Coherent Amplification of Continuous Laser Field via Superfluorescence

Superfluorescence (SF) is collective spontaneous emission wherein radiators spontaneously synchronize, resulting in an intense single-pulse emission. The avalanche radiation of photons is initiated by the first photon emitted into the SF propagation mode. Because this process is stochastic, the absolute phase of the SF changes randomly from shot to shot. We demonstrate that this phase can be controlled by seeding the SF with a resonant continuous-wave (CW) laser. The seed light was weak enough not to cause the stimulated emission but strong enough to inject the first photon into the SF propagation mode prior to injection by the radiators themselves. Cross-correlation measurements between the seeded SF and CW laser revealed that the seed light was coherently amplified by the SF. The amplification factor for the instantaneous intensity was estimated to be 7 orders of magnitude. These results will pave the way for the development of new types of quantum optical amplifiers.

Retrospective comparison between definitive stereotactic body radiotherapy and radical surgery for 538 patients with early-stage non-small cell lung cancer in a single institution

Introduction

Survival information for stereotactic body radiotherapy (SBRT) and surgery for stage I non-small cell lung cancer (NSCLC) was examined.

Methods

Stage I NSCLC patients who underwent surgery or SBRT between 2012 and 2016 were retrospectively enrolled in this single-institution study. Using the Kaplan--Meier method and Cox regression model, overall survival (OS) was estimated and compared.

Results

Among 538 enrolled patients, compared to the surgery group (443), the SBRT group (95) had more complications (P = 0.01), worse performance status (P = 0.001), and were older (P < 0.001). Three-year OS was 70.5% post SBRT and 90.1% postsurgery. The 3-year cancer-specific survival (CSS) and disease-free survival (DFS) post SBRT and postsurgery were 92.7% vs. 92.3% and 61.1% vs 79.3%, respectively. Three-year locoregional and distant control rates post SBRT and postsurgery were 85.6% vs. 90.1% and 82.5% vs. 86.4%, respectively. Multivariate analysis using the Cox model, including age, T-stage, CCI, and C/T ratio and treatment, showed the surgery group's OS to be significantly superior to that of the SBRT group (HR of SBRT per surgery: 1.90, 95%CI: 1.12-3.21, P = 0.017). No significant differences were observed in rates of adverse events.

Conclusion

Although OS was better in the surgery group, no differences in CSS existed. This analysis suggests the need for future studies that compare specific radical surgeries and SBRT in a prospective and randomized setting.

Modified Ravitch procedure for pectus excavatum in Marfan syndrome with annuloaortic ectasia

OBJECTIVES

This case series aimed to determine the feasibility of simultaneous modified Ravitch and David procedure for Marfan syndrome patients with pectus excavatum and annuloaortic ectasia.

METHODS

Between March 2014 and December 2019, seven consecutive patients underwent simultaneous surgery of modified Ravitch and David procedure for pectus excavatum and annuloaortic ectasia. The completion of cardiac surgery and sternal closure were followed by the modified Ravitch procedure. The bilateral fourth to seventh costal cartilages were resected, the sternal body partially wedge resected, and the sternum raised anteriorly with re-suture. An oblique incision was performed on bilateral third costal cartilages, and they were fixed on top of each other, with the medial end superior and the lateral end inferior. The sternum was raised anteriorly, bypassing the fourth to seventh rib ends through the back of the sternum with threads. The feasibility and safety of the procedure were assessed through a retrospective review of the patients' clinical charts.

RESULTS

The total sample had a median age of 28 years, and comprised five males and two females. There was a significant difference in the preoperative and postoperative median Haller index, which were 6.8 and 3.9, respectively. All patients were discharged without serious complications, and there was no significant recurrence of pectus excavatum at 35-92 months postoperatively.

CONCLUSIONS

The results of our case series suggest the feasibility of one-stage surgery for pectus excavatum combined with cardiac surgery using the modified Ravitch procedure. Future efforts should be tailored for more uneventful postoperative clinical courses.

Lung transplantation for cystic fibrosis complicated by cirrhosis: A case report

A 16-year-old girl with a genetic diagnosis of cystic fibrosis was referred to us for consideration of lung transplantation. She had been hospitalized repeatedly for pneumonia and pneumothoraxes and her respiratory function had worsened progressively. Although she also had liver cirrhosis, she was considered a candidate for lung transplantation because her liver disease was compensated and only slowly progressive. After bilateral lung transplantation from a brain-dead donor, she developed ascites that was well controlled with diuretics. Otherwise, her post-operative course was uneventful and she was transferred to another hospital for rehabilitation 39 days after lung transplantation.

Successful step-by-step diagnosis and management of expiratory central airway collapse

A 45-year-old woman with recurrent dyspnea for 40 years was previously diagnosed with bronchial asthma and spasmodic dysphonia. On admission, the patient was diagnosed with expiratory central airway collapse (ECAC) due to expiratory dynamic airway collapse based on radiographic examination, chest computed tomography, and bronchoscopy. After continuous positive airway pressure and temporal airway stenting, surgical tracheobronchoplasty and tracheal membranous portion reinforcement using polypropylene mesh successfully relieved the respiratory symptoms. In patients with airway obstructive disease refractory to conventional therapies, ECAC should be considered.

Cascade and yoked superfluorescence detected by sum frequency generation spectroscopy

We investigated the superfluorescent decay process of dense rubidium atomic vapor in a cell. Using a femtosecond laser pulse, the atoms were excited from the 5S ground state to the 6P state. The 2.73μm and 1.37μm fields were generated on the cascaded decay, 6P → 6S → 5P, which further stimulated the 780 nm forward emission on the 5P → 5S transition. Using sum frequency generation (SFG) spectroscopy, we observed all emission fields and the time delay between them, with sufficient temporal resolution. The experimental results were successfully reproduced using semiclassical simulations.

Number of dye marks required in virtual-assisted lung mapping

OBJECTIVES

Virtual-assisted lung mapping is a preoperative bronchoscopic multi-spot dye-marking technique used in sublobar lung resection for hardly palpable lung nodules. However, the number of marks required per nodule remains unknown. Therefore, we examined the correlation between the number of intraoperative visible marks and the successful resection rate.

METHODS

We retrospectively examined 210 consecutive patients with 256 lesions who underwent virtual-assisted lung mapping during January 2014-December 2020 at our hospital. When a nodule was not resected at the initial attempt, or when a nodule was very close to the cut margin in the resected specimen and required additional resection, we categorized it as unsuccessful resection. We divided 256 lesions into successful and unsuccessful groups and compared the numbers of intraoperative visible marks between the two groups.

RESULTS

Of 797 attempted marks, 738 (92.4%) were visible during the surgery. Fourteen (5.4%) of 256 lesions were determined to be unsuccessful according to the study criteria. There was a remarkable difference in the average numbers of intraoperative visible marks between both groups (3 [interquartile range: 2-4] vs. 2 [interquartile range: 1-2.8]; p < 0.01). Multivariable logistic analysis revealed a significant difference in the number of intraoperative visible marks (odds ratio: 0.28, 95% confidence interval: 0.14-0.57; p < 0.001) between both groups.

CONCLUSIONS

Successful sublobar lung resection requires three or more intraoperative visible marks established using virtual-assisted lung mapping per lung nodule.

Rapid imaging of lung cancer using a red fluorescent probe to detect dipeptidyl peptidase 4 and puromycin-sensitive aminopeptidase activities

Rapid identification of lung-cancer micro-lesions is becoming increasingly important to improve the outcome of surgery by accurately defining the tumor/normal tissue margins and detecting tiny tumors, especially for patients with low lung function and early-stage cancer. The purpose of this study is to select and validate the best red fluorescent probe for rapid diagnosis of lung cancer by screening a library of 400 red fluorescent probes based on 2-methyl silicon rhodamine (2MeSiR) as the fluorescent scaffold, as well as to identify the target enzymes that activate the selected probe, and to confirm their expression in cancer cells. The selected probe, glutamine-alanine-2-methyl silicon rhodamine (QA-2MeSiR), showed 96.3% sensitivity and 85.2% specificity for visualization of lung cancer in surgically resected specimens within 10 min. In order to further reduce the background fluorescence while retaining the same side-chain structure, we modified QA-2MeSiR to obtain glutamine-alanine-2-methoxy silicon rhodamine (QA-2OMeSiR). This probe rapidly visualized even borderline lesions. Dipeptidyl peptidase 4 and puromycin-sensitive aminopeptidase were identified as enzymes mediating the cleavage and consequent fluorescence activation of QA-2OMeSiR, and it was confirmed that both enzymes are expressed in lung cancer. QA-2OMeSiR is a promising candidate for clinical application.

Virtual-assisted lung mapping using dual staining with indocyanine green and indigo carmine enhanced marking detectability

Background

Virtual-assisted lung mapping (VAL-MAP) is a preoperative bronchoscopic multispot dye-marking procedure to facilitate sublobar lung resection for unidentifiable lung nodules. To increase detectable markings, we performed VAL-MAP using dual staining (VAL-MAP DS) with indocyanine green (ICG) and indigo carmine. This study was designed to evaluate the efficacy and safety of the modified technique.

Methods

We retrospectively reviewed the records of patients who underwent VAL-MAP DS. Twenty patients with 27 lesions underwent 72 VAL-MAP DS markings. We investigated the overall detectable marking rate, visible marking rate, successful resection rate, and complications.

Results

The overall detectable marking rate, thanks to both ICG and indigo carmine, tended to be higher than the indigo carmine visible marking rate (95.7% vs. 85.5%, P=0.08). The successful resection rate with sufficient margins was 92.0%. There were no adverse events related to the use of ICG. ICG markings of the lungs of patients with a history of smoking more than 50 pack-years tended to be visible, but the staining was too extensive compared with the staining in patients who smoked less or not at all (58.8% vs. 0.0%, P<0.001).

Conclusions

VAL-MAP DS is likely be efficacious and safe in enhancing the detectability of markings. This bronchoscopic technique should be considered as one of the optimal preoperative marking methods in thoracic surgery.

Effect of intraoperative needle biopsy on the survival of nonsmall cell lung cancer patients: a propensity score matching analysis

Purpose

It is unknown whether intraoperative needle biopsy (INB) predisposes to the postoperative recurrence of lung cancer and compromises the prognosis of these patients. We conducted this study to identify the effect of INB before lobectomy on the postoperative recurrence rate and prognosis of patients with nonsmall cell lung cancer (NSCLC).

Methods

The subjects of this retrospective study were 953 patients with pathological stage I–III NSCLC who underwent lobectomy between 2001 and 2016. The patients were divided into two groups: the INB group (n = 94) and the non-INB group (n = 859). After propensity score matching (PSM), we compared the postoperative cumulative recurrence rate, recurrence-free survival (RFS), disease-specific survival (DSS), and overall survival (OS) between the two groups.

Results

After PSM, 94 patient pairs were matched. The cumulative recurrence rate was significantly higher in the INB group than in the non-INB group (P = 0.01). The 5-year RFS rate was significantly lower in the INB group than in non-INB group (48% vs 68%), as were the 5-year DSS (76% vs 92%) and 5-year OS rates (67% vs 84%) (all P < 0.05).

Conclusions

The findings of this analysis suggest that INB before lobectomy may increase the cumulative recurrence rate and worsen the prognosis of patients with resectable NSCLC. Thus, we believe that INB should be avoided unless a lung lesion cannot be diagnosed by another type of biopsy.

Polarization correlation in the superfluorescent decay process

We investigated the polarization properties of superfluorescence (SF) emitted from dense cesium atomic vapor in a cell. The atoms were excited from the 6S ground to the 8P state using a femtosecond laser pulse. The SF fields generated on the cascaded decay, 8P→8S→7P, mediated the nonlinear optical process. We observed 4.2-µm and 456-nm forward directional emissions generated on the 8S→7P and 7P→6S transitions, respectively. The polarizations of the two fields were correlated in each laser shot, and their directions fluctuated from shot to shot, reflecting the noise that initiated the 4.2-µm emission.

Intrabronchial migration of hemostatic agent through a bronchial fistula after lung transplantation: a case report

Background

A bronchial fistula is a relatively rare and potentially fatal complication after lung transplantation. Thoracic surgeons and pulmonologists often face challenges when selecting treatment options. We herein report an exceptional case of intrabronchial migration of a nonabsorbable hemostatic agent, which had been placed around the pulmonary artery at the time of lung transplantation, through a bronchial fistula.

Case presentation

A 61-year-old man developed respiratory distress 1 year after left single-lung transplantation for idiopathic interstitial pneumonia. Bronchoscopic examination revealed an apparent foreign body protruding from the mediastinum into the distal site of the bronchial anastomosis. The foreign body was easily removed bronchoscopically and appeared to be a hemostatic agent that had been placed during the previous lung transplantation. The patient developed a similar clinical episode and finally developed hemoptysis. Computed tomography revealed a foreign body located between the bronchus and pulmonary artery, partially protruding into the bronchial lumen. Given the possibility of a bronchopulmonary arterial fistula, surgical treatment was performed. The foreign body was located between the bronchus and left pulmonary artery and was easily removed. Multiple bronchial fistulas were found, and all were closed with direct sutures. Bypass grafting of the left pulmonary artery was then performed, initially with a homograft but eventually with an extended polytetrafluoroethylene graft. The patient was finally discharged 5 months after the surgery.

Conclusion

We experienced an extremely rare case of intrabronchial migration of hemostatic agents used during the previous lung transplantation through a bronchial fistula, which were successfully managed by direct bronchial closure and bypass grafting of the left pulmonary artery.

Lung autotransplantation for bronchial necrosis after radiotherapy: a case report

Background

Bronchial necrosis is a rare but fatal complication after radiation therapy. Because of the anatomical complexity and rarity of this condition, determining the most appropriate management for individual patients is extremely challenging. Lung autotransplantation is a surgical technique that has been applied to hilar neoplastic lesions to preserve pulmonary function and avoid pneumonectomy. We herein report a case of bronchial necrosis secondary to radiotherapy that was treated with lung autotransplantation.

Case presentation

A 46-year-old man developed broad necrosis and infection of the right bronchus secondary to previous stereotactic body-radiation therapy. This treatment was supplied close to a right hilar metastatic pulmonary tumor derived from a mediastinal malignant germ cell tumor that had been surgically resected with the left phrenic nerve. The bronchial necrosis accompanied by infection with Aspergillus fumigatus was progressive despite antibiotics and repetitive bronchoscopic debridement. Because of the patient’s critical condition and limited pulmonary function, right lung autotransplantation with preservation of the right basal segment was selected. An omental flap was placed around the bronchial anastomosis to prevent later complications. The postoperative course involved multiple complications including contralateral pneumonia and delayed wound healing at the bronchial anastomosis with resultant stenosis, the latter of which was overcome by placement of a silicone stent. The patient was discharged 5 months postoperatively. Three months after discharge, however, the patient developed hemoptysis and died of bronchopulmonary arterial fistula formation.

Conclusions

We experienced an extremely challenging case of bronchial necrosis secondary to radiotherapy. The condition was managed with lung autotransplantation and omental wrapping; however, the treatment success was temporary and the patient eventually died of bronchopulmonary arterial fistula formation. This technique seems to be a feasible option for locally advanced refractory bronchial necrosis, although later complications can still be fatal.

Orthotopic Transplantation of Human Bioartificial Lung Grafts in a Porcine Model: A Feasibility Study

Lung transplantation is the only treatment for end-stage lung disease; however, donor organ shortage and intense immunosuppression limit its broad clinical impact. Bioengineering of lungs with patient-derived cells could overcome these problems. We created bioartificial lungs by seeding human-derived cells onto porcine lung matrices and performed orthotopic transplantation to assess feasibility and in vivo function. Porcine decellularized lung scaffolds were seeded with human airway epithelial cells and human umbilical vein endothelial cells. Following in vitro culture, the bioartificial lungs were orthotopically transplanted into porcine recipients with planned 1-day survival (n = 3). Lungs were assessed with histology and in vivo function. Orthotopic transplantation of cadaveric lungs was performed as control. Engraftment of endothelial and epithelial cells in the grafts were histologically demonstrated. Technically successful orthotopic anastomoses of the vasculatures and airway were achieved in all animals. Perfusion and ventilation of the lung grafts were confirmed intraoperatively. The gas exchange function was evident immediately after transplantation; PO₂ gradient between pulmonary artery and vein were 178 ± 153 mm Hg in the bioartificial lung group and 183 ± 117 mm Hg in the control group. At time of evaluation 24 hours after reperfusion, the pulmonary arteries were found to be occluded with thrombus in all bioartificial lungs. Engineering and orthotopic transplantation of bioartificial lungs with human cells were technically feasible in a porcine model. Early gas exchange function was evident. Further progress in optimizing recellularization and maturation of the grafts will be necessary for sustained perfusability and function.

Respiratory strength and pectoralis muscle mass as measures of sarcopenia: Relation to outcomes in resected non-small cell lung cancer

OBJECTIVES

Physical biomarkers to stratify patients with lung cancer into subtypes predictive of outcome beyond tumor-related characteristics are underexplored. This study was designed to investigate the clinical utility of preoperative sarcopenia based on respiratory strength and pectoralis muscle mass to predict the risk of death.

METHODS

This retrospective study included 346 consecutive patients undergoing curative-intent resection of non-small cell lung cancer from 2009 to 2013. Respiratory strength and muscle mass were assessed by peak expiratory flow rate and pectoralis muscle index (pectoralis muscle area/body mass index) using preoperative spirometry and chest axial images, respectively. Sarcopenia cutoff points were defined by gender-specific medians of peak expiratory flow rates and pectoralis muscle indices. Survival was compared between patients with sarcopenia and patients without.

RESULTS

Sarcopenia was present in 98 patients (28.3%) and was significantly associated with advancing age (P < .001). Patients with sarcopenia exhibited worse 5-year overall survival compared with patients without sarcopenia (69.9% vs 87.2%, P < .001). Multivariate analysis revealed that sarcopenia was an independent adverse prognostic factor (hazard ratio, 1.88; 95% confidence interval, 1.09-3.24; P = .023) after adjustment for gender, age, smoking status, coronary heart disease, diffusing capacity for carbon monoxide, neutrophil-to-lymphocyte ratio, albumin, histologic type, and pathologic stage.

CONCLUSIONS

Preoperative sarcopenia as identified by the criteria of low respiratory strength and reduced pectoralis muscle mass is significantly associated with poor overall survival. This may help to develop more individualized management strategies and optimize longitudinal care for patients.

Exacerbation of Secondary Pulmonary Hypertension by Flat Chest after Lung Transplantation

A 40-year-old woman with idiopathic pleuroparenchymal fibroelastosis (IPPFE) and flat chest underwent left single lung transplantation (SLT). Although she had developed over-systemic pulmonary arterial pressure (PAP) at transplantation, it was alleviated. However, her PAP gradually increased again. Her transplanted lung was well-inflated, but progression of fibrosis in her right native lung appeared to have caused a mediastinal shift, and her flat chest caused obstruction of the outflow tract of the pulmonary vein. She died of heart failure and associated infection 1.5 years after transplantation. An autopsy confirmed irreversible pulmonary arterial and venous changes in the transplanted lung, suggestive of chronic pressure overload. The flat chest associated with IPPFE can affect pulmonary circulation after SLT.

Adoptive transfer of zoledronate-expanded autologous Vγ9Vδ2 T-cells in patients with treatment-refractory non-small-cell lung cancer: a multicenter, open-label, single-arm, phase 2 study

BACKGROUND

Not all non-small cell lung cancer (NSCLC) patients possess drug-targetable driver mutations, and response rates to immune checkpoint blockade therapies also remain unsatisfactory. Therefore, more effective treatments are still needed. Here, we report the results of a phase 2 clinical trial of adoptive cell therapy using zoledronate-expanded autologous Vγ9Vδ2 T-cells for treatment-refractory NSCLC.

METHODS

NSCLC patients who had undergone at least two regimens of standard chemotherapy for unresectable disease or had had at least one treatment including chemotherapy or radiation for recurrent disease after surgery were enrolled in this open-label, single-arm, multicenter, phase 2 study. After preliminary testing of Vγ9Vδ2 T-cell proliferation, autologous peripheral blood mononuclear cells were cultured with zoledronate and IL-2 to expand the Vγ9Vδ2 T-cells. Cultured cells (>1×10⁹) were intravenously administered every 2 weeks for six injections. The primary endpoint of this study was progression-free survival (PFS), and secondary endpoints included overall survival (OS), best objective response rate (ORR), disease control rate (DCR), safety and immunomonitoring. Clinical efficacy was defined as median PFS significantly >4 months.

RESULTS

Twenty-five patients (20 adenocarcinoma, 4 squamous cell carcinoma and 1 large cell carcinoma) were enrolled. Autologous Vγ9Vδ2 T-cell therapy was administered to all 25 patients, of which 16 completed the foreseen course of 6 injections of cultured cells. Median PFS was 95.0 days (95% CI 73.0 to 132.0 days); median OS was 418.0 days (179.0-479.0 days), and best overall responses were 1 partial response, 16 stable disease (SD) and 8 progressive disease. ORR and DCR were 4.0% (0.1%-20.4%) and 68.0% (46.5%-85.1%), respectively. Severe adverse events developed in nine patients, mostly associated with disease progression. In one patient, pneumonitis and inflammatory responses resulted from Vγ9Vδ2 T-cell infusions, together with the disappearance of a massive tumor.

CONCLUSIONS

Although autologous Vγ9Vδ2 T-cell therapy was well tolerated and may have an acceptable DCR, this trial did not meet its primary efficacy endpoint.

TRIAL REGISTRATION NUMBER

UMIN000006128.

Abstract 1069: Autologous γδ T cell therapy for treatment-refractory non-small-cell lung cancer: An open-label, single-arm, multicenter, phase II study

Background: Only a fraction of non-small cell lung cancer (NSCLC) patients possess targetable driver mutations, and the response rates of immune checkpoint blockades are still unsatisfactory. Therefore, the development of more effective therapies is needed for treatment-refractory NSCLC. We conducted a phase I clinical study of autologous γδ T cell therapy for NSCLC patients and reported safety and feasibility. Here, we report the result of phase II clinical trial of adoptive γδ T cell transfer therapy for treatment-refractory NSCLC patients.

Methods: Patients with NSCLC who had undergone at least two regimens of standard chemotherapy for unresectable disease or who had undergone at least one treatment including chemotherapy or radiation for recurrent disease after surgery were enrolled in this open-label, single-arm, multicenter, phase II study. After preliminary testing of γδ T cell proliferative capacity, mononuclear cells of the patient collected by peripheral blood leukapheresis were cultured with zoledronic acid and IL-2. Expanded autologous γδ T cells (&gt;1 × 109) were transferred intravenously every two weeks for a total of six injections. If the patient perceived some clinical benefit, the patient could continue further treatments until the disease became progressive. The primary endpoint of this study was progression-free survival (PFS), and the secondary endpoints included overall survival (OS), best objective response rate (ORR), disease control rate (DCR), and safety. The clinical efficacy of the treatment was determined if the median PFS is significantly longer than 3 months.

Results: Autologous γδ T cell therapy was given for 25 patients, and 16 patients completed the 6 courses of the treatment. Among the 25 patients, 20 had adenocarcinoma, 4 squamous cell carcinoma and 1 large cell carcinoma. The median PFS was 95.0 days (95% CI 73.0-132.0 days). The median OS was 418.0 days (179.0-479.0 days). The best overall responses were 1 partial response (PR), 16 stable disease (SD) including 4 patients whose time to progression was longer than 180 days, and 8 progressive disease (PD). ORR and DCR were 4.0% (0.1-20.4%) and 68.0% (46.5-85.1%), respectively. Severe adverse events (SAE) were developed in 9 patients during the study, including pleural effusion, anorexia, cough, dyspnea, respiratory failure, pneumonitis, ascites, tumor pain, and intracranial hemorrhage. Most of them were associated with disease progression; however, a case of pneumonitis was related to γδ T cell therapy.

Conclusion: Although the trial did not meet its primary efficacy endpoint, the results of this study indicate that autologous γδ T cell therapy was well tolerated and may have an acceptable disease control rate. Considering the unique mechanism of action towards tumor cells, γδ T cell therapy may be a candidate counterpart of combination therapy for treatment-refractory NSCLC.

Citation Format: Kazuhiro Kakimi, Hirokazu Matsushita, Takamichi Izumi, Keita Masuzawa, Takahiro Karasaki, Shinnosuke Ikemura, Kentaro Kitano, Ichiro Kawata, Tadashi Manabe, Tomohiro Takehara, Toshiaki Ebisudani, Kazuiro Nagayama, Hiroyuki Yasuda, Masaaki Sato, Kenzo Soejima, Jun Nakajima. Autologous γδ T cell therapy for treatment-refractory non-small-cell lung cancer: An open-label, single-arm, multicenter, phase II study [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1069.

Prognostic significance of low pectoralis muscle mass on preoperative chest computed tomography in localized non-small cell lung cancer after curative-intent surgery

OBJECTIVES

The impact of sarcopenia on the outcome in patients following resection of non-small cell lung cancer is yet to be fully determined. This study aimed to evaluate the clinical utility of a computed tomography-based pectoralis muscle assessment, which reflects sarcopenia, to predict the risk of postoperative outcomes.

MATERIALS AND METHODS

This retrospective study included 347 consecutive patients undergoing curative-intent resection of non-small cell lung cancer from 2009 to 2013. The pectoralis muscle index (pectoralis muscle area/body mass index) was assessed at the level of the fourth thoracic vertebra on chest axial images. The primary outcomes were compared between the lowest gender-specific quintile (sarcopenia) and the other quintiles according to the index. The prognostic significance of low pectoralis muscle index was calculated by the Cox proportional hazards regression model. A propensity score matching analysis was performed to adjust the differences in clinical characteristics.

RESULTS

Sixty-nine patients were identified with sarcopenia according to the lowest gender-specific quintile of pectoralis muscle index. Patients with sarcopenia exhibited worse 5-year overall survival rate compared with patients without sarcopenia (64.2 % vs. 86.7 %, P < 0.001). Even in stage I non-small cell lung cancer, the rate of 5-year overall survival in the sarcopenia group was lower than that in the non-sarcopenia group (74.2 % vs. 92.4 %, P = 0.001). Multivariate analysis revealed that low pectoralis muscle index was independently associated with adverse overall survival (hazard ratio: 2.09, 95 % confidence interval: 1.20-3.62, P = 0.009). After propensity score matching, the prognostic impact of sarcopenia based on low pectoralis muscle index was also robust for overall survival (hazard ratio: 3.23, 95 % confidence interval: 1.38-7.60, P = 0.007).

CONCLUSIONS

Low pectoralis muscle index was significantly associated with poor long-term outcomes in patients with localized non-small cell lung cancer after curative surgery. This may help assist preoperative risk stratification and longitudinal management after surgery.

ɤ-glutamyl hydroxymethyl rhodamine green fluorescence as a prognostic indicator for lung cancer

OBJECTIVE

ɤ-glutamyltranspeptidase is an enzyme expressed in various malignancies including lung cancer. It rapidly activates non-fluorescent ɤ-glutamyl hydroxymethyl rhodamine green to highly fluorescent hydroxymethyl rhodamine green. The resultant tumor fluorescence is therefore an indicator of cellular ɤ-glutamyltranspeptidase activity. We have explored the use of ɤ-glutamyl hydroxymethyl rhodamine green as an intraoperative imaging tool for visualizing cancers. Herein, we evaluated the potential of the tumor fluorescence as a postoperative prognostic indicator.

METHODS

We included patients with non-small cell lung cancer who had undergone radical resection from 2012 to 2014 in the study. We assessed the fluorescence intensity of the resected tumor and normal lung tissue by ex vivo imaging using ɤ-glutamyl hydroxymethyl rhodamine green.

RESULTS

Sixty-seven patients were eligible for the study (adenocarcinomas, n = 44; squamous cell carcinoma, n = 14; other histologies, n = 8). The pathological stages were I, II, III, and IV in 39, 15, 12, and 1 patient, respectively. Based on the fluorescence of the tumor tissue, the patients were divided into high fluorescence (n = 33) and low fluorescence (n = 34) groups. The 5-year overall survival rate was significantly higher in the high fluorescence group (72.7%) compared to the low fluorescence group (47.1%, P = 0.025). Similarly, pathological stage I patients of the high fluorescence group had higher 5-year overall survival (85.7% vs. 44.4%, P = 0.009) and recurrence-free survival (76.2% vs. 44.4% P = 0.044) rates compared to those of the low fluorescence group.

CONCLUSIONS

ɤ-glutamyl hydroxymethyl rhodamine green fluorescence is a good postoperative prognostic indicator in patients with non-small cell lung cancer.

Transplantation of Bioengineered Lungs Created From Recipient-Derived Cells Into a Large Animal Model

The use of bioartificial lungs may represent a breakthrough for the treatment of end-stage lung disease. The present study aimed to evaluate the feasibility of transplanting bioengineered lungs created from autologous cells. Porcine decellularized lung scaffolds were seeded with porcine recipient-derived airway and vascular cells. The porcine recipient-derived cells were collected from lung tissue obtained by pulmonary wedge resection. Following culture of autologous cells in the scaffolds, the resulting grafts were unilaterally transplanted into porcine recipients (n = 3). Allograft left unilateral lung transplantation was performed in the control group (n = 3). Left unilateral transplantation of decellularized grafts was also performed in a separate control group (n = 2). In vivo functions were assessed for 2 hours after transplantation. Histologic evaluation and immunostaining showed the presence of airway and vascular cells in the bioengineered lungs. No animals survived in the decellularized transplant group, whereas all animals survived in the bioengineered transplant and allotransplant groups. However, bioengineered lung grafts showed marked bullous changes. The oxygen exchange was comparable between the bioengineered lung graft transplant and allograft transplant groups. However, the carbon dioxide gas exchange of the bioengineered lung graft transplant group was significantly lower than that of the allograft transplant group at 2 hours after transplantation (4.10 ± 0.87 mm Hg vs 24.7 ± 10.1 mm Hg, P = 0.02). Transplantation of bioartificial lung grafts created from autologous cells was feasible in the super-acute phase. However, bullous changes and poor carbon dioxide gas exchange remain limitations of this method.

Effect of normal saline flush injection into a bronchus on lung decellularization

BACKGROUND

The aim of this study was to evaluate effect of normal saline flush injection into bronchus on creation of decellularized lung scaffolds.

METHODS

Pigs were used: 3 lung grafts for decellularization with pre-treatment of normal saline injection into a bronchus, 3 for decellularization without pre-treatment and 3 treated as normal controls. We compared the characteristics of lung scaffolds created by each method.

RESULTS

The pretreatment procedure significantly reduced the DNA content of lung grafts, suggesting effective removal of cellular components. However, this pretreatment also reduced the elastin contents of lung grafts.

CONCLUSIONS

Considering this characteristic of saline pretreatment, we must continue to look for better methods to produce ideal decellularized lung grafts.

[Reexpansion Pulmonary Edema and Atrial Fibrillation after Resection of a Giant Solitary Fibrous Tumor of the Pleura]

We report a case of giant solitary fibrous tumor( SFT) of the pleura postoperatively complicated with probable reexpansion pulmonary edema and atrial fibrillation. An 85-year-old woman was diagnosed to have a 13 cm sized intrathoracic neoplasm. Upon thoracotomy, the tumor was found to pedunculate from the right lung with no direct invasion to the surrounding structures. Complete resection of the tumor and expansion of the right lung was obtained. Histopathology revealed the tumor was a benign SFT arising from the visceral pleura. An infiltrative shadow in the right lower lung field soon after the surgery suggested a reexpansion pulmonary edema, which eventually recovered within a week. The patient suffered from a refractory atrial fibrillation that led to a congestive heart failure requiring an intensive medical treatment. It is emphasized that thoracic surgeons should be aware of these postoperative complications in treating such a case like this.

Impact of Previous Malignancy on Outcome in Surgically Resected Non-Small Cell Lung Cancer

BACKGROUND

Patients with lung cancer with a history of treatment often undergo curative surgical resection. However, the impact of previous cancer treatment on the outcome of lung cancer remains unclear.

METHODS

We conducted a retrospective study of patients who underwent curative resection for non-small cell lung cancer between 1998 and 2011. We collected clinicopathologic data and patients were divided into groups by previous history of cancer treatment. Comparisons between groups, estimation of survival rates, and multivariate analyses were performed. Propensity score matching was used to create cohorts with reduced bias.

RESULTS

Of 878 patients, 196 (22.3%) had previous extrathoracic malignancies, and stage I lung cancer was more frequent in this group (P < .001). In multivariate analysis of the whole cohort, older patients, men, non-adenocarcinoma histologic type, more advanced pathologic stage of lung cancer, interstitial pneumonia, and previous extrathoracic malignancies were associated with appreciably worse prognosis. When propensity score matched cohorts were compared, prognosis was significantly worse in patients with previous extrathoracic malignancies than patients without (5-year survival rates, 75.3% vs 82.7%; P = .009), although recurrence was not frequently seen (5-year recurrence-free rates, 78.7% vs 83.0%; P = .491).

CONCLUSIONS

Because treatment history of extrathoracic malignancy was not associated with postsurgical lung cancer recurrence, proposing curative resection could be justifiable if the previous cancer is deemed cured or controlled. However, the results showing that patients with previous cancer history have a worse survival rate than patients without should be taken into account when curative surgery is considered.

Differences Between Patients With Idiopathic Pleuroparenchymal Fibroelastosis and Those With Other Types of Idiopathic Interstitial Pneumonia in Candidates for Lung Transplants

INTRODUCTION

The prognostic implications of having patients with idiopathic pleuroparenchymal fibroelastosis (IPPFE) on lung transplantation waiting lists have been unclear. In Japan, where a severe shortage of brain-dead donors remains a major limitation for organ transplantation, it is particularly important to predict the prognoses of patients when they are listed for transplantation. The purpose of this study was to investigate the characteristics of lung transplantation candidates with IPPFE and the influence of those characteristics on prognosis.

METHODS

This was a retrospective review of 29 consecutive adult lung transplant candidates with idiopathic interstitial pneumonia between January 2014 and April 2018.

RESULTS

Eight patients with IPPFE and 21 with other types of idiopathic interstitial pneumonia were included. Body mass index (median 17.1 kg/m² vs 23.5 kg/m², P < .01) and ratio of anteroposterior to transverse diameter of the thoracic cage were significantly lower (0.530 vs 0.583, P = .02) in the IPPFE group. Patients with a body mass index <20.0 kg/m² (P = .02), 6-minute walk distance <250.0 m (P < .01), ratio of PaO₂ to fraction of inspiratory oxygen <300.0 mm Hg (P < .01), and an inability to perform the diffusing capacity of carbon monoxide test (P < .01) had significantly shorter survival times in the other idiopathic interstitial pneumonia, but not in the IPPFE, group. Some patients with IPPFE survived for long enough to undergo transplantation.

CONCLUSIONS

Patients with IPPFE waiting for transplantation have some distinctive characteristics and should be retained on waiting lists to receive transplants.

Latest update about virtual-assisted lung mapping in thoracic surgery

Virtual-assisted lung mapping (VAL-MAP) is a preoperative bronchoscopic multi-spot dye-marking technique using virtual images developed to assist in navigational lung resection. The technique of VAL-MAP has been shown to be safe and effective surgical assistive tool for performing pulmonary sublobar resections. The technique is applicable for treating multiple small pulmonary lesions that are hardly palpable including ground glass nodules (GGNs). It also may help shorten surgical duration in wedge resection cases. Electromagnetic navigation bronchoscopy (ENB) may eliminate the need for post-mapping computed tomography (CT) scans in logistically challenged situations. In the most recent, multicenter prospective single-arm study, conventional VAL-MAP had reasonable efficacy for obtaining good surgical margin in pulmonary sublobar resections, although the successful resection rate did not reach the primary goal most significantly due to deep resection margins. The technique of VAL-MAP in combination with microcoil may be the next step to acquire better surgical margins.

Impact of the 8th Edition of the UICC-TNM Classification on Clinical Stage 0-IA Lung Adenocarcinoma: Does the New Classification Predict Postoperative Prognosis More Precisely than the Previous One?

PURPOSE

Early lung adenocarcinoma has been more frequently found recently. The 8th edition of the Union for International Cancer Control (UICC)-Tumor Node Metastasis (TNM) classification for lung cancer has been effective since January 2017. This study aims to elucidate advantages of the current classification for patients with clinical stage 0-IA lung adenocarcinoma, in comparison with the older one.

METHODS

We retrospectively reviewed the data of clinical stage IA (7th edition) lung adenocarcinoma patients who underwent surgery at our institute from 2001 to 2012, and reclassified them by the 8th edition. Survival analysis was used to evaluate the impact of the two classifications.

RESULTS

In all, 281 cases were eligible. Clinical T-factors (8th) were significant prognostic factors for overall survival (P = 0.001), recurrence-free survival (P <0.001), and cancer-specific survival (P = 0.001). However, those in the previous edition were not (P = 0.894, P = 0.144, and P = 0.822, respectively).

CONCLUSION

The 8th edition of the UICC-TNM classification predicts postoperative prognosis more precisely than the 7th one in clinical stage 0-IA lung adenocarcinoma. It is probably because the stage distribution of the population, which included in the research project the 8th edition based on, has been changed, and the new edition develops more accurate staging criteria for ground-glass nodule (GGN).

Bioengineering of functional human induced pluripotent stem cell-derived intestinal grafts

Patients with short bowel syndrome lack sufficient functional intestine to sustain themselves with enteral intake alone. Transplantable vascularized bioengineered intestine could restore nutrient absorption. Here we report the engineering of humanized intestinal grafts by repopulating decellularized rat intestinal matrix with human induced pluripotent stem cell-derived intestinal epithelium and human endothelium. After 28 days of in vitro culture, hiPSC-derived progenitor cells differentiate into a monolayer of polarized intestinal epithelium. Human endothelial cells seeded via native vasculature restore perfusability. Ex vivo isolated perfusion testing confirms transfer of glucose and medium-chain fatty acids from lumen to venous effluent. Four weeks after transplantation to RNU rats, grafts show survival and maturation of regenerated epithelium. Systemic venous sampling and positron emission tomography confirm uptake of glucose and fatty acids in vivo. Bioengineering intestine on vascularized native scaffolds could bridge the gap between cell/tissue-scale regeneration and whole organ-scale technology needed to treat intestinal failure patients.

There is a need for humanised grafts to treat patients with intestinal failure. Here, the authors generate intestinal grafts by recellularizing native intestinal matrix with human induced pluripotent stem cell-derived epithelium and human endothelium, and show nutrient absorption after transplantation in rats.

Rabi oscillations in the spatial profiles of superfluorescent pulses from rubidium vapor

In this study, we investigate 420-nm yoked superfluorescence (YSF) emitted from the atomic vapor of rubidium (Rb) by driving the Rb 5S - 5D two-photon transition with an ultrashort pulsed laser. When the pump pulse is close to its transform limit (~ 100 fs) or down-chirped up to around 200 fs, the 420-nm YSF appears as a low-divergence beam with a ring-shaped radial profile. Although such a beam profile is less sensitive to the vapor pressure of Rb in a cell, its diameter rigorously varies as a function of the pump-pulse power. By numerically solving a time-dependent Schrödinger equation for a single-Rb atom, we well reproduce our experimental observation, indicating that a single-atom Rabi oscillation is responsible for the spatial beam profile of the 420-nm emission.

Long-term outcomes of open and video-assisted thoracoscopic lung lobectomy for the treatment of early stage non-small cell lung cancer are similar: a propensity-matched study

BACKGROUND

Generally, in retrospective studies, favourable short- and long-term outcomes for patients after lung lobectomy for early stage non-small cell lung cancer (NSCLC) using video-assisted thoracoscopic surgery (VATS) have been reported. However, the interpretation of lung lobectomy outcomes may be biased in retrospective settings.

METHODS

We retrospectively reviewed patients who underwent lung lobectomy for cT1-2N0M0 NSCLC from 2001 to 2010. The outcomes of patients who underwent VATS lobectomy were compared to those who underwent open lobectomy before and after performing propensity score matching. Preoperative covariates were entered when developing the propensity score-matching model.

RESULTS

This study reviewed the outcomes of 101 VATS patients and 184 open lobectomy patients. Before propensity score matching, the VATS group had a higher mean age (p < 0.0001), smaller solid tumour size (p = 0.0042), similar whole tumour size (p = 0.2082), and larger tumour-disappearance ratio (p = 0.0007). The VATS group had a shorter mean operation time (p = 0.0002), less blood loss (p < 0.0001), shorter chest tube duration (p = 0.0002), and shorter hospital stay (p < 0.0001). As for long-term outcomes, the VATS group had higher disease-free, disease-specific, and overall survival rates (p values by log-rank test: 0.0049, 0.0154, and 0.032, respectively). After propensity score matching, all differences, except operation time, blood loss, chest tube duration, and hospital stay, were no longer significant.

CONCLUSIONS

VATS lobectomy is less invasive than open lobectomy, but in terms of survival outcomes, VATS lobectomy was oncologically equivalent to open lobectomy. The oncological benefit of VATS reported by retrospective studies might be overestimated.

Abstract 5113: Rapid Cancer Imaging By GGT-targeted Fluorescence Probe For Primary Lung Cancer

Introduction

Lung cancer is the leading cause of cancer death in Japan, however, it has been difficult to detect and diagnose precisely lung cancer with a diameter less than 1cm to date. The purpose of this study is to investigate clinical application of novel GGT-targeted fluorescence probe for detecting the primary lung cancer in an intraoperative manner.

Methods

As a fluorescence probe for γ-glutamyltranspeptidase (GGT), γ-glutamyl hydroxymethyl rhodamine green (gGlu-HMRG) was used. gGlu-HMRG is non-fluorescent, but is converted to a highly fluorescent hydroxymethyl rhodamine green (HMRG) upon reaction with the enzyme, which tends to accumulate in GGT-overexpressing cancer cells. First, we examined GGT activity of lung cancer cell lines, A549, H460, H441, H82 and H226, by applying gGlu-HMRG and evaluating fluorescence intensities by confocal fluorescence microscopy. We also compared mRNA expression level of GGT1 (one of the subtypes of GGT) by qRT-PCR. Further, by transfecting siRNA targeted to GGT1, we investigated the target of gGlu-HMRG. Next we performed in vivo imaging of orthotopic A549 lung cancer xenograft model in nude mouse to confirm the validity of fluorescence imaging. Finally, we carried out ex vivo fluorescence imaging of 73 human lung cancers and normal lung tissues which were surgically resected, and the fluorescence intensities were analyzed by Receiver Operating Characteristics curve.

Results

A549, H460 and H441 cells with high GGT1 expression could be visualized with high fluorescence intensity after application of gGlu-HMRG within several minutes, whereas H82 and H226 cells with relatively low GGT1 expression could not. We ascertained that the target of gGlu-HMRG was GGT1 by fluorescence imaging and qRT-PCR with lung cancer cell lines transfected with siRNA for GGT1. In lung cancer xenograft model, pleural dissemination, hilar and mediastinal lymph node metastasis and the surface of lung cancer were clearly detected within 15 minutes after topical drip of gGlu-HMRG. We confirm that every fluorescent lesion was adenocarcinoma pathologically. In ex vivo human lung cancer fluorescence imaging, the sensitivity, specificity and accuracy were calculated to be 43.8% (32/73cases), 84.9% (62/73cases) and 64.4% (94/146), respectively. The adenocarcinomas, cancer of female or never smoker were more significantly detected by fluorescence imaging (p&lt;0.05-0.001). Limited to 19 cases of adenocarcinomas, cancer of female and never smoker, sensitivity, specificity, and accuracy were 78.9% (15/19), 73.7% (14/19) and 76.3% (29/38), respectively.

Conclusions

We suggest that intraoperative application of gGlu-HMRG to detect pleural dissemination, small mediastinal lymph nodal metastasis, or other small foci of the lung cancer cells on surgical margin might be feasible when the cancer cells overexpress GGT. Intraoperative application of fluorescence probe is highly expected in near future.

Citation Format: Haruaki Hino, Mitsuaki Kawashima, Tomonori Murayama, Junji Ichinose, Kentaro Kitano, Kazuhiro Nagayama, Jun-ichi Nitadori, Masaki Anraku, Tomohiro Murakawa, Kasue Mizuno, Sayaka Tanaka, Mako Kamiya, Nobuhiro Nishiyama, Kazunori Kataoka, Kohei Miyazono, Yasuteru Urano, Jun Nakajima. Rapid Cancer Imaging By GGT-targeted Fluorescence Probe For Primary Lung Cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 5113. doi:10.1158/1538-7445.AM2015-5113

[Tracheal Resection and Reconstruction for a Squamous Cell Carcinoma of the Trachea;Report of a Case]

We report a case of tracheal resection and reconstruction for a squamous cell carcinoma of the trachea that was found in an 82-year-old male patient who had underwent right lower lobectomy for an adenosquamous cell carcinoma 3.5 years before. He noticed bloody sputum. Chest computed tomography (CT) revealed a 15 mm tumor in the anterior wall of the trachea. A transbronchial biopsy for the tracheal tumor showed a squamous cell carcinoma. Under right thoracotomy, we resected the tumor with 3 tracheal rings. Histologically a squamous cell carcinoma was diagnozed. As there was intraepithelial spread of cancer cells in the oral margin, the tracheal tumor was suspected to be a primary tracheal tumor rather than a metastasis from lung cancer. After the surgery, combination therapies of an external radiation therapy for 50 Gy and brachytherapy 2 times for totally 8 Gy were performed as a postoperative adjuvant therapy. He does not have any signs of recurrence in 1 year and 6 months after the surgery.

Design and validation of a clinical-scale bioreactor for long-term isolated lung culture

The primary treatment for end-stage lung disease is lung transplantation. However, donor organ shortage remains a major barrier for many patients. In recent years, techniques for maintaining lungs ex vivo for evaluation and short-term (<12 h) resuscitation have come into more widespread use in an attempt to expand the donor pool. In parallel, progress in whole organ engineering has provided the potential perspective of patient derived grafts grown on demand. As both of these strategies advance to more complex interventions for lung repair and regeneration, the need for a long-term organ culture system becomes apparent. Herein we describe a novel clinical scale bioreactor capable of maintaining functional porcine and human lungs for at least 72 h in isolated lung culture (ILC). The fully automated, computer controlled, sterile, closed circuit system enables physiologic pulsatile perfusion and negative pressure ventilation, while gas exchange function, and metabolism can be evaluated. Creation of this stable, biomimetic long-term culture environment will enable advanced interventions in both donor lungs and engineered grafts of human scale.

Results of bony chest wall reconstruction with expanded polytetrafluoroethylene soft tissue patch

PURPOSE

The early and long-term outcomes of bony chest wall reconstruction with expanded polytetrafluoroethylene (Gore-Tex) soft tissue patch remain a concern. No clinical study has reported the shrinkage of Gore-Tex following reconstruction to date.

METHODS

Thirty-seven patients who underwent bony chest wall reconstruction from 1994 to 2012 were retrospectively reviewed. Postoperative chest computed tomography images of 17 patients were examined, and shrinkage of reconstruction materials was measured and compared.

RESULTS

Gore-Tex was used for reconstruction in 18 patients, autologous materials were used in 14, Marlex mesh was used in four, and Medifit felt was used in one. No surgery-related deaths were observed. Twenty patients experienced early postoperative complications. Four patients experienced local infection. One patient with Marlex-mesh experienced empyema 33 days postoperatively. Chest drainage time in the Gore-Tex patients was significantly lower than in patients with other types of prosthetic reconstruction. No dislocation or dehiscence was found. Shrinkage of Gore-Tex was absent in 4 patients and acceptable in seven patients. No granulation formation was evident around the Gore-Tex, No significant difference in shrinkage was seen between the different materials used.

CONCLUSION

Chest wall reconstruction with Gore-Tex was feasible with favorable early and long-term results.