Preoperative Physical Dysfunction Characteristics and Influence Factors Among Elderly Patients with Early Lung Cancer: A Latent Class Analysis

Objective

To identify latent classes of preoperative physical dysfunction in elderly patients with early lung cancer. To analyze the differences in demographic characteristics between different classes.

Methods

We invited elderly patients with early lung cancer who were scheduled for surgery at Shanghai Elderly Characteristic Hospital to participate in the study using a convenience sampling method. We took latent class analysis to divide elderly patients with early lung cancer into latent classes based on preoperative physical dysfunction features. Furthermore, we used single-factor analysis and multinomial logistic regression to investigate the influence variables of each latent class.

Results

The characteristics of preoperative physical dysfunction in elderly patients with early lung cancer can be divided into "Anxiety/depression emotion-poor sleep group" "Frailty of physical function group" "Pulmonary hypofunction-low activity tolerance group". The distribution of age, chronic disease history, COPD history, smoking history and perceived social support level of elderly patients with early lung cancer in different potential categories were not the same, and the differences were statistically significant (P<0.05). The elderly lung cancer patients with chronic disease history and age ≥75 years were more likely to be classified as "frailty of physical function group". The elderly lung cancer patients with COPD and smoking history were more likely to be classified into "pulmonary hypofunction-low activity tolerance group". Elderly lung cancer patients with moderate or low degree of perceived social support were more prone to be grouped into "anxiety/depression emotion-poor sleep group".

Conclusion

The variety of preoperative physical dysfunction seen in elderly patients with early lung cancer can be categorized into three latent classes. Medical professionals should create strategies for intervention for multiple patient populations with the goal of further enhancing their general state of life.

Respirable crystalline silica and lung cancer in community-based studies: impact of job-exposure matrix specifications on exposure-response relationships

OBJECTIVES

The quantitative job-exposure matrix SYN-JEM consists of various dimensions: job-specific estimates, region-specific estimates, and prior expert ratings of jobs by the semi-quantitative DOM-JEM. We analyzed the effect of different JEM dimensions on the exposure-response relationships between occupational silica exposure and lung cancer risk to investigate how these variations influence estimates of exposure by a quantitative JEM and associated health endpoints.

METHODS

Using SYN-JEM, and alternative SYN-JEM specifications with varying dimensions included, cumulative silica exposure estimates were assigned to 16 901 lung cancer cases and 20 965 controls pooled from 14 international community-based case-control studies. Exposure-response relationships based on SYN-JEM and alternative SYN-JEM specifications were analyzed using regression analyses (by quartiles and log-transformed continuous silica exposure) and generalized additive models (GAM), adjusted for age, sex, study, cigarette pack-years, time since quitting smoking, and ever employment in occupations with established lung cancer risk.

RESULTS

SYN-JEM and alternative specifications generated overall elevated and similar lung cancer odds ratios ranging from 1.13 (1st quartile) to 1.50 (4th quartile). In the categorical and log-linear analyses SYN-JEM with all dimensions included yielded the best model fit, and exclusion of job-specific estimates from SYN-JEM yielded the poorest model fit. Additionally, GAM showed the poorest model fit when excluding job-specific estimates.

CONCLUSION

The established exposure-response relationship between occupational silica exposure and lung cancer was marginally influenced by varying the dimensions of SYN-JEM. Optimized modelling of exposure-response relationships will be obtained when incorporating all relevant dimensions, namely prior rating, job, time, and region. Quantitative job-specific estimates appeared to be the most prominent dimension for this general population JEM.

A Prospective Observational Study of Diagnostic Reliability of Semiquantitative and Quantitative High b-Value Diffusion-Weighted MRI in Distinguishing between Benign and Malignant Lung Lesions at 3 Tesla

Aim  The aim of this study was to evaluate the usefulness of high b-value diffusion-weighted imaging (DWI) to differentiate benign and malignant lung lesions in 3 Tesla magnetic resonance imaging (MRI). Materials and Methods  Thirty-one patients with lung lesions underwent a high b-value (b= 1000 s/mm 2 ) DW MRI in 3 Tesla. Thirty lesions were biopsied, followed by histopathological analysis, and one was serially followed up for 2 years. Statistical analysis was done to calculate the sensitivity, specificity, and accuracy of different DWI parameters in distinguishing benign and malignant lesions. Receiver operating characteristic (ROC) curves were used to determine the cutoff values of different parameters. Results  The qualitative assessment of signal intensity on DWI based on a 5-point rank scale had a mean score of 2.71 ± 0.75 for benign and 3. 75 ± 0.60 for malignant lesions. With a cutoff of 3.5, the sensitivity, specificity, and accuracy were 75, 86, and 77.6%, respectively. The mean ADC min (minimum apparent diffusion coefficient) value of benign and malignant lesions was 1. 49 ± 0.38 × 10-3 mm 2 /s and 1.11 ± 0.20 ×10-3 mm 2 /s, respectively. ROC curve analysis showed a cutoff value of 1.03 × 10-3 mm 2 /s; the sensitivity, specificity, and accuracy were 87.5, 71.4, and 83.3%, respectively. For lesion to spinal cord ratio and lesion to spinal cord ADC ratio with a cutoff value of 1.08 and 1.38, the sensitivity, specificity, and accuracy were 83.3 and 87.5%, 71.4 and 71.4%, and 80.6 and 83.8%, respectively. The exponential ADC showed a low accuracy rate. Conclusion  The semiquantitative and quantitative parameters of high b-value DW 3 Tesla MRI can differentiate benign from malignant lesions with high accuracy and make it a reliable nonionizing modality for characterizing lung lesions.

Lung cancer diagnosis and mortality beyond 15 years since quit in individuals with a 20+ pack-year history: A systematic review

Current US lung cancer screening recommendations limit eligibility to adults with a pack-year (PY) history of ≥20 years and the first 15 years since quit (YSQ). The authors conducted a systematic review to better understand lung cancer incidence, risk and mortality among otherwise eligible individuals in this population beyond 15 YSQ. The PubMed and Scopus databases were searched through February 14, 2023, and relevant articles were searched by hand. Included studies examined the relationship between adults with both a ≥20-PY history and ≥15 YSQ and lung cancer diagnosis, mortality, and screening ineligibility. One investigator abstracted data and a second confirmed. Two investigators independently assessed study quality and certainty of evidence (COE) and resolved discordance through consensus. From 2636 titles, 22 studies in 26 articles were included. Three studies provided low COE of elevated lung cancer incidence beyond 15 YSQ, as compared with people who never smoked, and six studies provided moderate COE that the risk of a lung cancer diagnosis after 15 YSQ declines gradually, but with no clinically significant difference just before and after 15 YSQ. Studies examining lung cancer-related disparities suggest that outcomes after 15 YSQ were similar between African American/Black and White participants; increasing YSQ would expand eligibility for African American/Black individuals, but for a significantly larger proportion of White individuals. The authors observed that the risk of lung cancer not only persists beyond 15 YSQ but that, compared with individuals who never smoked, the risk may remain significantly elevated for 2 or 3 decades. Future research of nationally representative samples with consistent reporting across studies is needed, as are better data from which to examine the effects on health disparities across different populations.

A systematic review and meta-analysis to evaluate blood levels of interleukin-6 in lung cancer patients

Introduction

The exact mechanism responsible for inflammation in malignancy is not completely understood, but it is possible that interleukin-6 (IL-6) plays a major role in triggering and maintaining an inflammatory response.

Aim

To conduct a systematic review and meta-analysis of the levels of IL-6 in the serum/plasma of lung cancer (LC) patients.

Material and methods

The researchers searched four databases up to September 11, 2022, to find studies that reported on IL-6 levels in LC patients compared to healthy controls (HCs). They calculated effect sizes using standardized mean difference (SMD) with a 95% confidence interval (CI). To evaluate the quality of each study, they used the Newcastle-Ottawa Scale (NOS). They performed subgroup analysis, sensitivity analysis, meta-regression analysis, heterogeneity analyses, trial sequential analysis, and publication bias with the trim-and-fill method.

Results

The meta-analysis included 28 studies, and the results showed that the pooled SMD was 1.71 (95% CI: 1.22, 2.19; p < 0.00001; I2 = 98%), indicating that LC patients had significantly higher levels of IL-6 in their serum/plasma than HCs.

Conclusions

The study found that the publication year and quality score of the studies were positively associated with the level of IL-6, while the sample size was inversely related. The research suggests that measuring IL-6 levels in the blood could be useful for detecting and monitoring LC as it appears to be a reliable biomarker.

Influence of Brain Metastasis on Analgesia-Related Outcomes in Patients with Lung and Breast Cancers Treated with Naldemedine: A Propensity Score-Matched Analysis

Naldemedine is structurally designed to prevent passage across the blood-brain barrier (BBB), resulting in the attenuation of opioid-induced constipation without interfering with the analgesic effects of opioids. However, the influence of brain metastasis (BM), as one indicator of BBB disruption, on the analgesic effects of opioids in patients treated with naldemedine remains unclear. To examine whether the analgesic effects of opioids following naldemedine treatment are lower in patients with BM than in those without BM, we surveyed inpatients with lung and breast cancers treated with naldemedine at Fujita Health University Hospital between April 2017 and March 2022. Changes in the numeric rating scale (NRS) scores, morphine milligram equivalents (MMEs), and the number of rescues were assessed as analgesia-related outcomes during the first 7 days of naldemedine treatment in patients with or without BM, matched by the propensity score. In total, 172 patients were enrolled. After propensity-score matching, 30 patients with BM and 60 patients without BM were included in the analysis. Changes in NRS scores, MMEs, and the number of rescues did not differ between patients with and without BM. In the linear mixed-effects model, the coefficient of interaction between patients with or without BM and the days for each outcome was not statistically significant. BM does not influence the analgesic effect of opioids in patients with lung and breast cancers treated with naldemedine. Naldemedine may be useful for treating BM.

Primary Mucoepidermoid Carcinoma of the Lung Coexisting With Pulmonary Tuberculosis: A Rare Case Report

Mucoepidermoid carcinoma (MEC) is a well-established neoplasm of the salivary glands. However, the MEC of the lung is an exceedingly rare neoplasm that falls under the category of salivary gland-type tumors of the lung. Pulmonary MEC is recognized for its indolent progression. Pulmonary tuberculosis (TB) is a prevalent infectious disease in India and ranks among the leading causes of death from infectious diseases. Nevertheless, the co-occurrence of pulmonary MEC with pulmonary TB is a rare phenomenon that has not been documented in the literature. In this report, we describe a 54-year-old male patient who presented with symptoms of dysphagia, weight loss, and fever. Histopathological examination diagnosed him with pulmonary MEC, and concurrent cytology and Gene-Xpert tests confirmed tuberculosis. This case represents the first documented instance of this particular co-occurrence. It underscores the limitations of radiology in diagnosing such a rare neoplasm, especially when there is an absence of lung parenchyma infiltration and a mass lesion. Additionally, this case supports the possibility of an interdependent relationship between malignancies and tuberculosis.

The Association Between Lung Cancer and Sarcoidosis: A Literature Review

Lung cancer is responsible for a significant number of cancer-related deaths worldwide. While various factors can lead to lung cancer, such as tobacco smoking, this article focuses on the relationship between sarcoidosis, a multisystem granulomatous disorder, and lung neoplasm. To investigate this association, the authors conducted a literature search using relevant keywords. The analysis of these reports concluded that while Sarcoidosis and lung cancer together is rare, it is possible. The presenting symptoms, age, gender, and diagnostic procedures of each case should be evaluated, and appropriate diagnostic procedures should be carried out to determine the appropriate treatment for each patient. Clinicians need to be aware of the possibility of these two diseases co-occurring, as they can impact the management of the patient's condition, whether it is curative or palliative. It is essential to rule out metastatic cancer in individuals with sarcoidosis-like clinical and radiographic features.

Targeted therapy for rare lung cancers: Status, challenges, and prospects

Lung cancer causes the most cancer-related deaths worldwide. In recent years, molecular and immunohistochemical techniques have rapidly developed, further inaugurating an era of personalized medicine for lung cancer. The rare subset of lung cancers accounts for approximately 10%, each displaying distinct clinical characteristics. Treatments for rare lung cancers are mainly based on evidence from common counterparts, which may lead to unsolid clinical benefits considering intertumoral heterogeneity. The increasing knowledge of molecular profiling of rare lung cancers has made targeting genetic alterations and immune checkpoints a powerful strategy. Additionally, cellular therapy has emerged as a promising way to target tumor cells. In this review, we first discuss the current status of targeted therapy and preclinical models for rare lung cancers, as well as provide mutational profiles by integrating the results of existing cohorts. Finally, we point out the challenges and future directions for developing targeted agents for rare lung cancer.

Hyalinising clear cell carcinoma of the lung: A case report and review of literature

BACKGROUND

Hyalinising clear cell carcinoma (HCCC) of the lung is a rare tumor, with only 12 reported cases. To improve the differential diagnosis, the aim of this study was to clarify the clinicopathological characteristics, immunophenotype, and molecular characteristics of HCCC of the lung and relate these to prognosis.

METHODS

Sections of HCCC of the lung were collected from a patient for pathological observation, immunohistochemistry, histochemistry, and fluorescence in situ hybridization; the clinical, pathological, and molecular characteristics were compared with those reported in the literature.

RESULTS

The tumor had a well-demarcated border nodule with a maximal diameter of 2.5 cm. Microscopic findings showed either clear or eosinophilic cytoplasm in the tumor cells. Growth was predominantly in the sheets, nests, and trabeculae in a background of hyalinised, fibrotic stroma, and mucus degeneration. Immunohistochemistry showed that the tumor cells expressed cytokeratin 7, P63, P40, CK5/6, Pan Cytokeratin (PCK), and epithelial membrane antigen, whereas they were negative for thyroid transcription factor-1, napsin A, CD10, vimentin, and smooth muscle actin. The Ki67 proliferation index was 5%. The tumor was positive for both period acid-Schiff (PAS) and Alcian blue-PAS, with a small amount of mucus staining positive for PAS-diastase. Fluorescence in situ hybridization revealed Ewing sarcoma breakpoint region 1 rearrangement and Ewing sarcoma breakpoint region 1-activating transcription factor 1 fusion.

CONCLUSIONS

HCCC is a low-grade carcinoma with excellent prognosis. Tumour necrosis may be a potential risk factor for recurrence and metastasis. Our review of reported cases suggests that regional lymph node dissection combined with lobectomy is a safer treatment than only lobectomy for HCCC of the lung.

Short-term outcomes of robotic lobectomy versus video-assisted lobectomy in patients with pulmonary neoplasms

BACKGROUND

To explore whether robotic lobectomy (RL) is superior to video-assisted lobectomy (VAL) in terms of short-term outcomes in patients with pulmonary neoplasms.

METHODS

From January 30, 2019 to February 28, 2022, a series of consecutive minimally invasive lobectomies were performed for patients with pulmonary neoplasms. Perioperative outcomes such as operation time, blood loss, dissected lymph nodes (LNs), surgical complications, postoperative pain control, length of postoperative stay in hospital, and total cost of hospitalization were compared.

RESULTS

A total of 336 cases including 173 RLs and 163 VALs were enrolled. Baseline characteristics were comparable between groups. RLs were associated with shorter operation time (median [interquadrant range, IQR], 107 min [90-130] vs. 120 min [100-149], p < 0.001), less blood loss (median [IQR], 50 mL [30-60] vs. 50 mL [50-80], p = 0.02), and lower blood transfusion rate (3.5% vs. 9.8%, p = 0.02) compared with VALs. More LNs were harvested by the robotic approach (median [IQR], 29 [20-41] vs. 22 [15-45], p = 0.04). The incidences of conversion, major postoperative complications, extra analgesic usage, and postoperative length of stay were all comparable between the RL and VAL groups. As predicted, the total cost of hospitalization was greater in the RL group (median [IQR], $16728.35 [15682.16-17872.15] vs. $10713.47 [9662.13-11742.15], p < 0.001).

CONCLUSION

RL improved surgical efficacy with shortened operative time, less blood loss, and more thorough LN dissection compared with VAL, compromised by higher cost.

Lung neuroendocrine neoplasms: a single centre surgical series and analysis of staging

BACKGROUND

To review the outcomes of surgically resected lung neuroendocrine neoplasms (LNEN) at a tertiary referral centre and to validate a previously published LNEN-specific staging system (NETL).

METHODS

All patients who were identified on histopathology to have LNEN were included. Pre-, intra- and post-operative outcomes were collected, including long-term survival. Patients were staged by both the TNM (seventh and eighth edition) and NETL staging (seventh and eighth edition definitions). Kaplan-Meier (KM) survival analysis was performed according to histopathology and stage, along with uni- and multivariate analyses.

RESULT

A total of 132 patients were included in the study, with a median age of 65 years; 55% were female. Typical carcinoid (TC) was the most common pathology (53.4%) followed by large cell neuroendocrine carcinoma (LCNEC - 23.5%), atypical carcinoid (AC - 20.5%) and small cell carcinoma (3.0%). The most common operation performed was a lobectomy (55.3%). Overall survival at 5 years was 80% (100% TC, 78.2% AC, LCNEC 40.9%) and 5-year disease free survival was 76.8% (TC 94.3%, AC 56.8%, LCNEC 56.4%). KM curves showed a trend towards NETL performing better than TNM, however, in multivariate analysis only the histological subtype was found to be significant in our study.

CONCLUSION

This is the largest known Australian series of LNEN to date, showing survival comparable to international outcomes. We have demonstrated large variations in outcome, driven by histological grade. The TNM system does not correlate with survival and we have not been able to show that currently proposed NETL staging is superior.

Primary acinic cell carcinoma of the trachea: A case report and literature review

RATIONALE

Salivary gland-type acinic cell carcinoma (ACC) is a low-grade malignancy. Primary ACC of the trachea and lungs is rare; here, we describe 1 such case. The histological morphology of tracheal ACC was similar to that of its salivary gland-associated equivalent. Because of its rarity, it is easily misdiagnosed as another type of tracheal or lung tumor. Microscopic analysis of pathological features and immunohistochemistry help diagnose primary ACC of the trachea and lungs.

PATIENT CONCERNS

A 33-year-old female complained of shortness of breath and hemoptysis for 2 years, and reported the symptoms to have aggravated over the last 4 months. The patient was admitted to our hospital for further treatment. Enhanced computed tomography revealed a soft tissue density nodule shadow in the trachea, which was approximately 1.3 × 1.2 cm in size.

DIAGNOSES

Based on the clinical information, morphological features, and immunohistochemistry, the pathological diagnosis was primary ACC of the trachea.

INTERVENTION

The tracheal lesion was resected with an electric snare, electrotomy, freezing, and an argon knife using a rigid bronchoscope.

OUTCOMES

The patient's postoperative course was uneventful.

LESSONS

It is important to prevent misdiagnosis of this type of tumor as another type of lung tumor. Morphological and immunohistochemical features can be useful in diagnosing primary ACC of the trachea and lungs.

A critical systematic review for inhaled corticosteroids on lung cancer incidence: not yet concluded story

Background

To systematically review studies on inhaled corticosteroids (ICS) and lung cancer incidence in chronic airway disease patients.

Methods

We conducted electronic bibliographic searches on OVID-MEDLINE, EMBASE, and the Cochrane Database before May 2020 to identify relevant studies. Detailed data on the study population, exposure, and outcome domains were reviewed.

Results

Of 4,058 screened publications, thirteen eligible studies in adults with chronic obstructive pulmonary disease (COPD) or asthma evaluated lung cancer incidence after ICS exposure. Pooled hazard ratio and odds ratio for developing lung cancer in ICS exposure were 0.81 (95% confidence interval, 0.64-1.02; I2=95.7%) from 10 studies and 1.02 (95% confidence interval 0.50-2.07; I2=94.7%) from 3 studies. Meta-regression failed to explain the substantial heterogeneity of pooled estimates. COPD and asthma were variously defined without spirometry in 11 studies. Regarding exposure assessment, 3 and 10 studies regarded ICS exposure as a time-dependent and fixed variable, respectively. Some studies assessed ICS use for the entire study period, whereas others assessed ICS use for 6 months to 2 years within or before study entry. Smoking was adjusted in four studies, and only four studies introduced 1-2 latency years in their main or subgroup analysis.

Conclusion

Studies published to date on ICS and lung cancer incidence had heterogeneous study populations, exposures, and outcome assessments, limiting the generation of a pooled conclusion. The beneficial effect of ICS on lung cancer incidence has not yet been established, and understanding the heterogeneities will help future researchers to establish robust evidence on ICS and lung cancer incidence.

Alveolar Adenoma With CD34 Diffusely Positive Stromal Cells: A Rare Case Report and Literature Review

Alveolar adenoma (AA) is a rare type of pulmonary neoplasm showing proliferation of alveolar epithelium and septal mesenchyme. Clinically, AA is asymptomatic, benign, and usually diagnosed incidentally. Surgical excision is curative. The etiology of AA is controversial and the pathogenesis is unknown, but it is thought to stem from type II pneumocytes and fibroblasts or fibroblast-like cells. The stromal cells in AA may show rare staining for CD34. Diffuse CD34 positivity of the interstitial stromal cells has rarely been described and reviewed. Here, we report a case of AA with strong and diffuse CD34 staining in the stromal cells.

Study Protocol for the Breathe Easier Trial: A Pilot RCT of a Dyad-Based, Multiple-Behavior Intervention for Improving Physical and Emotional Health in Survivors Facing Lung Cancer

BACKGROUND

Research targeting survivors of lung cancer has yet to adequately address the management of physical deconditioning and unresolved symptoms (dyspnea, fatigue). The objective of the Breathe Easier trial is to test the feasibility and preliminary effects of a theory-based, multiple-behavior intervention (physical activity, smoking reduction for current smokers, stress management) targeting survivors of localized non-small-cell lung cancer (NSCLC, stages I-III) and their supportive partners.

METHODS

This pilot RCT will enroll 30 dyads (60 participants). Each dyad will consist of one survivor and one partner (defined as a family member or friend) Dyads will be randomized to the Intervention Group (IG) or the Attention Control Group (AC). IG members will receive the 12-week, home-based intervention based on the individual and family self-management theory, which targets improvements in self-efficacy, social support, and self-regulation. Improvement in lifestyle behaviors is a proximal outcome. Improvements in physical and emotional health are distal outcomes. Breathe Easier (IG) includes educational content written in plain language as well as breathing exercises and meditations; SMART goal setting; daily text messaging; and weekly telephone calls with trained staff. The AC program includes relevant National Institutes of Health publications plus weekly telephone chats. Members who currently smoke will also receive an evidence-based smoking cessation resource.

DISCUSSION

Breathe Easier focuses on changes in multiple behaviors in dyads coping with a diagnosis of NSCLC (stages I-III) with the overall purpose of improving physical and emotional health. Findings will provide additional evidence of the feasibility and preliminary effects of this intervention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05956782; This trial was registered retrospectively.

Bronchoalveolar Lavage Fluid-Isolated Biomarkers for the Diagnostic and Prognostic Assessment of Lung Cancer

Lung cancer is considered one of the most fatal malignant neoplasms because of its late detection. Detecting molecular markers in samples from routine bronchoscopy, including many liquid-based cytology procedures, such as bronchoalveolar lavage fluid (BALF), could serve as a favorable technique to enhance the efficiency of a lung cancer diagnosis. BALF analysis is a promising approach to evaluating the tumor progression microenvironment. BALF's cellular and non-cellular components dictate the inflammatory response in a cancer-proliferating microenvironment. Furthermore, it is an essential material for detecting clinically significant predictive and prognostic biomarkers that may aid in guiding treatment choices and evaluating therapy-induced toxicities in lung cancer. In the present article, we have reviewed recent literature about the utility of BALF analysis for detecting markers in different stages of tumor cell metabolism, employing either specific biomarker assays or broader omics approaches.

Nondiagnostic, radial-probe endobronchial ultrasound-guided biopsy for peripheral lung lesions: The added value of radiomics from ultrasound imaging for predicting malignancy

OBJECTIVES

This study investigated whether radiomic features extracted from radial-probe endobronchial ultrasound (radial EBUS) images can assist in decision-making for subsequent clinical management in cases with indeterminate pathologic results.

METHODS

A total of 494 patients who underwent radial EBUS biopsy for lung nodules between January 2017 and December 2018 were allocated to our training set. For the validation set, 229 patients with radial EBUS biopsy results from January 2019 to April 2020 were used. A multivariate logistic regression analysis was used for feature selection and prediction modeling.

RESULTS

In the training set, 157 (67 benign and 90 malignant) of 212 patients pathologically diagnosed as indeterminate were analyzed. In the validation set, 213 patients were diagnosed as indeterminate, and 158 patients (63 benign and 95 malignant) were included in the analysis. The performance of the radiomics-added model, which considered satellite nodules, linear arc, shape, patency of vessels and bronchi, echogenicity, spiculation, C-reactive protein, and minimum histogram, was 0.929 for the training set and 0.877 for the validation set, whereas the performance of the model without radiomics was 0.910 and 0.891, respectively.

CONCLUSION

Although the next diagnostic step for indeterminate lung biopsy results remains controversial, integrating various factors, including radiomic features from radial EBUS, might facilitate decision-making for subsequent clinical management.

Successful extracorporeal membrane oxygenation in a patient with central airway obstruction due to an endotracheal mass

Extracorporeal membrane oxygenation (ECMO) assists blood circulation and gas exchange via a heart–lung machine. ECMO is used mainly in intensive care units as bridging therapy until heart and respiratory failure can be addressed or until transplantation can be performed. ECMO is sometimes used during surgery under general anaesthesia, depending on the patient’s underlying diseases and the nature of the operation. If the oxygen supply and carbon dioxide removal capacity are limited, venovenous (VV)-ECMO can be helpful. Here, we describe the use of VV-ECMO for surgical resection of an endotracheal mass through rigid bronchoscopy in a patient who developed decompensating dyspnoea due to central airway obstruction (CAO).

Genetic predisposition to lung adenocarcinoma outcome is a feature already present in patients' noninvolved lung tissue

Emerging evidence suggests that the prognosis of patients with lung adenocarcinoma can be determined from germline variants and transcript levels in nontumoral lung tissue. Gene expression data from noninvolved lung tissue of 483 lung adenocarcinoma patients were tested for correlation with overall survival using multivariable Cox proportional hazard and multivariate machine learning models. For genes whose transcript levels are associated with survival, we used genotype data from 414 patients to identify germline variants acting as cis-expression quantitative trait loci (eQTLs). Associations of eQTL variant genotypes with gene expression and survival were tested. Levels of four transcripts were inversely associated with survival by Cox analysis (CLCF1, hazard ratio [HR] = 1.53; CNTNAP1, HR = 2.17; DUSP14, HR = 1.78; and MT1F: HR = 1.40). Machine learning analysis identified a signature of transcripts associated with lung adenocarcinoma outcome that was largely overlapping with the transcripts identified by Cox analysis, including the three most significant genes (CLCF1, CNTNAP1, and DUSP14). Pathway analysis indicated that the signature is enriched for ECM components. We identified 32 cis-eQTLs for CNTNAP1, including 6 with an inverse correlation and 26 with a direct correlation between the number of minor alleles and transcript levels. Of these, all but one were prognostic: the six with an inverse correlation were associated with better prognosis (HR < 1) while the others were associated with worse prognosis. Our findings provide supportive evidence that genetic predisposition to lung adenocarcinoma outcome is a feature already present in patients' noninvolved lung tissue.

Association between Temporal Muscle Thickness and Overall Survival in Non-Small Cell Lung Cancer Patients with Brain Metastasis

Temporal muscle thickness (TMT) has recently been suggested as a novel biomarker of sarcopenia in head and neck malignancies. However, few studies have evaluated TMT as a prognostic marker in patients with brain metastasis. This study investigated the association of TMT with overall survival (OS) in non-small cell lung cancer (NSCLC) patients with brain metastasis. The records of all NSCLC patients with brain metastasis between 2009 and 2018 at St. Vincent’s Hospital were reviewed retrospectively. A total of 221 patients met our eligibility criteria. In the group with TMT thicker than the median, OS was longer than the group with TMT thinner than the median (240 days versus 139 days, p = 0.014). In multivariate analysis, the thicker TMT group had longer survival (HR 0.73 CI 0.56−0.96, p = 0.024). Male (HR 1.58 CI 1.19−2.09, p = 0.002) and older age (≥65 years) (HR 2.05 CI 1.53−2.74, p < 0.001) also showed statistical significance. We also performed subgroup analysis in older patients (≥65 years). In this subgroup of 107 patients, the thicker TMT group also showed longer OS than the thinner TMT group (209 days versus 82 days, p = 0.009). Our findings suggest that TMT can be a useful biomarker for OS in NSCLC patients with brain metastasis.

Social Determinants of Health, Environmental Exposures and Home Radon Testing

Home radon testing is a primary lung cancer prevention strategy, yet the majority of Americans have not tested their home. This descriptive, ecological study uses 54,683 observed radon values collected in Kentucky homes from 1996 to 2016 to examine the association of county-level social determinants of health and environmental exposures on home radon testing rates. Multivariate linear regression analysis indicates that as median home value, rurality, and radon risk potential increased, counties experienced an increase in annual home radon testing rates. As adult smoking prevalence increased, counties experienced a decrease in annual rates of residential radon testing. These findings indicate that counties with low median home values, high adult smoking prevalence, and high incidence of lung cancer may benefit most from prevention interventions aimed at promoting home radon testing, adopting radon- and smoke-free home policies, and integrating radon risk reduction messaging into tobacco cessation and lung cancer screening programs.

Primary salivary gland-type polymorphous adenocarcinoma in the lung: A case report and literature review

RATIONALE

Polymorphous low-grade adenocarcinoma is a low-risk infiltrative malignant tumor of the salivary glands. However, some of these tumors are more malignant than the low-grade tumors and therefore, according to the most recent recommendation of the World Health Organization, they are renamed as polymorphous adenocarcinomas (PACs). Primary polymorphous low-grade adenocarcinomas/PACs of the lungs are rare. Herein, we report a case of primary PAC of the lung with bronchial cartilage and perineural invasion, and lymph node metastasis.

PATIENT CONCERNS

A 58-year-old man had developed fever half a month prior, without chills or other accompanying symptoms, and the underlying reasons were unknown. His self-measured temperature was up to 39°C, accompanied by cough and expectoration, yellow and thin sputum, and shortness of breath. The patient's general state was normal, and respiratory sounds originating from the right lung were weak. Enhancement computed tomography revealed that the bronchial lumen of the basal segment of the lower lobe of the right lung was narrow; soft tissue density nodules were seen, with a range of approximately 2.4 cm × 1.3 cm.

DIAGNOSIS

Based on clinical information, morphological features, and immunohistochemistry results, the pathological diagnosis was primary PAC of the lungs.

INTERVENTION

Thoracoscopic resection of the middle and lower lobes of the right lung was performed, further extended dissection of the mediastinal lymph nodes was performed.

OUTCOMES

The postoperative course was uneventful.

LESSONS

Primary PAC of the lung is rare and may cause misdiagnosis. When encountering a lung tumor with diverse tissue structures, uniform cell type and nerve invasion, we should consider the possibility of PAC. Morphological and immunohistochemical features can be useful for diagnosing primary PAC of the lungs.

Final report on plasma ctDNA T790M monitoring during EGFR-TKI treatment in patients with EGFR mutant non-small cell lung cancer (JP-CLEAR trial)

Osimertinib is active against T790M-positive epidermal growth factor receptor mutant non-small cell lung cancer. We enrolled 122 sensitive epidermal growth factor receptor mutant non-small cell lung cancer patients who were planned to receive or were receiving first-/second-generation epidermal growth factor receptor tyrosine kinase inhibitors without disease progression and monitored plasma T790M every 1-2 months using the cobas® EGFR Mutation Test v2. We previously reported the concordance between T790M status in plasma and tissue. This is the final report on the sensitivity of plasma T790M and the efficacy of sequential osimertinib. The sensitivity was 21.1% (95% confidence interval: 6.1-45.6%). The best overall response was 25.0% (95% confidence interval: 9.8-46.7) in the plasma T790M-positive group and 28.6% (95% confidence interval: 8.4-58.1) in the plasma T790M-negative but tissue T790M-positive group. Median progression-free survival was 7.9 months (95% confidence interval: 4.7-17.5) for the former and 4.4 months (95% confidence interval: 3.0-N.E.) for the latter, with no statistically significant difference (P = 0.74).

A case report of low grade fetal lung adenocarcinoma with TP53 mutation

RATIONALE

Fetal lung adenocarcinoma (FLAC) is a rare malignant tumor that occurs in the alveolar epithelium. FLAC, as a distinct entity, is a malignancy with a very low incidence, accounting for less than 0.5% of all lung tumors, with a high rate of misdiagnosis due to its rarity, lack of typical presentation and imaging signs. According to histopathological differences, FLAC is further divided into 2 types: low-grade FLAC and high-grade FLAC. In the article, we report a young woman who was diagnosed with low-grade fetal-type lung adenocarcinoma.

PATIENT CONCERNS

An 18-year-old female patient was admitted due to cough and chest distress.

DIAGNOSIS

The final pathological examination confirmed that the lesion was a low-grade fetal lung adenocarcinoma.

INTERVENTIONS

The patient underwent thoracoscopic left lower lobectomy and regional lymph node dissection.

OUTCOMES

The postoperative course was stable, and no recurrence was observed 1 year after operation.

LESSONS

To the best of our knowledge, there are no previous case reports of low-grade fetal-type adenocarcinoma, TP53 gene mutation, and the significance of its mutation is not extensively studies. FLAC, although extremely rare, is considered in the differential diagnosis of lung cancer. In addition, biopsy, histopathology, and specific immunohistochemical staining of larger tissue specimens are helpful for accurate diagnosis of FLAC.

Developing an ACT-based intervention to address lung cancer stigma: Stakeholder recommendations and feasibility testing in two NCI-designated cancer centers

Objective: Few psychosocial interventions have been tailored to meet the unique needs of patients diagnosed with lung cancer. This pilot study developed and tested a six-week intervention for reducing lung cancer stigma.Design and Subjects: Guided by qualitative interviews conducted with 9 lung cancer patients and 5 thoracic oncology care providers, Acceptance and Commitment Therapy was adapted for treatment of lung cancer stigma (ACT-LCS). In a subsequent single arm pilot study, 22 lung cancer patients reporting high levels of stigma completed the intervention.Setting: NCI-designated cancer centers in the Southwestern and Eastern United States.Results: Of 46 eligible patients, 22 provided consent, with 20 completing the intervention (10 in-person, 10 telehealth). Overall stigma decreased across timepoints, largely driven by reductions in internalized stigma. There were also significant reductions in social isolation, sleep disturbance, and fatigue.Conclusions: The ACT-LCS protocol demonstrates preliminary feasibility and acceptability. This intervention may be particularly suited for helping patients navigate feelings associated with internalized stigma.

Efficacy and predictors of rechallenge with immune checkpoint inhibitors in non-small cell lung cancer

BACKGROUND

The efficacy of rechallenge with immune checkpoint inhibitors (ICIs) in non-small cell lung cancer (NSCLC) patients has not yet been fully clarified. This study aimed to identify the clinical characteristics of patients with NSCLC who benefited from rechallenge with ICIs.

METHODS

We retrospectively reviewed the clinical records of 24 patients who were diagnosed with NSCLC and rechallenged with ICIs between August 2016 and July 2021.

RESULTS

Of the 24 patients included in the study, 11 were in the responder group (45.8%) and 13 in the nonresponder group (54.2%). The number of patients who used a different ICI from that used in the initial therapy was significantly higher in the responder group than in the nonresponder group (p = 0.006). Multivariate analysis identified lung metastasis and female sex as significant independent risk factors for nonresponse to rechallenge with ICIs. Compared to the nonresponder group, the duration of treatment after rechallenge with ICIs was significantly longer in the responder group (p = 0.016), and there was a trend toward longer overall survival (p = 0.059).

CONCLUSIONS

Patients with lung cancer who were rechallenged with ICIs and without progressive disease after initial ICI therapy were able to continue ICI therapy for a longer period of time. This may be associated with longer survival. Patients with lung metastases and female patients are more likely to be nonresponsive to rechallenge with ICIs. Administration of a different type of ICI from that used in the initial ICI therapy may result in disease control.

Yang-Yin-Jie-Du decoction overcomes gefitinib resistance in non-small cell lung cancer via down-regulation of the PI3K/Akt signalling pathway

CONTEXT

Yang-Yin-Jie-Du Decoction (YYJDD) was used to improve gefitinib efficacy in our clinical practice, but its mechanism remains unclear.

OBJECTIVE

This study explored if YYJDD could reverse gefitinib resistance.

MATERIALS AND METHODS

H1975 cells were exposed to control, 10 μM gefitinib, 3.2 mg/mL YYJDD or combination treatment. Cell viability was detected by MTT during 0-96 h. Apoptosis and the PI3K/Akt proteins were tested by flow cytometry and western-blot at 24 h. LY294002 was applied to further determine the role of the PI3K/Akt. 23 BALB/c nude xenograft mice received normal saline (n = 5), 80 mg/kg gefitinib (n = 6), 2.35 g/kg lyophilised powder of YYJDD (n = 6) or combination treatment (n = 6) by gavage for 4 weeks and submitted to TUNEL, immunohistochemistry, and western-blot.

RESULTS

In vitro, gefitinib (IC₅₀: 20.68 ± 2.06 μM) and YYJDD (IC₅₀: 6.6 ± 0.21 mg/mL) acted in a moderate synergistic way. Combination treatment inhibited cell viability from 100% to 25.66%. Compared to gefitinb (33.23 ± 3.99%), cell apoptosis was increased with combination treatment (54.11 ± 7.32%), accompanied by down-regulation of the PI3K/Akt. LY294002 further inhibited cell viability, increased apoptosis, and down-regulated p-Akt/Akt. In vivo, the tumour sizes in the combination group (1165.13 ± 157.79 mm³) were smaller than gefitinib alone (1630.66 ± 208.30 mm³). The positive rate of TUNEL staining was increased by combination treatment (22.33 ± 2.75%) versus gefitinib (7.37 ± 0.87%), while the PI3K/Akt was down-regulated.

DISCUSSION AND CONCLUSION

YYJDD has potential to overcome gefitinib resistance. Future investigations should be focussed on its specific targets.

Assessment and Prognostic Value of Immediate Changes in Post-Ablation Intratumor Density Heterogeneity of Pulmonary Tumors via Radiomics-Based Computed Tomography Features

Objectives

To retrospectively observe the instantaneous changes in intratumor density heterogeneity after microwave ablation (MWA) of lung tumors and to determine their prognostic value in predicting treatment response and local tumor progression (LTP).

Methods

Pre- and post-MWA computed tomography (CT) images of 50 patients (37-males; 13-females; mean-age 65.9 ± 9.7y, 39 primary and 11 metastasis) were analyzed to evaluate changes in intratumor density. Global, regional, and local scale radiomics features were extracted to assess intratumor density heterogeneity. In four to six weeks, chest enhanced CT was used as the baseline evaluation of treatment response. The correlations between the parametric variation immediately after ablation and the visual score of ablation response (Rvisu) were analyzed by nonparametric Spearman correlation analysis. The 1-year LTP discrimination power was assessed using the area under the receiver operating characteristic (ROC) curves. A Cox proportional hazards regression model was used to identify the independent prognostic features.

Results

Although no significant volume changes were observed after ablation, the radiomics parameters changed in different directions and degrees. The mean intensity value from baseline CT image was 30.3 ± 23.2, and the post-MWA CT image was -60.9 ± 89.8. The ratio of values change was then calculated by a unified formulation. The largest increase (522.3%) was observed for cluster prominence, while the mean CT value showed the largest decline (321.4%). The pulmonary tumors had a mean diameter of 3.4 ± 0.8 cm. Complete ablation was documented in 36 patients. Significant correlations were observed between Rvisu and quantitative features. The highest correlations were observed for changes in local features after MWA, with r ranging from 0.594 to 0.782. LTP developed in 22 patients. The Cox regression model revealed Δcontrast% and response score as independent predictors (Δcontrast%: odds ratio [OR]=5.61, p=0.001; Rvisu: OR=1.73, p=0019). ROC curve analysis showed that Δcontrast% was a better predictor of 1-year LTP. with higher sensitivity (83.5% vs. 71.2%) and specificity (87.1% vs. 76.8%) than those for Rvisu.

Conclusions

The changes in intratumor density heterogeneity after MWA could be characterized by analysis of radiomics features. Real-time density changes could predict treatment response and LTP in patients with pulmonary tumors earlier, especially for tumors with larger diameters.

Previous pulmonary tuberculosis enhances the risk of lung cancer: systematic reviews and meta-analysis

PURPOSE

The possible association between history of pulmonary tuberculosis (TB) and lung cancer (LC) has attracted researchers' attention for several decades. This systematic review and meta-analysis aim to assess the association between previous pulmonary TB infection and LC risk.

METHODS

A Systematic and comprehensive search was performed in the following databases: PubMed, Embase, clinical key, Web of Science and Google Scholar, in articles and abstracts published from 1987 to 2021. Thirty-two articles (involving 50,290 cases and 846,666 controls) met the inconclusive criteria. The Comprehensive Meta-Analysis version 2.2 software was used for this meta-analysis.

RESULTS

The result of this meta-analysis demonstrates that pre-existing active pulmonary TB increases the risk of LC (RR = 2.170, 95% confidence interval [CI] 1.833-2.569, p < .001, I² = 91.234%). The results showed that the risk of the history of active pulmonary TB infection in adenocarcinoma was 2.605 (95% CI 1.706-3.979, p < .001, I² = 55.583%), in small-cell carcinoma was 2.118 (95% CI 1.544-2.905, p < .001, I² = 0.0%), in squamous-cell carcinoma, was 3.570 (95% CI 2.661 - 4.791, p < .001, I² = 42.695%) and 2.746 (95% CI 2.300-3.279, p < .001, I² = 41.686%) for other histological types of LCs. According to these results, a history of active pulmonary TB increases the risk of LC.

CONCLUSIONS

This study emphasizes the importance of LC screening in pulmonary TB patients even after the infection is treated. With the increased chances of LC in a patient who had a history of active pulmonary TB, there could be a need for a further follow-up period after pulmonary TB recovery.

A Prospective Pilot Study Evaluating Feasibility and Preliminary Effects of Breathe Easier: A Mindfulness-based Intervention for Survivors of Lung Cancer and Their Family Members (Dyads)

Objective: Symptom burden remains a distressing problem for survivors with non-small-cell lung cancer (stages I-IIIa). This pilot study evaluated feasibility and preliminary effects of a tailored mindfulness-based intervention, Breathe Easier, which encompasses meditation, 2 levels of mindful hatha yoga, breathing exercises, and participant interaction.

METHODS

Participants were recruited from 2 cancer programs in the US Southeast. A family member was required for participation. Sixty-two participants enrolled (20% recruitment) and 49 completed the intervention (79% retention). Participants chose level 1 yoga (basic) or level 2 (more advanced). Of the completers, survivors were 39% male and 65% Black. A community-based participatory research framework helped identify the specific needs and interests of potential participants and foreseeable barriers to implementation. A 2-month prospective, 1-group, pre-post design evaluated feasibility. Intervention dosage was measured using written protocols. Attendance and completion of daily home assignments measured adherence. Acceptability was assessed using a 10-item questionnaire, completed at three time points. Preliminary outcome data collected pre- and post-intervention tested the hypothesis that participants who received the 8-week intervention Breathe Easier would, post-intervention, demonstrate (a) less dyspnea, (b) less fatigue, (c) less stress, (d) improved sleep, (e) improved anxiety and depression, and (f) improved functional exercise capacity. Exit interviews were conducted, transcribed verbatim, and analyzed for content using descriptive statistics.

RESULTS

Quantitative and qualitative measures indicated strong feasibility. Over time, level 1 participants had statistically less dyspnea, fatigue and improved exercise capacity, as well as improved sleep, and stress scores. Level 2 participants experienced slightly increased dyspnea and fatigue but improved sleep, stress, and exercise capacity. All participants experienced anxiety and depression within normal limits pre- and post-intervention. Five major themes emerged out of exit interviews: Learning to Breathe Easier; Interacting with Others as a Personal Benefit; Stretching, Releasing Tension, and Feeling Energized; Enhancing Closeness with Committed Partners; Refocusing on Living; and Sustaining New Skills as a Decision.

CONCLUSIONS

The study offers insight into the feasibility of an 8-week in-person mindfulness-based intervention with a unique subset of understudied survivors of lung cancer and family members. Outcome data interpretation is limited by the 1-group design and sample size.

Feasibility, safety and outcomes of ambulation within 2 h postoperatively in patients with lung cancer undergoing thoracoscopic surgery

AIMS

The aims of this study were to evaluate the safety, feasibility and outcomes of ambulation within 2 h after thoracoscopic surgery in patients with lung cancer.

BACKGROUND

There are no consensus guidelines on the ideal time for early ambulation following thoracic surgery, although enhanced recovery programmes have been proposed since years.

METHODS

This non-randomized, concurrent-control study was conducted on patients who underwent thoracoscopic surgery between October 2020 and February 2021. Participants were assigned to either the observation group (ambulation within 2 h of extubation) or the control group (ambulation on the first postoperative day).

RESULTS

Of the 325 patients who were eligible, 227 were included in the study. Eighty-three per cent of patients were able to walk any distance within 2 h of extubation, and no adverse events occurred in patients. The length of hospital stay and time to first postoperative flatus were significantly shorter in the observation group than in the control group. There were no differences in the occurrence of postoperative complications and orthostatic hypotension, readmission rate and 6-min walk distance at discharge.

CONCLUSION

Ambulation within 2 h of extubation was safe and feasible and could lead to better recovery in patients with lung cancer undergoing thoracoscopic surgery.

CT-Detected Subsolid Nodules: A Predictor of Lung Cancer Development at Another Location?

The purpose of this case-cohort study was to investigate whether the frequency and computed tomography (CT) features of pulmonary nodules posed a risk for the future development of lung cancer (LC) at a different location. Patients scanned between 2004 and 2012 at two Dutch academic hospitals were cross-linked with the Dutch Cancer Registry. All patients who were diagnosed with LC by 2014 and a random selection of LC-free patients were considered. LC patients who were determined to be LC-free at the time of the scan and all LC-free patients with an adequate scan were included. The nodule count and types (solid, part-solid, ground-glass, and perifissural) were recorded per scan. Age, sex, and other CT measures were included to control for confounding factors. The cohort included 163 LC patients and 1178 LC-free patients. Cox regression revealed that the number of ground-glass nodules and part-solid nodules present were positively correlated to future LC risk. The area under the receiver operating curve of parsimonious models with and without nodule type information were 0.827 and 0.802, respectively. The presence of subsolid nodules in a clinical setting may be a risk factor for future LC development in another pulmonary location in a dose-dependent manner. Replication of the results in screening cohorts is required for maximum utility of these findings.

Survival of Patients with Lung Cancer in the Setting of Liver Cirrhosis: A Multicenter Propensity Score Matching Study

Purpose

The survival outcome of lung cancer patients with coexisting liver cirrhosis has thus far received limited attention in the literature. In this study, we evaluated whether liver cirrhosis is an independent risk factor for the survival of patients with lung cancer.

Materials and Methods

We conducted a retrospective, multicenter, propensity-matched study of lung cancer patients with and without liver cirrhosis. To determine differences in survival, we sought to identify risk factors associated with poor outcomes using Kaplan–Meier survival analysis and Cox proportional hazards regression.

Results

There were no statistically significant differences in the baseline clinical characteristics of patients between the cirrhosis and non-cirrhosis groups. The median overall survival of patients with and without cirrhosis was 13.07 months (95% confidence interval [CI]: 10.56–16.84) and 13.67 months (95% CI: 10.42–16.91), respectively (p=0.76). Cox proportional hazards regression analysis revealed that liver cirrhosis was not an independent risk factor for poor outcome (hazard ratio [HR]: 1.057, 95% CI: 0.805–1.388, p=0.690). In patients with cirrhosis, lower serum albumin levels, higher Charlson Comorbidity Index score, advanced-stage lung cancer, and treatment modality were factors associated with poor outcome. Increase in serum albumin by 1 g was associated with a 30% reduction in the risk of mortality (HR: 0.700, 95% CI: 0.494–0.993, p=0.045). While every point increase in the Charlson Comorbidity Index score by 1 point was linked to a 9% higher risk of mortality (HR: 1.090, 95% CI: 1.023–1.161, p=0.007).

Conclusion

The survival rates of lung cancer patients with and without cirrhosis did not differ significantly. Higher serum albumin levels and lower Charlson Comorbidity Index scores were associated with improved survival.

Computed Tomography-Guided Transthoracic Needle Biopsy: Predictors for Diagnostic Failure and Tissue Adequacy for Molecular Testing

Background: Adequate and representative tissue from lung tumor is important in the era of precision medicine. The aim of this study is to identify detailed procedure-related variables and factors influencing diagnostic success and tissue adequacy for molecular testing in CT-guided TTNB.

Methods: Consecutive patients undergoing CT-guided TTNB were retrospectively enrolled between January 2013 and May 2020. Multivariate analysis was performed for predictors for diagnostic accuracy and tissue adequacy for molecular testing. Logistic regression was used to identify risk factors for procedure-related complications.

Results: A total of 2,556 patients undergoing CT-guided TTNB were enrolled and overall success rate was 91.5% (2,338/2,556). For lung nodules ≤3 cm, predictors for diagnostic success included coaxial needle use [OR = 0.34 (0.16–0.71), p = 0.004], CT scan slice thickness of 2.5 mm [OR = 0.42 (0.15–0.82), p = 0.011] and additional prefire imaging [OR = 0.31 (0.14–0.68), p = 0.004]. For lung tumor >3 cm, ground glass opacity part more than 50% [OR = 7.53 (2.81–20.23), p < 0.001] or presence of obstructive pneumonitis [OR = 2.31 (1.53–3.48), p < 0.001] had higher risk of diagnostic failure. For tissue adequacy, tissue submitted in two cassettes (98.9 vs. 94.9%, p = 0.027) was a positive predictor; while male (5.7 vs. 2.5%, p = 0.032), younger age (56.61 ± 11.64 vs. 65.82 ± 11.98, p < 0.001), and screening for clinical trial (18.5 vs. 0.7%, p < 0.001) were negative predictors.

Conclusions: Using a coaxial needle, with thin CT slice thickness (2.5 mm), and obtaining additional prefire imaging improved diagnostic success, while obtaining more than two tissue cores and submitting in two cassettes improved tissue adequacy for molecular testing.

Performance of an AI based CAD system in solid lung nodule detection on chest phantom radiographs compared to radiology residents and fellow radiologists

Background

Despite the decreasing relevance of chest radiography in lung cancer screening, chest radiography is still frequently applied to assess for lung nodules. The aim of the current study was to determine the accuracy of a commercial AI based CAD system for the detection of artificial lung nodules on chest radiograph phantoms and compare the performance to radiologists in training.

Methods

Sixty-one anthropomorphic lung phantoms were equipped with 140 randomly deployed artificial lung nodules (5, 8, 10, 12 mm). A random generator chose nodule size and distribution before a two-plane chest X-ray (CXR) of each phantom was performed. Seven blinded radiologists in training (2 fellows, 5 residents) with 2 to 5 years of experience in chest imaging read the CXRs on a PACS-workstation independently. Results of the software were recorded separately. McNemar test was used to compare each radiologist’s results to the AI-computer-aided-diagnostic (CAD) software in a per-nodule and a per-phantom approach and Fleiss-Kappa was applied for inter-rater and intra-observer agreements.

Results

Five out of seven readers showed a significantly higher accuracy than the AI algorithm. The pooled accuracies of the radiologists in a nodule-based and a phantom-based approach were 0.59 and 0.82 respectively, whereas the AI-CAD showed accuracies of 0.47 and 0.67, respectively. Radiologists’ average sensitivity for 10 and 12 mm nodules was 0.80 and dropped to 0.66 for 8 mm (P=0.04) and 0.14 for 5 mm nodules (P<0.001). The radiologists and the algorithm both demonstrated a significant higher sensitivity for peripheral compared to central nodules (0.66 vs. 0.48; P=0.004 and 0.64 vs. 0.094; P=0.025, respectively). Inter-rater agreements were moderate among the radiologists and between radiologists and AI-CAD software (K’=0.58±0.13 and 0.51±0.1). Intra-observer agreement was calculated for two readers and was almost perfect for the phantom-based (K’=0.85±0.05; K’=0.80±0.02); and substantial to almost perfect for the nodule-based approach (K’=0.83±0.02; K’=0.78±0.02).

Conclusions

The AI based CAD system as a primary reader acts inferior to radiologists regarding lung nodule detection in chest phantoms. Chest radiography has reasonable accuracy in lung nodule detection if read by a radiologist alone and may be further optimized by an AI based CAD system as a second reader.

Primary pulmonary diffuse large B-cell lymphoma in a young female patient

Even if the patient is young or female, a primary pulmonary diffuse large B-cell lymphoma could be considered as a differential diagnosis of multifocal consolidation in the lung.

Learning curve of robotic portal lobectomy for pulmonary neoplasms: A prospective observational study

Background

We aim to assess the learning curve of robotic portal lobectomy with four arms (RPL‐4) in patients with pulmonary neoplasms using prospectively collected data.

Methods

Data from 100 consecutive cases with lung neoplasms undergoing RPL‐4 were prospectively accumulated into a database between June 2018 and August 2019. The Da Vinci Si system was used to perform RPL‐4. Regression curves of cumulative sum analysis (CUSUM) and risk‐adjusted CUSUM (RA‐CUSUM) were fit to identify different phases of the learning curve. Clinical indicators and patient characteristics were compared between different phases.

Results

The mean operative time, console time, and docking time for the entire cohort were 130.6 ± 53.8, 95.5 ± 52.3, and 6.4 ± 3.0 min, respectively. Based on CUSUM analysis of console time, the surgical experience can be divided into three different phases: 1–10 cases (learning phase), 11–51 cases (plateau phase), and >51 cases (mastery phase). RA‐CUSUM analysis revealed that experience based on 56 cases was required to truly master this technique. Total operative time (p < 0.001), console time (p < 0.001), and docking time (p = 0.026) were reduced as experience increased. However, other indicators were not significantly different among these three phases.

Conclusions

The RPL‐4 learning curve can be divided into three phases. Ten cases were required to pass the learning curve, but the mastery of RPL‐4 for satisfactory surgical outcomes requires experience with at least 56 cases.

Azygos Continuation of the Inferior Vena Cava: Potential for Misdiagnosis as Lung Neoplasm

BACKGROUND

The azygos venous system is an accessory venous pathway supplying an important collateral circulation between the superior and inferior vena cava (IVC).

CASE SUMMARY

We report a case of complicated community-acquired pneumonia with interruption of the IVC with azygos continuation that was misdiagnosed as lung neoplasm.

DISCUSSION

The aim of this case report is to emphasize the importance of recognizing an enlarged azygos vein at the confluence with the superior vena cava and in the retrocrural space to avoid misdiagnosis as a right-sided para-tracheal mass. The angiographic features and clinical importance of this condition are discussed.

LEARNING POINTS

An enlarged azygos vein at the confluence with the superior vena cava and in the retrocrural space can be misdiagnosed as a right-sided para-tracheal mass/neoplasm or retrocrural adenopathy.Biopsy is the most important tool to confirm the diagnosis of malignancy but could be catastrophic in this situation.Re-imaging after treatment for infection and pneumonia could potentially avoid this error.

Efficacy of an inpatient smoking cessation program at a single regional cancer center: A prospective observational study

ABSTRACT

Smoking is the leading cause of preventable death and a risk factor for cancer, but smoking cessation is difficult even in patients who need hospitalization. This study aimed to investigate the usefulness of an inpatient smoking cessation consultation program and to analyze the clinical factors associated with abstinence. In this observational study, patients received regular counseling for 6 months, and abstinence was objectively assessed via urine and exhaled carbon monoxide testing. Cessation rates were assessed at 4 weeks and 6 months, and clinical characteristics associated with cessation success were investigated. Of the 571 patients referred to participate in the program, 170 (29.8%) were enrolled, and only 2 (1.2%) used smoking cessation drugs in addition to counseling. The smoking cessation rate was 77.6% after 4 weeks and 59.1% after 6 months. The cessation rates were significantly higher in patients with cancer than in those without cancer at both timepoints (63.8% vs 21.9%, P < .001, 53.6% vs 12.5%, P < .001), and they were also higher in the first admission group than in the re-admission group (87.4% vs 74.7%, P = .033, 88.5% vs 76.1%, P = .037). In patients with lung cancer, progression-free survival and overall survival tended to be better in those enrolled in the program (P = .158, P = .183). In conclusion, the inpatient smoking cessation program was associated with a high abstinence rate. Most patients maintained cessation without medication, suggesting that initial admission, along with a cancer diagnosis, can provide enough motivation to abstain from smoking. In addition, the smoking cessation effort showed potential to improve survival during lung cancer treatment.

Bronchoplasty for the treatment of carcinoid tumour

Lung carcinoid tumours are rare neoplasms with a favourable prognosis. Bronchoplasty can be a conservative treatment for typical carcinoid tumours and can be applied for patients with limited respiratory function. We report the case of a 34-year-old woman, with a polypoid tumour located at the distal right main bronchus. Bronchial biopsy showed a typical carcinoid tumour. After resection of the tumour in the right main bronchus, bronchoplasty was performed by end-to-end anastomosis of the remaining right main bronchus, right upper lobar bronchus, and the upper bronchus intermedius. Bronchoscopy showed a good quality anastomosis with slightly reduced endoluminal calibre only. The post-operative period was uneventful and the patient was discharged at the seventh day. One year later, no complications occurred and the patient is still being followed up regularly.

Feasibility of Ultra-Low-Dose CT for Bronchoscopy of Peripheral Lung Lesions

Background and objectives: Thin-section computed tomography (CT) is essential for identifying small bronchi during bronchoscopy using radial endobronchial ultrasound. Some patients should receive an additional CT for a thin-section image. We performed a retrospective study with a prospectively collected database to identify the optimal radiation dose for thin-section CT during peripheral bronchoscopy. Materials and Methods: In total, 91 patients with peripheral lung lesions underwent thin-section CT (both standard CT as a reference and ultra-low-dose CT (ultra-LDCT)). The patients were randomly assigned to one of four groups according to the ultra-LDCT parameters: group 1 = 120 kVp, 25 mAs; group 2 = 100 kVp, 15 mAs; group 3 = 120 kVp, 5 mAs; and group 4 = 100 kVp, 5 mAs. Two radiologists and two physicians analyzed both the standard CT and ultra-LDCT. Results: The effective doses (EDs) of ultra-LDCT significantly differed among the four groups (median EDs were 0.88, 0.34, 0.19, and 0.12 mSv for groups 1-4, respectively; p < 0.001). Median differences in peripheral airway wall thickness were higher in group 4 than in other groups (differences in median wall thickness measured by two radiologists were 0.4-0.5 mm and 0.8-0.9 mm for groups 1-3 and group 4, respectively). Bronchus signs on ultra-LDCT in groups 1 and 2 were well correlated with those of the standard-dose CT (accuracies of two radiologists and two pulmonary physicians were 95-100%). Conclusions: Our results indicate that ultra-LDCT with ED of >0.34 mSv (ED of group 2) is feasible for peripheral bronchoscopy.

Vitiligo-like depigmentation after pembrolizumab treatment in patients with non-small cell lung cancer: a case report

Immune checkpoint inhibitors (ICIs) targeting programmed death-1 (PD-1) pathway have significantly improved outcomes for patients with a variety of malignancies, including non-small cell lung cancer (NSCLC). In contrast, the incidence of immune-related cutaneous adverse events such as vitiligo have been on the rise because of the increasing use of ICIs. Vitiligo-like depigmentation has been reported in only 2.0% to 8.3% of patients with melanoma and is considered a favorable prognostic factor. However, it has been rarely reported in patients with non-melanoma malignancies. We describe a case of vitiligo-like skin depigmentation after pembrolizumab use in a patient with stage IV NSCLC. Multiple ill-defined painless and non-pruritic depigmented patches appeared on the patient’s hands, scrotum, and lower lip after five months of pembrolizumab. We continued treatment with pembrolizumab 2 mg/kg for 14 months with close monitoring of vitiligo lesions until the progression of brain metastasis, but the vitiligo-like depigmentation did not improve by the combined excimer laser and topical corticosteroid therapy. Clinicians should be aware that immune-related cutaneous adverse events such as vitiligo-like depigmentation are not limited to cases of melanoma but arise as a direct result of anti-PD-1 therapy.

Relationship between periodontal disease and lung cancer: A systematic review and meta-analysis

Periodontal disease (PD), as a chronic bacterial infection, might cause cardiovascular and some other systemic diseases, with recent studies reporting that it exhibits some connection with lung cancer. While studies have shown that poor oral health might increase the risk of lung cancer, the veracity of these reports is questionable. Therefore, this meta-analysis was undertaken to investigate the association between PD and the risk of lung cancer. A search was run in PubMed, EMBASE, MEDLINE, CENTRAL, and ClinicalTrials.gov databases up to January 1, 2020. Cohort and case-control studies investigating the correlation between PD and lung cancer were included. Eligibility assessment and data extraction were conducted independently, and a meta-analysis was performed to synthesize the data. The association between PD, edentulism, and lung cancer was measured by the adjusted hazard ratios (HRs) or odds ratios (ORs) and their 95% confidence intervals (CIs) provided in articles. We employed appropriate effect model in terms of I² (a fixed-effect model for PD and a random-effect model for edentulism) to obtain summary effect estimates. Statistical heterogeneity was investigated by chi-square test and I² statistics. Newcastle-Ottawa Scale (NOS) was used to assess the quality of their method. Six cohort studies (eight references) and two case-control studies, assessed as high-quality, involving 167 256 participants, were included in the review. The summary estimates based on adjusted data showed an association between PD and a significant risk of lung cancer both in cohort studies (HR = 1.40, 95% CI = 1.25-1.58; I²  = 8.7%) and case-control studies (OR = 1.51, 95% CI = 1.16-1.98; I²  = 36.5%). Similar features were found in the sensitivity analysis and subgroups for six cohort studies, of male only (HR = 1.36, 95% CI = 1.15-2.60), setting the lung cancer incidence as endpoint (HR = 1.39, 95% CI = 1.24-1.57; I²  = 23.9%), and adjusting alcohol for multifactorial HR (HR = 1.38, 95% CI = 1.21-1.57; I²  = 39.9%). The summary HR for edentulism was 1.93 (95% CI = 1.05-3.57; I²  = 55.3%). No obvious publication bias was detected. This systematic review and meta-analysis demonstrated a significant association between PD and the incidence of lung cancer. Further observational studies are required by using standardized measurements to assess the periodontal status and by eliminating confounding factors, such as alcohol and diabetes, to verify such a relationship.

Pleural Plaques and the Risk of Lung Cancer in Asbestos-exposed Subjects

Rationale: Asbestos exposure is associated with a dose-dependent risk of lung cancer. The association between lung cancer and the presence of pleural plaques remains controversial.

Objectives: To define the relationship between pleural plaques and lung cancer risk.

Methods: Subjects were from two cohorts: 1) crocidolite mine and mill workers and Wittenoom Township residents and 2) a mixed-asbestos-fiber, mixed-occupation group. All subjects underwent annual review since 1990, chest X-ray or low-dose computed tomography scan, and outcome linkage to national cancer and mortality registry data. Cox regression, with adjustment for age (as the underlying matching time variable), was used to estimate hazard ratios (HRs) for lung cancer incidence by sex, tobacco smoking, asbestos exposure, presence of asbestosis, and pleural plaques.

Measurements and Main Results: For all 4,240 subjects, mean age at follow up was 65.4 years, 3,486 (82.0%) were male, 1,315 (31.0%) had pleural plaques, and 1,353 (32.0%) had radiographic asbestosis. Overall, 3,042 (71.7%) were ever-smokers with mean tobacco exposure of 33 pack-years. In total, 200 lung cancers were recorded. Risk of lung cancer increased with cumulative exposure to cigarettes, asbestos, and presence of asbestosis. Pleural plaques did not confer any additional lung cancer risk in either cohort (cohort 1: HR, 1.03; 95% confidence interval, 0.64-1.67; P = 0.89; cohort 2: HR, 0.75; 95% confidence interval, 0.45-1.25; P = 0.28).

Conclusions: The presence of pleural plaques on radiologic imaging does not confer additional increase in the risk of lung cancer. This result is consistent across two cohorts with differing asbestos fiber exposures and intensity.

Australia-wide cross-sectional survey of general practitioners' knowledge and practice of lung cancer screening

BACKGROUND

Low-dose computed tomography (LDCT) screening can reduce lung cancer deaths in high-risk individuals, yet current Australian guidelines do not recommend screening. Little is known about current screening practices in Australia.

AIM

To evaluate the proportion of general practitioners who report ordering lung cancer screening for their patients, identify factors associated with ordering lung cancer screening and assess general practitioners (GP) rationale for recommending screening and preference of composition of any future national targeted screening programme.

METHODS

A survey was distributed to a nationally representative sample of 4000 Australian GP. The questionnaire included respondent demographics, self-reported screening practices, knowledge of screening recommendations, recent screening education, preference for recruitment methodologies for potential screening programmes and potential factors influencing the screening practices of GP. Two logistic regression models identified factors associated with self-reported chest X-ray (CXR) and LDCT screening within the past 12 months.

RESULTS

A total of 323 GP completed the survey (participation rate 8.1%). Participants were mostly females (50.6%), from collective/group (79.1%) and metropolitan-based practices (73.5%). Despite the majority of responders understanding that screening is not recommended by Australian professional societies (71.2%), a substantial proportion of participants requested a CXR or LDCT screening (46.4% and 20.8% respectively). A variety of shared (GP reassurance, affordability of screening, believing screening is funded) and unique practice, educational and cognitive factors were associated with self-reported LDCT and CXR screening, with the strongest association being recent education about screening from radiology practices (odds ratio (aOR) for LDCT screening 10.4, P < 0.001).

CONCLUSION

In Australia, lung cancer screening occurs outside a coordinated programme, and there is discordance between practice and national recommendations. This highlights an urgent need for clearer guidance from national and professional bodies.

Implementing 'Goals of Care' discussion and palliative care referral for patients with advanced lung cancer: an outpatient-based pilot project

BACKGROUND

Early involvement of palliative care and advance care planning improves quality-of-life outcomes and survival for patients with advanced lung cancer; however, there are barriers to implementation.

AIMS

A single-centre prospective audit reviewing 'Goals of Care' (GOC) form completion and palliative care referrals in an oncology clinic was undertaken with the aim of increasing GOC completion and palliative care referrals for patients with advanced lung cancer.

METHODS

Involved physicians attended a communication skills course and then received a communication-priming intervention. Clinicopathological factors associated with GOC completion and palliative care referral were explored.

RESULTS

A total of 84 patients receiving palliative treatment for advanced lung cancer was enrolled. Clinicopathological factors, such as poorer performance status, were associated with higher likelihood of GOC completion (P = 0.018) prior to the intervention. Male sex (P = 0.023), absence of sensitising epidermal growth factor receptor mutation or anaplastic lymphoma kinase rearrangement (P = 0.017), type of systemic therapy (P = 0.031) and poorer performance status (P < 0.001) were associated with higher likelihood of palliative care referral. The intervention improved GOC completion (relative risk (RR) 1.29, P = 0.004); however, this was not sustained in a follow-up audit (RR 0.98, P = 0.92) and there was no change in palliative care referral rate (RR 2.5, P = 0.16). Predictors of palliative referral following clinical review included age (RR 1.16, P = 0.001), male sex (RR 14.2, P = 0.02) and poorer performance status (RR 1.76, P < 0.001).

CONCLUSIONS

Communication-priming interventions can improve GOC completion for patients with advanced lung cancer. Further investigation is needed to pursue sustainable options for managing this complex patient group and improve guideline-adherence and patient care.

Herbal medicine on cancer-related fatigue of lung cancer survivors: Protocol for a systematic review

BACKGROUND

Lung cancer is one of the most common cancers worldwide, and approximately half of the patients with lung cancer receiving chemotherapy suffer from cancer-related fatigue (CRF). Herbal medicines (HMs) have been used in Oriental countries for centuries as tonics. Various beneficial effects of HM on fatigue and cancer have been reported. However, the effectiveness and safety of HM for CRF in lung cancer patients have not been synthesized. The purpose of this systematic review is to evaluate the effectiveness and safety of HM for CRF in patients with lung cancer, regardless of their cancer type or stage.

METHODS AND ANALYSIS

A comprehensive search will be conducted in 12 electronic medical databases including 5 English-language databases (Medline via PubMed, EMBASE via Elsevier, the Cochrane Central Register of Controlled Trials [CENTRAL], the Allied and Complementary Medicine Database [AMED] via EBSCO, and the Cumulative Index to Nursing and Allied Health Literature [CINAHL] via EBSCO), 4 Korean-language databases (Oriental Medicine Advanced Searching Integrated System [OASIS], Koreanstudies Information Service System [KISS], Research Information Service System [RISS], and Korea Citation Index [KCI]), 2 Chinese-language databases (China National Knowledge Infrastructure [CNKI] and Wanfang Data), and 1 Japanese-language database (CiNii). Only randomized controlled trials (RCTs) and quasi-RCTs on HM for CRF will be allowed. The severity of fatigue assessed using a validated tool will be considered as theprimary outcome. The secondary outcomes will include the patients' quality of life, activities of daily life, incidence of adverse events, and total effective rate. Two independent researchers will perform the study selection, data extraction, and quality assessment. RevMan version 5.3 will be used for data synthesis. The methodological quality of the included RCTs will be assessed using the Cochrane Collaboration's risk of bias tool. In the meta-analysis, for dichotomous data and continuous data, risk ratio and mean difference, respectively, will be estimated with their 95% confidence intervals. According to the heterogeneity, either a fixed-effects or a random-effects model will be used.

ETHICS AND DISSEMINATION

Ethical approval is not required because individual patient data are not included. The findings of this systematic review will be disseminated through a peer-reviewed publication or conference presentation.

PROSPERO REGISTRATION NUMBER

CRD42019141660.

Multidisciplinary Team-Based Management of Incidentally Detected Lung Nodules

BACKGROUND

Each year, > 1.5 million Americans are diagnosed with an incidentally detected lung nodule. Practice guidelines attempt to balance the benefit of early detection of lung cancer with the risks of diagnostic testing, but adherence to guidelines is low. The goal of this study was to determine guideline adherence rates in the setting of a multidisciplinary nodule clinic and describe reasons for nonadherence as well as associated outcomes.

METHODS

This cohort study included 3 years of follow-up of patients aged ≥ 35 years with an incidentally detected lung nodule evaluated in a multidisciplinary clinic that used the 2005 Fleischner Society Guidelines.

RESULTS

Among 113 patients, 67% (95% CI, 58-76) were recommended a guideline-concordant nodule evaluation; 7.1% (95% CI, 3.1-13) and 26% (95% CI, 18-25) were recommended less or more intense evaluation, respectively. In contrast, 58% (95% CI, 48-67), 22% (95% CI, 18-25), and 23% (95% CI, 16-32) received a guideline-concordant, less intense, or more intense evaluation. The most common reason for recommending guideline-discordant care was concern for two different diagnoses that would each benefit from early detection and treatment. A majority of lung cancer diagnoses (88%) occurred in patients who received guideline-concordant care. There were no lung cancer cases in those who received less intense nodule care.

CONCLUSIONS

A multidisciplinary nodule clinic may serve as a system-level intervention to promote guideline-concordant care, while also providing a multidisciplinary basis by which to deviate from guidelines to address the needs of a heterogeneous patient population.

Evaluation of the solitary pulmonary nodule

The solitary pulmonary nodule represents a common diagnostic challenge for clinicians. While most are benign, a significant number represent early, potentially curable lung cancers. With the increased utilisation of chest computed tomography, solitary pulmonary nodules are increasingly being identified and with lung cancer screening programmes now on the horizon globally, it is crucial clinicians are familiar with the evaluation and management of solitary pulmonary nodules. Through the evaluation of patient risk factors combined with computed tomography characteristics of solitary pulmonary nodules, including size, growth rate, margin characteristics, calcification, density and location; a clinician can assess the risk of malignancy. This article provides an up to date review of the imaging features of both benign and malignant solitary pulmonary nodules to assist in the identification of nodules that require histological confirmation or ongoing surveillance. In addition, we summarise the newly updated Fleischner Society Guidelines that provide clinicians with a framework for the evaluation and management of solitary pulmonary nodules.