (42.1%) received ICI rechallenge. Multivariate analysis showed that severe grade (grades ≥3) and ground-glass opacity of pneumonitis lesions were negatively associated with rechallenge. Following rechallenge, 9 (20.0%) patients developed recurrent pneumonitis, and 11 (24.4%) developed a new irAE. Severe grade of CIP and poor performance status at initial CIP as well as levels of interleukin (IL)-6 and C-reactive protein (CRP), and absolute white blood cell and neutrophil counts at the time of ICI rechallenge were associated with a higher recurrence rate. The median (95% confidence interval) PFS1 and PFS2 were 17.9 (9.9-24.2) and 15.5 (5.5-25.6) months, respectively. The median (95% confidence interval) OS1 and OS2 were 23.5 (16.5-30.5) and 18.4 (10.1-26.7) months, respectively. Lower OS2 was observed in patients with severe grade of CIP and poor performance status at the initial CIP, recurrence of CIP, and in patients with high levels of CRP and IL-6 at rechallenge. Only IL-6 was found to affect OS2 on multivariate analysis.

CONCLUSIONS

ICI rechallenge following CIP may be a promising treatment for patients with advanced lung cancer, particularly in those with low-grade of CIP and good performance status at initial CIP, and low levels of IL-6 and CRP at the time of initial challenge. Prospective studies are needed for further verification.

Proposed clinical phases for the improvement of personalized treatment of checkpoint inhibitor–related pneumonitis

Background

Checkpoint inhibitor–related pneumonitis (CIP) is a lethal immune-related adverse event. However, the development process of CIP, which may provide insight into more effective management, has not been extensively examined.

Methods

We conducted a multicenter retrospective analysis of 56 patients who developed CIP. Clinical characteristics, radiological features, histologic features, and laboratory tests were analyzed. After a comprehensive analysis, we proposed acute, subacute, and chronic phases of CIP and summarized each phase’s characteristics.

Results

There were 51 patients in the acute phase, 22 in the subacute phase, and 11 in the chronic phase. The median interval time from the beginning of CIP to the different phases was calculated (acute phase: ≤4.9 weeks; subacute phase: 4.9~13.1 weeks; and chronic phase: ≥13.1 weeks). The symptoms relieved from the acute phase to the chronic phase, and the CIP grade and Performance Status score decreased (P<0.05). The main change in radiologic features was the absorption of the lesions, and 3 (3/11) patients in the chronic phase had persistent traction bronchiectasis. For histologic features, most patients had acute fibrinous pneumonitis in the acute phase (5/8), and most had organizing pneumonia in the subacute phase (5/6). Other histologic changes advanced over time, with the lesions entering a state of fibrosis. Moreover, the levels of interleukin-6, interleukin-10 and high-sensitivity C-reactive protein (hsCRP) increased in the acute phase and decreased as CIP progressed (IL-6: 17.9 vs. 9.8 vs. 5.7, P=0.018; IL-10: 4.6 vs 3.0 vs. 2.0, P=0.041; hsCRP: 88.2 vs. 19.4 vs. 14.4, P=0.005).

Conclusions

The general development process of CIP can be divided into acute, subacute, and chronic phases, upon which a better management strategy might be based devised.

The Diagnostic Utility of Cell-Free DNA from Ex Vivo Bronchoalveolar Lavage Fluid in Lung Cancer

Simple Summary

This study aims to detect cell-free DNA released from lung cancer cells into the airway using the ex vivo BAL model of our own establishing. We finally demonstrated that cell-free DNA released from lung cancer cells is more abundant in the airway than in the blood, and the efficient collection of cell-free DNA derived from lung cancer in the airway by BAL and its genomic analysis could allow the accurate diagnosis of lung cancer. We believe that this approach will possibly make a breakthrough in the currently unsatisfactory diagnostic yield for lung cancer, since it is a new and constitutive diagnostic focusing on the gene mutations of lung cancer and their release into the airway in the form of cell-free DNA.

Abstract

Although bronchoscopy is generally performed to diagnose lung cancer, its diagnostic yield remains unsatisfactory. Assuming that lung cancer cells release cell-free DNA into the epithelial lining fluid, we hypothesized that lung cancer could be diagnosed by analyzing gene mutations in cell-free DNA in this fluid. This study included 32 patients with lung cancer who underwent surgery at our hospital. Bronchoalveolar lavage (BAL) was performed on the resected lung samples (ex vivo BAL model) after lobectomy. Each DNA sample (i.e., BAL fluid, primary lesion, and plasma) underwent deep targeted sequencing. Gene mutation analyses in the BAL fluid samples identified mutations identical to those in the primary lesions in 30 (93.8%) of 32 patients. In contrast, the microscopic cytology of the same BAL fluid samples yielded a diagnosis of lung cancer in only one of 32 patients, and the analysis of plasma samples revealed gene mutations identical to those in the primary lesions in only one of 32 patients. In conclusion, cell-free DNA released from lung cancer cells exists more abundantly in the airway than in the blood. The collection and analysis of the BAL fluid containing cell-free DNA derived from lung cancer can thus allow lung cancer diagnosis and the screening of driver mutations.

Lung Cancer Surgery with Persistent COVID-19 Infection

A 71-year-old man with a history of drug-induced interstitial pneumonia was diagnosed with COVID-19 infection and simultaneously found to have a pulmonary mass, suggesting a coexisting lung cancer. Approximately 1 month after COVID-19 pneumonia resolved, the patient electively underwent right upper lobectomy. Postoperatively, acute exacerbation of interstitial pneumonia occurred and the patient died on the fifteenth postoperative day. By quantitative reverse transcription polymerase chain reaction, high levels of COVID-19-derived RNA were detected in the specimen of lung parenchyma. Despite resolved COVID-19 infection, it may persist locally in the lungs, with the risk of acute exacerbation of interstitial pneumonia due to secondary stressors including surgery.

Discrimination Between Primary Lung Cancer and Lung Metastases by Genomic Profiling

Introduction

In cases of lung tumors that occur after treatment for malignancies in other organs, the tumor may represent either a primary lung cancer or a solitary pulmonary metastasis from the other tumor. Because some lung tumors are difficult to differentiate on the basis of imaging and pathologic findings, treatment selection is often difficult. In this study, we attempted to make a genomic diagnosis of primary and metastatic lung tumors by analyzing tumor samples using next-generation sequencing and evaluated the efficacy and validity of the genomic diagnosis.

Methods

A total of 24 patients with a solitary lung nodule and a history of other malignancies were enrolled in this study. Tumor cells were selected from tissue samples using laser capture microdissection. DNA was extracted from those cells and subjected to targeted deep sequencing of 53 genes.

Results

The driver mutation profiles of the primary lung tumors were discordant from those of the primary tumors in other sites, whereas the mutation profiles of pulmonary metastases and previous malignancies were concordant. In all 24 patients, we could diagnose either primary lung cancer (six patients) or lung metastases (18 patients) on the basis of whether gene mutation profiles were concordant or discordant. In 12 patients (50.0%), discrepancies were observed between the genomic and clinical or histopathologic diagnoses.

Conclusions

In patients with a solitary lung lesion and a history of cancer, tumor-specific mutations can serve as clonal markers, affording a more accurate understanding of the pathological condition and thus possibly improving both treatment selection and patient outcome.

Mobile 3-dimensional (3D) C-arm system-assisted transbronchial biopsy and ablation for ground-glass opacity pulmonary nodules: a case report

Identification of pulmonary ground-glass opacity (GGO) lesions during bronchoscopic procedures remains challenging, as GGOs cannot be directly visualized under 2-dimensional (2D) fluoroscopy and are often difficult to detect by radial endobronchial ultrasound. Recently, a mobile 2D/3D C-arm fluoroscopy system was developed that provides both 2D fluoroscopy and mobile 3D imaging to assess and confirm the location of the lesions and ancillary bronchoscopic tools. However, previous studies focused mainly on experience of utilizing mobile 3D C-arm system for transbronchial biopsy of solid pulmonary nodules. Here, we evaluated the feasibility of mobile 3D imaging assisted transbronchial biopsy with and without ablation of two patients with GGO nodules. The first patient underwent biopsy only, and the second patient underwent biopsy in the right upper lobe lung nodule and ablation of a left upper lobe lung nodule in one session. Procedures in both patients were successfully performed, and no significant complications have been observed intra- or post-procedurally. Our case study highlights the potential value of the mobile 3D imaging system in accurate identification of the target lung lesion, confirmation of bronchoscopic tools within the lesion, and assessment of the target lesion and surrounding tissue following bronchoscopic ablation procedure. Furthermore, a “one-stop shop” bronchoscopy workflow combining both biopsy and ablation for one or more lung lesions in one session could be made possible by utilizing a hybrid mobile 2D/3D C-arm system in the bronchoscopy suite.

Petroclival meningiomas: update of current treatment and consensus by the EANS skull base section

BACKGROUND

The optimal management of petroclival meningiomas (PCMs) continues to be debated along with several controversies that persist.

METHODS

A task force was created by the EANS skull base section along with its members and other renowned experts in the field to generate recommendations for the management of these tumors. To achieve this, the task force reviewed in detail the literature in this field and had formal discussions within the group.

RESULTS

The constituted task force dealt with the existing definitions and classifications, pre-operative radiological investigations, management of small and asymptomatic PCMs, radiosurgery, optimal surgical strategies, multimodal treatment, decision-making, and patient's counselling.

CONCLUSION

This article represents the consensually derived opinion of the task force with respect to the management of PCMs.

EML4-ALK fusion variant.3 and co-occurrent PIK3CA E542K mutation exhibiting primary resistance to three generations of ALK inhibitors

The ALK inhibitors are promising therapeutic agents against lung cancer harboring ALK fusion genes and are currently under development up to the third generation. However, its therapeutic effects are reported to be affected by differences in ALK variants and co-occurrent mutations. Materials and Methods; We experienced an autopsy case of an ALK-positive lung cancer patient who showed primary resistance to three generations of ALK inhibitors. The poor survival time of the case was 14 months. To reveal the mechanism of primary resistance to three generations of ALK inhibitors, we performed next generation sequencing for 12 specimes obtained from an autopsy with covering whole exons of 53 significantly mutated, lung cancer-associated genes and amplicon-based target RNA sequenceing for the ALK fusion gene. The NGS analysis revealed a rare variant.3 of ALK fusion, in which 30 bp of base was inserted at the end of ALK intron.19 and was associated with EML exon.6 [E6_ins30A20] and a co-occurrent oncogenic PIK3CA E542K mutation in all specimens. Structural analysis of the fusion protein ALK [E6_ins30A20] showed no interferance with the binding of ALK inhibitors to the kinase domain. The NGS analysis of primary and metastatic lesions obtained from an autopsy revealed a co-occurrent oncogenic PIK3CA E542K mutation in all specimens. The constitutive activation of PI3K-Akt signal by PIK3CA E542K mutation occurred downstream of ALK signaling pathway, could lead to primary resistance to ALK inhibitors in all generations.

Is rigid tracheobronchoscopy safe enough for airway disease?

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Streptococcus australis and Ralstonia pickettii as Major Microbiota in Mesotheliomas

The microbiota has been reported to be correlated with carcinogenesis and cancer progression. However, its involvement in the pathology of mesothelioma remains unknown. In this study, we aimed to identify mesothelioma-specific microbiota using resected or biopsied mesothelioma samples. Eight mesothelioma tissue samples were analyzed via polymerase chain reaction (PCR) amplification and 16S rRNA gene sequencing. The operational taxonomic units (OTUs) of the effective tags were analyzed in order to determine the taxon composition of each sample. For the three patients who underwent extra pleural pneumonectomy, normal peripheral lung tissues adjacent to the tumor were also included, and the same analysis was performed. In total, 61 OTUs were identified in the tumor and lung tissues, which were classified into 36 species. Streptococcus australis and Ralstonia pickettii were identified as abundant species in almost all tumor and lung samples. Streptococcus australis and Ralstonia pickettii were found to comprise mesothelioma-specific microbiota involved in tumor progression; thus, they could serve as targets for the prevention of mesothelioma.

Midterm outcomes of early versus late surgery for infective endocarditis with neurologic complications: a meta-analysis

BACKGROUND

Cerebral infarction (CI) remains one of the most common and fatal complications of infective endocarditis (IE), and the timing of surgery for IE with neurologic complications is controversial. As outcomes beyond the perioperative period have not been assessed with a meta-analysis previously, we conducted a meta-analysis comparing mid- to long-term outcomes of early and late surgery in patients with IE and neurologic complications.

METHODS

All studies that investigated early and late surgery in patients with IE and neurologic complications were identified. The primary and secondary endpoints were all-cause mortality and recurrence, respectively. Hazard ratios (HRs) for all-cause mortality and recurrence were extracted from each study.

RESULTS

Our search identified five eligible studies, which were all observational studies consisting of a total of 624 patients with IE and neurologic complications. Pooled analyses demonstrated that all-cause mortality was similar between the early and late surgery groups (HR [95% confidence interval [CI]] = 0.90 [0.49-1.64]; P = 0.10; I² = 49%). Similarly, the recurrence rates were similar between both groups (HR [95% CI] = 1.86 [0.76-4.52]; P = 0.43; I² = 0%).

CONCLUSIONS

Our meta-analysis showed similar mortality and recurrent rates between the early and late surgery groups. The optimal timing of surgery should be individualized on a case-to-case basis.

Surgery for advanced-stage non-small cell lung cancer: lobectomy or sub-lobar resection?

Background

Metastatic non-small cell lung cancer (NSCLC) has many comorbidities, such as chronic obstructive pulmonary disease, coronary heart disease, and older age-related comorbidities. A survival benefit was observed in such patients who underwent surgery for selected oligometastatic disease. However, to the best of our knowledge, there is no evidence to support whether lobectomy (compared with sub-lobar resection) would further prolong these patients' lives.

Methods

Patients with metastatic NSCLC who underwent primary tumor resection were identified from the Surveillance, Epidemiology, and End Results (SEER) database and then divided into lobectomy and sub-lobar resection groups. Propensity score matching (PSM, 1:1) was performed to match the baseline characteristics of the two groups. Cancer-specific survival (CSS) was estimated.

Results

In total, 24,268 patients with metastatic NSCLC were identified; 4,114 (16.95%) underwent primary tumor surgery, and of these, 2,045 (49.71%) underwent lobectomy and 1,766 (42.93%) underwent sub-lobar resection. After PSM, 644 patients in each group were included. Lobectomy was independently correlated with longer median CSS time [hazards ratio (HR): 0.70, 95% confidence interval (CI): 0.61-0.80, P<0.001]. The 1, 2, and 3-year survival rates after PSM also favored the lobectomy group. However, no significant survival difference was found for wedge resection and segmentectomy (HR: 0.96, 95% CI: 0.70-1.31, P=0.490). The 1-, 2-, and 3-year survival rates after PSM also exhibited no difference within the sub-lobar group. We explored whether lymph node dissection would provide additional survival benefits for stage IV NSCLC patients. According to the multivariate Cox analysis of the matched population, lymph node dissection was independently associated with better CSS (HR: 0.76, 95% CI: 0.66-0.88, P<0.001) and overall survival (OS) (HR: 0.74, 95% CI: 0.65-0.86, P<0.001). We confirmed this result in the different types of surgery and found that the lymph node dissection group consistently had better survival outcomes both in the lobectomy group and sub-lobar resection population. According to the subgroup analysis, with the exception of stage T4 and brain metastatic patients, all of the patient subtypes exhibited greater benefit from lobectomy than sub-lobar resection.

Conclusions

Lobectomy has a greater survival benefit in metastatic NSCLC patients compared with sub-lobar resection when radical treatment of primary site was indicated.

Comprehensive genomic profiling of combined small cell lung cancer

Background

Combined small cell lung cancer (CSCLC) is an uncommon and heterogeneous subtype of small cell lung cancer (SCLC). However, there is limited data concerning the different molecular changes and clinical features in CSCLC compared to pure SCLC.

Methods

The clinical and pathological characteristics of pure SCLC and CSCLC patients were analyzed. Immunohistochemistry and microdissection were performed to isolate the CSCLC components. Further molecular analysis was carried out by next-generation sequencing (NGS) in 12 CSCLC and 30 pure SCLC.

Results

There were no significant differences in clinical features between CSCLC and pure SCLC. Overall survival (OS) of CSCLC patients was worse than pure SCLC (P=0.005). NGS results indicated that TP53 and RB1 were the most frequently mutated genes in both CSCLC (83.33% and 66.67%) and pure SCLC (80.00% and 63.33%) groups. However, less than 10% common mutations were found in both CSCLC and pure SCLC. When analyzing the data of SCLC and non-small cell lung cancer (NSCLC) components of CSCLC, more than 50% common mutations, and identical genes with mutations were detected. Moreover, there were also common biological processes and signaling pathways identified in CSCLC and pure SCLC, in addition to SCLC and NSCLC components.

Conclusions

There were no significant differences in terms of clinical features between CSCLC and pure SCLC. However, the prognosis for CSCLC was worse than pure SCLC. NGS analysis suggested that CSCLC components might derive from the same pluripotent single clone with common initial molecular alterations and subsequent acquisitions of other genetic mutations.

Clinical features, risk factors, and prognosis of anthracycline-induced cardiotoxicity in patients with malignant lymphoma who received a CHOP like regimen

Background

Anthracycline-induced cardiotoxicity is a serious complication in patients with malignant lymphoma (ML) who received chemotherapy, which threatens life prognosis and quality of life of patients. However, incidence and risk factors of cardiotoxicity in patients with ML who undergo intensive chemotherapy which aims complete remission is not clarified. Furthermore, prognosis after cardiotoxicity and that after recovery from cardiotoxicity have not been elucidated.

Method

We screened 443 ML patients who received either rituximab (R)-CHOP or CHOP regimen between January 2008 and December 2017 at Nagoya City University Hospital. Two handled forty-four patients who underwent echocardiography before and after chemotherapy were enrolled and data were analyzed retrospectively. Cardiotoxicity was defined as a decline in left ventricular ejection fraction (LVEF) of 10% or greater and an LVEF was below 50%. Partial recovery was defined as a 5% or more of increase in LVEF and an LVEF was ≥50% after cardiotoxicity. Complete recovery was defined as an increase in LVEF became more than 95% of the baseline value. Patient's basic characteristics, chemotherapeutic regimen, laboratory data, echocardiographic data, and prognosis were collected from the medical records by two cardiologists and two hematologists.

Result

At baseline, the median age was 71 years, the median cumulative dose of doxorubicin was 302 mg/m2 and the median LVEF was 69%. During the follow-up period, cardiotoxicity was observed in 52 out of 244 patients (21%), 30 patients (12%) had a symptomatic heart failure, and 5 patients died from cardiovascular cause. Thirty-five patients developed cardiotoxicity during the first year of chemotherapy. Multivariate analysis identified that only the baseline LVEF (HR 0.949, 95% CI 0.919–0.981, p=0.002) was an independent risk factor for cardiotoxicity. In our study, patients who received more than 200 mg/m2 of doxorubicin developed cardiotoxicity frequently. Among 52 patients who experienced cardiotoxicity, partial recovery and full recovery were observed in 18 (35%) and 4 (8%) patients, respectively. Four patients without recovery died due to heart failure and 1 patient with partial recovery died suddenly. Six out of 18 patients with partial recovery developed re-cardiotoxicity.

Conclusion

ML patients who undergo more than 200 mg/m2 of doxorubicin need a watchful follow-up. Only a baseline LVEF was an independent risk factor for cardiotoxicity. one third of patients with partial recovery developed re-cardiotoxicity.

Funding Acknowledgement

Type of funding source: None

Is tomosynthesis an ingenious scheme for bronchoscopic diagnosis of lung nodules?

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Clinical features and prognosis of acute myocardial infarction due to coronary artery embolism

Background

Coronary artery embolism (CE) is one of the important causes of acute coronary syndrome (ACS). The feature of CE is that angiographic evidence of coronary artery embolism and thrombosis without atherosclerotic components. However, the prevalence of CE remains unknown because of the diffifulty to diagnose in the acute settings. A recent retrospective analysis suggested that up to 3% of ACS cases may result from CE.

Purpose

The aim of this study was to elucidate the prevalence, clinical features and long-term outcomes including all-cause and cardiac death.

Methods

We analysed the consecutive 2695 patients with first AMI performed coronary intervention between January 2004 and July 2017. CE was diagnosed by clinical histories and angiographic findings. We retrospectively evaluated the clinical and lesion characteristics and outcomes including all-cause and cardiac death.

Results

The prevalence of CE was 2.0% (n=55; CE group and n=2640; non-CE group), including 8 (15%) patients with multivessel CE. The CE group had higher average age (70.8±14.9 vs. 68.4±12.6, p&lt;0.01), prevalence of female (54% vs. 27%, p&lt;0.01), lower prevalence of smoking (34% vs. 62%, p&lt;0.01). The common causes with CE were atrial fibrillation (47%), and malignant tumor (9%), and cardiomyopathy (5%), and patent foramen ovale (4%). Only 20% of patients with CE were treated with anti-coagulant therapy. The rate of distal infarction site (defined as #4, #8, #14–15) was significantly higher in CE group than non-CE group (54.0% vs. 4.9%, p&lt;0.01). During median follow-up of 53.6 [32.6–77.3] months, CE and thromboembolism recurred in 5 patients (CE: 1 patient, stroke 4 patients). The 4-year incidence of all-cause death was significantly higher in the CE group, but cardiac death was not significantly different between the groups (28.8% vs. 14.8%, p=0.03; 12.8% vs. 5.1%, p=0.11).

Conclusion

Compared with non-CE group, the prevalence of distal infarction site was significantly higher in the CE group, and the incidence of cardiac death is not significantly different.

Funding Acknowledgement

Type of funding source: None

Risk stratification based on academic research consortium high bleeding risk criteria for long-term bleeding event after everolimus-eluting stent implantation

Background

Recently, the Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria has been suggested as the standard definition of HBR.

Purpose

We aimed to investigate the risk stratification based on ARC-HBR Criteria for long-term bleeding event after everolimus-eluting stent implantation

Methods

The study population comprised 1193 patients treated with EES without in-hospital event between 2010 and 2011. Individual ARC-HBR criteria was retrospectively assessed. Major bleeding were defined as the occurrence of a Bleeding Academic Research Consortium type 3 or 5 bleeding event. The mean follow-up period was 2996±433 days.

Results

There were 656 patients (55.0%) in HBR-groups. Cumulative incidence of major bleeding was significantly higher in HBR-group (8.1% vs 3.4% at 4 year, and 16.2% vs 5.7% at 8 year, P&lt;0.001). Cumulative rate of major bleeding tend to be higher as the number of ARC-HBR criteria increased (≥2 Majors: 24.3%, 1 Major: 17.0%, ≥2 Minors:11.7%, and Non-HBR: 5.7%, P&lt;0.001).

Conclusion

ARC-HBR criteria successfully stratified the long-term bleeding risk after drug-eluting stent implantation in real-world practice.

Funding Acknowledgement

Type of funding source: None