Factors Associated with Neutralizing Antibody Responses following 2-Dose and 3rd Booster Monovalent COVID-19 Vaccination in Japanese People Living with HIV

People living with HIV (PLWH) could be at risk of blunted immune responses to COVID-19 vaccination. We investigated factors associated with neutralizing antibody (NAb) responses against SARS-CoV-2 and variants of concern (VOCs), following two-dose and third booster monovalent COVID-19 mRNA vaccination in Japanese PLWH. NAb titers were assessed in polyclonal IgG fractions by lentiviral-based pseudovirus assays. Overall, NAb titers against Wuhan, following two-dose vaccination, were assessed in 82 PLWH on treatment, whereby 17/82 (20.73%) were classified as low-NAb participants. Within the low-NAb participants, the third booster vaccination enhanced NAb titers against Wuhan and VOCs, albeit to a significantly lower magnitude than the rest. In the multivariate analysis, NAb titers against Wuhan after two-dose vaccination correlated with age and days since vaccination, but not with CD4+ count, CD4+/CD8+ ratio, and plasma high-sensitivity C-Reactive protein (hsCRP). Interestingly, an extended analysis within age subgroups revealed NAb titers to correlate positively with the CD4+ count and negatively with plasma hsCRP in younger, but not older, participants. In conclusion, a third booster vaccination substantially enhances NAb titers, but the benefit may be suboptimal in subpopulations of PLWH exhibiting low titers at baseline. Considering clinical and immune parameters could provide a nuanced understanding of factors associated with vaccine responses in PLWH.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Lifetime Follow-Up of a Patient with Metastatic Prostate Cancer Undergoing Multiple Surgical Resections: A Case Report

BACKGROUND Prostate cancer (PC) often metastasizes after primary resection, and long-term survival following surgical removal of multiple pulmonary metastases is rare. We present a case of a surgeon who demonstrated long-term survival after overcoming repeated surgical challenges for multiple pulmonary metastases from PC. CASE REPORT Twenty-six years ago, a 62-year-old man initially reported discomfort during urination. A prostate examination revealed mildly elevated prostate-specific antigen (PSA) levels. Six months later, PC was diagnosed, and a radical prostatectomy was performed, revealing moderately differentiated adenocarcinoma but no vessel infiltration. At 9 years after the operation, three 10-mm nodules were detected in the right lung. Then, surgical biopsy by wedge pulmonary resection revealed metastatic PC, and therefore, right lower lobectomy including all nodules was planned. Although postoperative maintenance with luteinizing hormone-releasing hormone agonists kept the low PSA levels for 3 years, other newly limited metastases were observed in the opposite left lung, necessitating more surgeries of partial left lung resection. Six years later, a third lung metastasis was detected, as well as mild increases in the tumor size and PSA level, and the patient died 26 years after the initial PC intervention because of malnutrition for 1 year after sustaining bone compression fractures due to a fall, and not due to PC progression. CONCLUSIONS Repeated surgical resections for slow-growing metastatic pulmonary PC was an alternative treatment that facilitated favorable survival and a good quality of life for 26 years in the present case.

Haemophilia and cardiovascular disease in Japan: Low incidence rates from ADVANCE Japan baseline data

INTRODUCTION

With the increasing life expectancy of people with haemophilia, the risk of cardiovascular disease (CVD) and thrombotic events has become a growing concern. Longitudinal studies on the incidence and risk factors of CVD in this population are limited, and optimal prevention and treatment strategies are yet to be established.

AIM

This study aimed to present the baseline data of a prospective longitudinal study focusing on a subset of Japanese patients with haemophilia, specifically investigated the incidence, risk factors and treatment modalities for CVD and thrombotic diseases in people aged 40 years in Japan over 10 years through the ADVANCE Japan study.

METHODS

The ADVANCE Japan study is a prospective multicentre cohort study involving 600 adult individuals with haemophilia A/B aged 40 years in Japan. The primary endpoint was the incidence of CVD, with secondary endpoints encompassing anticoagulant use, mortality rates, and comparison with the general population.

RESULTS

Baseline data from the 600 participants revealed that thrombotic events occurred in 13 individuals (2.2%), mostly in those with haemophilia A. Atrial fibrillation was observed in 11 participants (1.8%). Hypertension and dyslipidaemia were identified as the prevalent risk factors. Various prophylactic treatments were employed, and no severe bleeding events were observed during the study period.

CONCLUSION

This study provides vital baseline data for a 10-year prospective investigation of CVD and thrombotic disease risk in people with haemophilia. These findings will contribute to refining prevention and treatment approaches and improving patients' quality of life.

Relationship between CD4+ T-cell counts at baseline and initial periodontal treatment efficacy in patients undergoing treatment for HIV infection: A retrospective observational study

AIM

To retrospectively investigate the relationship between the CD4+ T-cell counts at baseline and the efficacy of the initial periodontal treatment of patients undergoing treatment for human immunodeficiency virus (HIV) infection using the periodontal inflamed surface area (PISA).

MATERIALS AND METHODS

Thirty-three patients with chronic periodontitis who had undergone periodontal examination at baseline and after the initial periodontal treatment were enrolled. PISA was calculated from the periodontal probing depth and bleeding on probing, and the ratio of PISA after treatment to that at baseline (PISA response ratio) was calculated. Groups with a response ratio of <1 and ≥1 were defined as the improvement and the non-improvement groups, respectively.

RESULTS

PISA after the initial periodontal treatment significantly decreased compared with that at baseline (p < .05). A weak negative correlation was found between the PISA response ratio and CD4+ T-cell counts at baseline (p < .05). The CD4+ T-cell counts at baseline were significantly higher in the improvement group than in the non-improvement group (p < .05). Multivariate analysis revealed that the CD4+ T-cell counts at baseline was an independent factor that affects the PISA (p < .05).

CONCLUSIONS

The higher the CD4+ T-cell counts at baseline in patients undergoing treatment for HIV infection, the more effective the initial periodontal treatment.

The seroprevalence of neutralizing antibodies against the adeno-associated virus capsids in Japanese hemophiliacs

Adeno-associated virus (AAV) vectors are promising modalities of gene therapy to address unmet medical needs. However, anti-AAV neutralizing antibodies (NAbs) hamper the vector-mediated therapeutic effect. Therefore, NAb prevalence in the target population is vital in designing clinical trials with AAV vectors. Hence, updating the seroprevalence of anti-AAV NAbs, herein we analyzed sera from 100 healthy individuals and 216 hemophiliacs in Japan. In both groups, the overall seroprevalence against various AAV serotypes was 20%–30%, and the ratio of the NAb-positive population increased with age. The seroprevalence did not differ between healthy participants and hemophiliacs and was not biased by the concomitant blood-borne viral infections. The high neutralizing activity, which strongly inhibits the transduction with all serotypes in vitro, was mostly found in people in their 60s or of older age. The multivariate analysis suggested that “60s or older age” was the only independent factor related to the high titer of NAbs. Conversely, a large proportion of younger hemophiliacs was seronegative, rendering them eligible for AAV-mediated gene therapy in Japan. Compared with our previous study, the peak of seroprevalences has shifted to older populations, indicating that natural AAV exposure in the elderly occurred in their youth but not during the last decade.

High sensitivity cardiac troponin T is a useful biomarker for predicting prognosis of the patients with sarcoidosis

Background

Cardiac involvement is one of the most significant prognostic factors for the patients with sarcoidosis. In spite of the advancement of diagnostic tools, such as cardiac magnetic resonance imaging or 18F-fluoro-2-deoxyglucose positron emission tomography, there is still significant room for improvement in cardiac screening and prognostic prediction.

Purpose

To evaluate the prognostic factors for the patients with sarcoidosis.

Methods and results

We prospectively studied 133 patients with sarcoidosis and evaluated clinical data including biomarkers. The mean age at diagnosis was 62.1±12.8 years. During a mean follow up period of 5.6±4.1 years, nine patients died and 27 patients suffered from cardiac events (cardiac death, heart failure admission, arrhythmic event). We divided patients into two groups according to cardiac events, event group had high serum high-sensitivity cardiac troponin T (hs-cTnT) (0.028±0.017 vs. 0.015±0.011 ng/ml, p&lt;0.001), high BNP (409.2±634.0 vs. 122.4±195.8 pg/ml, p&lt;0.001), low EF (43.1±16.4 vs. 59.2±15.5%, p&lt;0.001). This was observed even if those patients were not diagnosed with cardiac involvement at the enrollment. On the other hand, there were no significant differences in the values of angiotensin-converting enzyme, lysozyme, soluble interleukin-2 receptor, or calcium in both groups. Multivariate analysis revealed that hs-cTnT was an independent biomarker to predict cardiac events (hs-cTnT &gt;0.014 ng/ml: HR 3.2, 95% CI 1.02 to 10.19, p=0.046).

Conclusion

Hs-cTnT was a useful biomarker for predicting cardiac events for the patients with sarcoidosis even if cardiac involvement was not detected at initial evaluation.

Figure 1

Funding Acknowledgement

Type of funding source: None

Prognostic impact of atrial fibrillation in patients with hypertrophic cardiomyopathy in a community-based Japanese cohort: results from Kochi RYOMA study

Background

The prognostic impact of atrial fibrillation (AF) in patients with hypertrophic cardiomyopathy (HCM) is not fully elucidated.

Purpose

The aim of this study was to examine the prevalence and prognostic impact of AF in a prospectively assembled community-based HCM patient cohort in an aged Japanese community.

Methods

In 2004, we established a cardiomyopathy registration network in Kochi Prefecture, Japan, consisting of 9 hospitals, and finally 293 patients with HCM were followed.

Results

The ages at registration and at diagnosis were 63±14 and 56±16 years, respectively, and 197 patients (67%) were men. 86 patients (29%) showed AF. During follow-up period of 6.1±3.2 years, 44 patients died. In those patients, HCM-related deaths occurred in 23 patients with an annual mortality rate of 1.3%. Regarding HCM-related adverse events including HCM-related deaths, appropriate ICD discharge, heart failure admission and hospitalization for embolic events, a total of 77 cardiovascular events in 70 patients occurred. Multivariate analysis revealed that presence of AF, left ventricular (LV) outflow obstruction, NYHA functional class III, and lower LV fractional shortening at registration were significant predictors of these adverse events. During the follow-up period, additional 31 patients (11%) developed new-onset AF. Importantly, the incidence of HCM-related adverse events was significantly higher in patients with new AF observed from its onset compared with those with AF at registration (log-rank p=0.029) (Figure 1).

Conclusions

In an unselected HCM registry in an aged Japanese community, presence of AF, particularly new-onset AF, was associated with unfavorable clinical outcomes. AF is not just a marker of the disease stage but an important trigger of HCM-related adverse events.

Figure 1

Funding Acknowledgement

Type of funding source: None

Clinical Outcomes of Post-exposure Prophylaxis following Occupational Exposure to Human Immunodeficiency Virus at Dental Departments of Hiroshima University Hospital

Background

Dental professionals have so many opportunities to use injection needles and sharp instruments during dental treatment that they face an increased risk of needlestick injuries. This retrospective study reports the utilization and clinical outcomes of occupational post-exposure prophylaxis (PEP) with anti-retroviral agents after being potentially exposed to HIV at the dental departments of Hiroshima University Hospital.

Objective

This study reports the utilization and clinical outcomes of occupational post-exposure prophylaxis (PEP) with antiretroviral agents after being potentially exposed to HIV at dental departments of Hiroshima University Hospital.

Methods

Data on the clinical status of HIV-infected source patients and information on HIV-exposed dental professionals from 2007 to 2018 were collected.

Results

Five dentists with an average experience of 5.6 years (1-15 years) were exposed. The averaged CD4-positive cell number and HIV-RNA load were 1176 (768-1898) /μl and less than 20 copies/ml, respectively, in all the patients. Two of the five HIV exposed dentists received PEP. Three months after the exposures, all of their results were negative in HIV antibody/antigen tests.

Conclusion

These data might support the concept of “undetectable equals untransmittable”, although HIV exposure in this study was not through sexual transmission.

Discrepancies in preferences regarding the care of terminal-phase pneumonia in elderly patients among patients, families, and doctors: A multicenter questionnaire survey in nagasaki, Japan

BACKGROUND

Before advance care planning, it is essential to understand the differences in preferences for medical care of terminal-phase pneumonia in elderly patients among the patients, their families, and their doctors. This study aimed to clarify these differences and investigate the actual care provided to elderly patients with pneumonia in nursing hospitals.

METHODS

Multicenter questionnaire surveys of 179 patients admitted to nursing homes and long-term care beds in hospitals of three healthcare corporations, their families, and their physicians were conducted between January and August 2018. The questionnaires mainly assessed preferences for life-prolonging medical care procedures, including antibiotic treatments, in terminal-phase pneumonia. A follow-up survey regarding the prognosis and the actual care provided by the physicians was conducted 1 year after the first survey.

RESULTS

Only 16.2% of the patients had sufficient prior discussions with their families about their care. More families preferred cardiac massage, intubation, and tracheostomy, while fewer families preferred peripheral intravenous fluids or antibiotics than physicians. A total of 30 patients' families (16.7%) answered to withhold antibiotic treatment, while all physicians supported antibiotic administration. The only significant factor related to withholding antibiotics was high age (P = 0.0057). The follow-up survey administered to the doctors revealed that 49 patients (35.7%) had died within one year. Of the 137 patients, 54 patients (39.4%) had developed pneumonia during this observation period and all were treated with antibiotics.

CONCLUSIONS

This study revealed large discrepancies between patients/families and physicians regarding preferences for care. Medical staff should make efforts to fill the gap by ensuring advance care planning.

Factors Influencing Functional Exercise Capacity After Lung Resection for Non-Small Cell Lung Cancer

Purpose: We investigated, in patients who underwent lung resection for non–small cell lung cancer (NSCLC), the magnitude of early limitation in functional exercise capacity and the associations with pre- and postoperative factors. Methods: Consecutive patients with preoperative clinical stage I to IIIA NSCLC who underwent lung resection were prospectively enrolled. We measured functional exercise capacity (6-minute walk distance [6MWD]) and skeletal muscle strength (handgrip [HF] and quadriceps force [QF]) within 2 days prior to surgery and on day 7 postoperatively. Results: Two hundred eighteen participants were recruited (median age 69 years) of whom 49 developed postoperative complications (POCs). 6MWD was markedly decreased (514 m vs 469 m, P < .001); HF and QF were slightly decreased following surgery. Multiple linear regression showed that preoperative vital capacity (P < .01), QF (P < .05), the duration of chest tube drainage (P < .001), and presence of POCs (P < .05) were significant predictors. However, intraoperative factors were not significantly associated with the decline in 6MWD. Conclusions: These results suggest that patients with preoperative impairments in pulmonary function and muscle strength, and those who require prolonged chest tube drainage or develop POCs are likely to have impaired exercise capacity. Therefore, individual assessment and follow-up of patients with such factors is indicated.

P3536Prevalence and clinical impact of social frailty in elderly patients hospitalized for acute decompensated heart failure: a multicenter prospective cohort study

Purpose

The aim of this study was to investigate clinical characteristics of socially frail patients and an association with social frailty and short-term rehospitalization for worsening heart failure.

Methods

We analyzed 169 elderly patients (≥65 years old) hospitalized for acute decompensated heart failure (ADHF) between June 2017 and August 2018 in our prospective HF registry in Japan. The patients with activities of daily living dependence and without data of social frailty and outcome were excluded. Social frailty was determined based on their responses to the 5 questions (living alone, eating alone, going out less frequently, rarely visiting friends, not helpful to friends or family). Patients with none of these components were considered social non-frailty; those with one component were considered social prefrailty; those with two or more components were considered social frailty. The outcome was rehospitalization for worsening HF within 6 months after discharge.

Results

The mean age was 79±8 years old. Social frailty in 86 patients (50.8%), social prefrailty in 41 patients (24.3%), and social non-frailty in 42 patients (24.9%) were observed. Age, body mass index, geriatrics nutritional risk index, Hasegawa dementia rating scale-revised score, gait speed, and handgrip strength values were significantly different among the these three groups (all Ps for trend <0.01). Left ventricular ejection fraction, brain natriuretic peptide values, and the proportion of the patients with the symptom of New York Heart Association class III/IV did not vary significantly between the groups. Kaplan-Meier analysis revealed that higher prevalence of rehospitalization for worsening HF within 6 months in the social frailty group compared to that in the social non-frailty group (Log-rank p<0.05). In a Cox proportional hazard model after adjusting covariates, patients with social frailty (hazard ratio 4.77; 95% CI 1.61–14.12, p<0.005) and social prefrailty (hazard ratio 3.73; 95% CI 1.12–12.41, p<0.05) had an increased risk of rehospitalization for worsening HF within 6 months compared with those with social non-frailty.

Conclusion

This study revealed that social frailty was common in elderly patients hospitalized for ADHF, and social frailty was an independent predictor of rehospitalization for worsening HF within 6 months after discharge.

Oral environment and taste function of Japanese HIV-infected patients treated with antiretroviral therapy

The aim of the study was to evaluate the oral environment and the taste function of Japanese HIV-infected patients treated with antiretroviral therapy. Their median age of 73 patients taking anti-HIV drugs was 46 years. The median period of taking anti-HIV drugs was 30 months. The oral condition was evaluated by measurement of oral moisture, amount of saliva secretion, the number of oral bacteria, presence of oral candida, a taste test, and the number of missing teeth. The levels of oral moisture and secreted saliva were significantly lower in the HIV-infected group than in the healthy volunteer (control) group. The HIV-infected group showed a more robust decrease in taste sensation than the control group. The number of missing teeth was significantly higher in the HIV-infected group than in the control group. Furthermore, all of the evaluated oral conditions were worse in the HIV-infected patients whose CD4+ T lymphocyte counts were less than 500/mm³ than in the control group. It became clear that the patients taking anti-HIV drugs, especially the CD4+ count < 500/mm3 group, had a deteriorated oral environment and dysgeusia, suggesting that the management of oral hygiene is necessary to maintain oral health, which leads to systemic health.

Successful treatment based on molecular biological assessment of invasive anaplastic lymphoma kinase-positive inflammatory myofibroblastic tumor of the lung

BACKGROUND

Inflammatory myofibroblastic tumor (IMT) of the lung is rare. This disease often shows neoplastic features with anaplastic lymphoma kinase positiveness as well as inflammatory features, such as steroid-responsive immunoglobulin G4 (IgG4)-related sclerosing disease. Since many cases have been reported as advanced, various treatment strategies should be considered based on clinical and biological features of each case.

CASE PRESENTATION

We report a 49-year-old male with IMT, which seemed invading the left atrium from preoperative imaging modalities. Serological and pathological examinations from the biopsy specimen revealed high expression of anaplastic lymphoma kinase expression in the tumor. On the other hand, IgG4/IgG ration in the tumor was small, where a therapeutic effect of steroid was not expected, leading to surgical treatment rather than a steroid administration. The tumor was completely resected en bloc with the right lower lobe of the lung and a part of the left atrium. The postoperative course of the patient was uneventful. The patient has remained recurrence free over 5 years from the surgery.

CONCLUSION

In this case, preoperative biological assessment prior to the treatment led to a good clinical course. We believe that molecular biological examination is important in the determination of treatment strategy for this rare disease as well as imaging modalities.

Correction: Regeneration of esophagus using a scaffold-free biomimetic structure created with bio-three-dimensional printing

[This corrects the article DOI: 10.1371/journal.pone.0211339.].

Replacement of Rat Tracheas by Layered, Trachea-Like, Scaffold-Free Structures of Human Cells Using a Bio-3D Printing System

Current scaffold-based tissue engineering approaches are subject to several limitations, such as design inflexibility, poor cytocompatibility, toxicity, and post-transplant degradation. Thus, scaffold-free tissue-engineered structures can be a promising solution to overcome the issues associated with classical scaffold-based materials in clinical transplantation. The present study seeks to optimize the culture conditions and cell combinations used to generate scaffold-free structures using a Bio-3D printing system. Human cartilage cells, human fibroblasts, human umbilical vein endothelial cells, and human mesenchymal stem cells from bone marrow are aggregated into spheroids and placed into a Bio-3D printing system with dedicated needles positioned according to 3D configuration data, to develop scaffold-free trachea-like tubes. Culturing the Bio-3D-printed structures with proper flow of specific medium in a bioreactor facilitates the rearrangement and self-organization of cells, improving physical strength and tissue function. The Bio-3D-printed tissue forms small-diameter trachea-like tubes that are implanted into rats with the support of catheters. It is confirmed that the tubes are viable in vivo and that the tracheal epithelium and capillaries proliferate. This tissue-engineered, scaffold-free, tubular structure can represent a significant step toward clinical application of bioengineered organs.

Concurrent chemoradiotherapy using cisplatin and S-1, followed by surgery for stage II/IIIA non-small cell lung cancer

OBJECTIVES

Because chemoradiotherapy using cisplatin and S-1, an oral fluoropyrimidine, is effective for unresectable non-small cell lung cancer (NSCLC), an induction setting was used in a multicenter phase II study (Clinical trial number: UMIN000008205). The correlations of relapse and clinicopathological factors were analyzed.

METHODS

We defined locally advanced NSCLC as pathologically proven chest wall invasion or hilar and/or mediastinal lymph node metastases by endobronchial ultrasound-guided transbronchial needle aspiration. The patients received two courses of S-1 administration for 14 days and intravenous cisplatin injection on day 8. A total dose of 40 Gy radiotherapy was concurrently received. Surgical resection was performed after completion of the treatment.

RESULTS

Of the 23 eligible patients, 18 had stage IIIA and 5 had stage IIB NSCLC. Twenty of the eligible patients (87.0%) completed the regimen. Six (26.1%) complete responses were identified and 12 cases (52.2%) were histopathologically downstaged by induction chemoradiotherapy (ICRT). The 3-year overall survival rate was 58.1% and relapse-free survival (RFS) rate was 52.0%, respectively. Among several clinicopathological parameters, univariate RFS analysis identified that only downstaging was significantly associated with longer RFS times (p = 0.003). The radiological response did not reflect pathological response. When the variables of preoperative pathologically proven N2 metastasis, pathological ICRT effectiveness, and downstaging were included in the Cox proportional hazard modes, only the parameter of downstaging displayed significant hazard ratio (hazard ratio 0.13, p = 0.010).

CONCLUSION

This protocol is considered an option among preoperative therapies and has obvious benefits for pathologically downstaged cases.

CLINICAL TRIAL NUMBER

UMIN000008205.

TRIAL REGISTRATION DATE

June 19, 2012.

Successful resection to treat idiopathic azygos vein aneurysm

Azygos vein aneurysm is a rare disease. Surgical resection is usually performed when it ruptures. To avoid the thromboembolism, procedures that do not touch or push the aneurysm are recommended. Herein, we report a case of idiopathic azygos vein aneurysm. A 56-year-old woman was admitted to the hospital for right lateral chest pain. Chest enhanced multi-detector CT revealed an azygos vein aneurysm in the posterior mediastinal space. No thrombus in the aneurysm was detected before surgery. Video-assisted thoracic surgery was performed to treat the aneurysm. The patient was discharged from the hospital 4 days after surgery. Video-assisted thoracic surgery was a good option to treat an azygos vein aneurysm, and an enhanced multi-detector CT was useful for performing surgery safely.

Balloon-Based Organ Retractor With Increased Safety and Reduced Invasiveness During Video-Assisted Thoracoscopic Surgery

OBJECTIVES

In recent years, video-assisted thoracoscopic surgery (VATS) has increasingly become the preferred technique for thoracic surgery. However, the inherent characteristics of the lungs as large, soft, slippery, and delicate creates difficulties for pulmonary surgery. In this article, we outline the development and assessment of a balloon-based organ retractor for VATS via collaboration between medical and engineering personnel.

METHODS

A dry lab trial and accompanying questionnaire assessment were performed by a group of thoracic surgeons. Objective pressure measurements were obtained, and animal experiment on pigs was performed.

RESULTS

In the dry lab trial, use of the developed organ retractor required significantly less time and resulted in fewer difficulties than using a Cherry Dissector. The measured pressure per mm² of the developed retractor was clearly lower than that for the Cherry Dissector. The questionnaire completed by the surgeons following the dry lab and animal experiments showed that most of the surgeons (7 surgeons out of 9) were satisfied with the quality of the balloon-based retractor based on a score of 3.13 ± 0.28 (mean ± standard deviation) out of 4.0. During the animal experiment, the balloon-based retractor provided stable and clear viewing with minimal need for adjustment.

CONCLUSION

This balloon-based retractor could contribute to increased safety and less-invasive VATS.

Adenocarcinoma arising from an enteric cyst of the posterior mediastinum

Mediastinal enteric cysts are rare congenital thoracic cysts. The majority of mediastinal enteric cysts occur in infants, while they are rare in adults. Although most of these cysts are benign, surgical resection is sometimes performed, and malignant changes found in enteric cysts are rare. A 52-year-old man was incidentally discovered to have a posterior mediastinal mass and we excised the mass thoracoscopically. Histopathological findings showed an enteric cyst with adenocarcinoma. Comparing the pathological and magnetic resonance imaging (MRI) findings, MRI would help to detect malignant changes in such cysts. Although malignant changes found in mediastinal enteric cysts are extremely rare, clinicians should always keep in mind that those cysts have malignant potential and careful evaluation of MRI would be a clue for surgical indication.

Is Pleurectomy/Decortication Superior to Extrapleural Pneumonectomy for Patients with Malignant Pleural Mesothelioma? A Single-Institutional Experience

PURPOSE

This study was performed to compare the outcome of pleurectomy/decortication (P/D) with that of extrapleural pneumonectomy (EPP) for patients with malignant pleural mesothelioma (MPM).

METHODS

Patients with MPM underwent either P/D or EPP from August 2008 to December 2014. Various clinicopathological factors were analyzed to identify differences between the two procedures.

RESULTS

P/D was performed in nine patients and EPP in 30 patients. Most of the patients' background characteristics were not significantly different between the groups. The surgery time (680 vs. 586 min, p = 0.0034) and bleeding volume (4050 vs. 2110 mL, p = 0.002) were significantly greater in P/D than in EPP; however, grade ≥3 complications (44% vs. 33%, p = 0.54) and length of postoperative hospital stay (29 vs. 37 days, p = 0.26) were not significantly different. The median survival time and 2- and 3-year survival rates in all patients were 16.7 months, 28.5%, and 15.3%, respectively. The median survival time and 2- and 3-year survival in the P/D and EPP groups were 22.5 months, 43.8%, and 43.8% and 16.5 months, 24.0%, and 14.4%, respectively (p = 0.13).

CONCLUSION

Survival of patients with MPM remains poor despite multidisciplinary treatment. P/D is comparable with EPP and could be a safe and another surgical treatment for patients with MPM.

Initial experience with a 3D printed model for preoperative simulation of the Nuss procedure for pectus excavatum

The incidence of pectus excavatum has been estimated to be between 0.1% and 0.8% though a large autopsy series reports. After publication of the Nuss procedure for pectus excavatum, it became widely accepted. However, there are still some complications, such as over-correction and recurrence. To reduce differences in the procedure due to surgeons' experience level, preoperative simulation may be useful. Thus, we performed simulated surgery using a specific patient's three-dimensional (3D) chest wall model made by a 3D printer before operation. A 13-year-old male patient with a severe deformity of the chest underwent the Nuss procedure. As in the simulation, bars were inserted into the 5^th and 7^th intercostal spaces (ICS), leading to improvement of the chest wall. This simulation can increase surgeons' confidence to improve the deformity by determination of the number and insertion sites of bars.

Three-dimensional (3D) bronchial tree model for bronchial resection with pulmonary segmentectomy

There has been an increase in pulmonary segmentectomy procedures because of increased numbers of individuals with small lung cancer. However, it is difficult to identify the correct bronchus during surgery even with pre-operative three-dimensional (3D) computed tomography. We investigated using a 3D-printed model of the bronchi to prepare for bronchus resection during pulmonary segmentectomy. The model was useful to determine pre-operatively which bronchus should be transected, and being composed of a soft material it could be mobilized similarly to the actual bronchus during surgery. This simulation can increase surgeons' confidence to identify the correct bronchus during pulmonary segmentectomy.

Intratumoral heterogeneity of programmed cell death ligand-1 expression is common in lung cancer

Programmed cell death ligand-1 (PD-L1) expression may predict the response to both programmed cell death-1 and PD-L1 inhibitors in lung cancer. However, the extent of intratumoral heterogeneity of PD-L1 expression, which may cause false negative results, is largely unexplored. We aimed to assess the intratumoral heterogeneity of PD-L1 expression in surgically resected lung cancer specimens by applying a novel method of tissue microarray, namely Spiral Arrays, which enables us to observe the heterogeneity in spiral-shaped tissue cores. Adenocarcinoma and squamous cell carcinoma specimens were obtained from consecutive patients with lung cancer who had undergone surgical resection at Nagasaki University Hospital (Nagasaki, Japan) since 2009. Small cell lung cancer and large cell carcinoma specimens were selected from patients in the same archive who had undergone resection since 1998. Spiral Arrays were constructed of spiral-shaped cores, prepared from representative blocks of each case, which were subjected to immunohistochemistry using an anti-PD-L1 antibody. Each core was divided into 8 segments and each segment was classified as either PD-L1-positive or PD-L1-negative using thresholds of 1.0%, 5.0%, 10.0%, and 50.0%, respectively. In total, 138 specimens were selected, including 60 adenocarcinomas, 59 squamous cell carcinomas, 12 small cell lung cancers, and 7 large cell carcinomas. The majority of specimens with PD-L1-positive segments exhibited heterogeneous expression (i.e., had a mixture of PD-L1-positive and PD-L1-negative segments within a core) irrespective of the threshold (1.0%, 66.7%; 5.0%, 74.4%; 10.0%, 75.8%; and 50.0%, 85.7%]. Large variations in the ratios of PD-L1-positive segments were observed. At least 50.0% of the segments within a core were negative in no fewer than 50.0% (range, 50.0–76.0%) of cases with heterogeneous PD-L1 expression. In conclusion, intratumoral heterogeneity of PD-L1 expression was frequently observed in cases of lung cancer. Thus, multiple tumor biopsy specimens may be needed to accurately determine the PD-L1 expression status.

Successful Resection of locally infiltrative Glomus Tumor without pulmonary resection

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Extracutaneous glomus tumors occurring in the bronchus is very rare.

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Two term resections enabled us to make an accurate diagnosis and evaluation.

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After bronchoscopic treatment, curative pulmonary resection was performed and preservation of lung function was successful.

Introduction

Extracutaneous glomus tumors occurring in the bronchus is very rare. Complete resection is basic procedure for treatment of glomus tumor. We present a glomus tumor of the left main bronchus that was successfully treated with rigid bronchoscopy followed by sleeve resection of the left main bronchus.

Presentation of case

A 56-year-old man underwent two term resections to glomus tumor that originated from the left main bronchus. Firstly, we performed palliative resection with rigid bronchoscopy to make the correct diagnosis and evaluate the extent of the tumor. We subsequently performed curative resection. No complications or recurrence has occurred since the operation took place one year ago.

Discussion

Before curative resection, it is important to confirm the diagnosis and spread of the tumor. Therefore, palliative tumor resection by rigid bronchoscopy was useful to make the correct diagnosis, evaluate the extent of the tumor and open the bronchial lumen. After bronchoscopic treatment, curative pulmonary resection was performed and preservation of lung function was successful.

Conclusion

Two term resections enabled us to make an accurate diagnosis and evaluation, thereby preserving respiratory function without pulmonary resection.

Single lung retrieval from a donor supported by a left ventricular assist device

The number of patients who need cardiac support with a left ventricular assist device (LVAD) has increased over the last decade. However, the number of reports of organ retrieval from donors with an LVAD is still small. Successful lung retrieval for single lung transplantation was performed from a donor on LVAD support. This required special care not to injure the heart, great vessels, and the device, particularly the outflow conduit, because of significant conglutination around the device. A right single lung transplantation was performed successfully, with no postoperative complications. This means that patients on an LVAD could be potential donors for lung transplantation.

Ciliated muconodular papillary tumors of the lung with KRAS/BRAF/AKT1 mutation

Background

Ciliated muconodular papillary tumors (CMPTs) are newly recognized rare peripheral lung nodules that are histologically characterized by ciliated columnar, goblet, and basal cells. Although recent studies have shown that CMPTs constitute a neoplastic disease, the complete histogenesis of CMPTs is not fully understood and molecular data are limited.

Methods

We reviewed four cases of CMPT and performed immunohistochemical and genomic analyses to establish CMPT profiles.

Results

All cases were positive for hepatocyte nuclear factor-4α and mucin 5B and negative for programmed death ligand 1 expression, as determined by immunohistochemistry. The genetic analysis revealed three pathogenic mutations (BRAF V600E, AKT1 E17K, and KRAS G12D), with the KRAS mutation reported here for the first time.

Conclusion

Histological and genetic profiles indicate that CMPTs are likely neoplastic and exhibit features similar to mucinous adenocarcinoma. This suggests that some CMPTs may be a precursor lesion of mucinous adenocarcinoma.

Electronic supplementary material

The online version of this article (doi:10.1186/s13000-017-0651-2) contains supplementary material, which is available to authorized users.

Transplantation of bioengineered rat lungs recellularized with endothelial and adipose-derived stromal cells

Bioengineered lungs consisting of a decellularized lung scaffold that is repopulated with a patient's own cells could provide desperately needed donor organs in the future. This approach has been tested in rats, and has been partially explored in porcine and human lungs. However, existing bioengineered lungs are fragile, in part because of their immature vascular structure. Herein, we report the application of adipose-derived stem/stromal cells (ASCs) for engineering the pulmonary vasculature in a decellularized rat lung scaffold. We found that pre-seeded ASCs differentiated into pericytes and stabilized the endothelial cell (EC) monolayer in nascent pulmonary vessels, thereby contributing to EC survival in the regenerated lungs. The ASC-mediated stabilization of the ECs clearly reduced vascular permeability and suppressed alveolar hemorrhage in an orthotopic transplant model for up to 3 h after extubation. Fibroblast growth factor 9, a mesenchyme-targeting growth factor, enhanced ASC differentiation into pericytes but overstimulated their proliferation, causing a partial obstruction of the vasculature in the regenerated lung. ASCs may therefore provide a promising cell source for vascular regeneration in bioengineered lungs, though additional work is needed to optimize the growth factor or hormone milieu for organ culture.

Temporary bypass for superior vena cava reconstruction with Anthron bypass tubeTM

Total superior vena cava (SVC) clamping for SVC replacement or repair can be used in thoracic surgery. A bypass technique is an option to avoid hemodynamic instability and cerebral venous hypertension and hypoperfusion. The present report describes a venous bypass technique using Anthron bypass tube^TM for total SVC clamping. Indications for this procedure include the need for a temporary bypass between the brachiocephalic vein and atrium for complete tumor resection. This procedure allows the surgeons sufficient time to complete replacement of SVC or partial resection of SVC without adverse effects. Further, it is a relatively simple procedure requiring minimal time.

Avoiding completion pneumonectomy by omentopexy for bronchial dehiscence

A 56-year-old man underwent right upper sleeve lobectomy with mediastinal lymph node dissection after induction chemoradiotherapy (CRT) for advanced non-small cell lung cancer (NSCLC). The patient developed anastomotic dehiscence 11 days postoperatively. A fistula measuring 10 mm in diameter was found around the transition region between cartilage and membranous portions of the bronchus. To avoid completion right pneumonectomy, omentopexy was performed to cover the bronchial dehiscence and facilitate healing. The patient's condition improved after a redo operation with surveillance bronchoscopy to check the anastomotic status. Omentopexy may be a feasible treatment option for bronchial dehiscence and could help to avoid completion pneumonectomy (CP).

[Granuloma by Foreign Body Reaction to the Stapler Used for Partial Resection of the Lung]

A 66-year-old woman underwent right lower lobectomy and partial resection of the middle lobe for Stage I A double lung cancer. Five years after the operation, a routine computed tomography (CT) scan showed a mass on the staple line at the middle lobe. The mass was enlarged on CT scan after 6 months. A definitive diagnosis could not be made by bronchoscopic examination and fluoro-2-deoxy-glucose(FDG)/positron emission tomography( PET)-CT showed FDG uptake in the mass( early phase:SUVmax=3.24, late phase:SUVmax=4.31). Local recurrence of lung cancer was not completely denied, and right middle lobectomy was performed. Histopathologically, the resected specimen revealed granuloma with foreign body reaction. We should keep in mind the possibility of granuloma as differential diagnosis of lung cancer when using stapler.

Double stenting with silicone and metallic stents for malignant airway stenosis

For severe malignant airway stenosis, there are several types of commercially available airway stents, and each has its own advantages and disadvantages. We herein describe the safety and efficacy of combination stenting with silicone and metallic stents for patients with extended malignant airway stenosis. Seven patients with malignant airway stenosis were treated via combination stenting with a silicone stent and a metallic stent for extended airway stenosis from the central to peripheral airways. Five patients were diagnosed with advanced esophageal cancer, two of whom had tracheoesophageal fistulas. One patient had adenoid cystic carcinoma, and another had mediastinal tumor. There were no specific complications related to the double stenting. Combination stenting with silicone and metallic stents proved to be a safe option for patients with severe, extended, and complicated malignant airway stenosis.

Is early postoperative administration of pregabalin beneficial for patients with lung cancer?-randomized control trial

BACKGROUND

Post-thoracotomy pain is an obstacle for lung-cancer patients even after introduction of less invasive surgical procedures. The aim of this prospective study was to evaluate if early postoperative administration of pregabalin is beneficial for patients with non-small cell lung cancer (NSCLC).

METHODS

We conducted a randomized open control trial. Patients with NSCLC were allocated randomly to epidural and nonsteroidal anti-inflammatory drug (NSAID) use for analgesia (control group) or pregabalin use (pregabalin group). Primary endpoint was the frequency of additional administration of a NSAID. Secondary endpoints were intensity of ongoing pain, frequency of neuropathic pain, and pain catastrophizing.

RESULTS

Seventy-two patients were registered and allocated. Thirty-four cases in the control group and 33 in the pregabalin group were assessed. Age, sex, body mass index (BMI), type of surgical procedure, type of lymph-node dissection, operation time, bleeding, duration of chest-tube insertion, and postoperative hospital stay between the two groups was not significantly different. Frequency of additional NSAID use between the control group (2±4 suppositories) and pregabalin group (2±3 suppositories) was not significantly different (P=0.62). Numeric Rating Scale (NRS) for the intensity of ongoing pain, frequency of neuropathic pain, and Pain Catastrophizing Scale (PCS) between each group were not significantly different at any time until 3 months after surgery.

CONCLUSIONS

Early postoperative administration of pregabalin is not beneficial for patients with NSCLC.

Ratio of C-reactive protein to albumin is a prognostic factor for operable non-small-cell lung cancer in elderly patients

PURPOSE

The aim of this retrospective study was to evaluate inflammation-based scoring as a prognostic factor for operable non-small-cell lung cancer (NSCLC) in elderly patients.

METHODS

We collected preoperative data from 108 patients aged above 80 years with NSCLC. Inflammation-based scoring systems, including the C-reactive protein to albumin ratio (CAR) and the Glasgow prognostic score (GPS), as well as other clinicopathological factors, were evaluated as potential prognostic factors.

RESULTS

The median patient age was 82 (range 80-93) years and the 5-year overall and disease-specific survival rates were 49.7 and 73.9%, respectively. The cut-off value for CAR was calculated using a receiver operator characteristics analysis and patients were dichotomized accordingly. Patients with a low CAR had significantly higher overall survival than those with a high CAR (<0.028; 65.2% vs. ≥0.028; 31.0%, respectively; p < 0.01). In univariate analysis, female gender, a low Charlson comorbidity index of 0 or 1 and a low CAR were significantly identified in overall survival. On multivariate analysis, a low CAR (p = 0.03, hazard ratio: 2.13, 95% confidence interval 1.074-4.295) was identified as a significant prognostic factor.

CONCLUSIONS

The preoperative CAR is a useful predictor of overall survival and could be a simple prognostic tool to help identify resectable NSCLC in elderly patients.