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Objective: The aim of the cross-over study was to evaluate skill acquisition in lobectomy-naive surgical trainees completing a 4-week program to learn VATS lobectomy on a virtual reality surgical simulator (LapSim). Method(s): Lobectomynaive surgical trainees (year 1 and 2 postgraduation) were enrolled during the COVID pandemic from March to June 2021 for a 4-week course on basic VATS skills and right upper lobectomy. They were divided into 2 groups. Both groups completed an initial assessment, Group 1 completed the course first, then both groups completed a second assessment. Then Group 2 completed the course, and both groups completed a final assessment. Skill acquisition was assessed using instrument movement, procedure time, and blood loss for both the trained operation and an untrained operation (left lower lobectomy). Result(s): 16 trainees were enrolled, 10 completed the training program. There was no difference in baseline assessment. After Group 1 completed the training, they outperformed Group 2 in all metrics but this did not reach statistical significance. After training Group 2 at week 8, there was no longer difference in performance from Group 1. After completing the training program, the entire cohort showed a significant improvement in basic VATS tasks as well as lobectomies. There was statistically significant improvement in both right upper lobectomy instrument movement (P=0.002) and time (P=0.009) and left lower lobectomy time (P=0.047). Conclusion(s): This study showed that VATS simulation training on LapSim allowed junior trainees to learn advanced VATS resection during a pandemic and within 4 weeks. The acquired skills is transferrable to untrained operations. (Table Presented).
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Lobectomy with pulmonary artery (PA) angioplasty in locally advanced lung cancer is an alternative to pneumonectomy. It is feasible, oncologically effective and the procedure of choice in patients with recurrent hemoptysis and limited pulmonary reserves. We present a case of a successful left upper lobectomy with PA resection and reconstruction by an autologous pericardial patch.Copyright © 2022 EDIZIONI MINERVA MEDICA.
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INTRODUCTION: The COVID-19 pandemic has presented patients with barriers to receiving healthcare. We sought to determine whether changes in healthcare access and practice during the COVID-19 pandemic has affected perioperative outcomes after robotic-assisted pulmonary lobectomy (RAPL). METHOD(S): We retrospectively analyzed 721 consecutive patients who underwent RAPL between September 2010 and March 2022 by one surgeon at one institution. With March 1st, 2020, defining the start of the COVID-19 pandemic, we grouped 638 patients as PreCOVID-19 and 83 patients as COVID-19-Era based on surgical date. An optimal variable ratio matching method of one to four PreCOVID-19 patients (with average of three) were matched to each COVID-19-Era patient. Variables used for matching were age, gender, smoking history in pack-years, and preoperative diabetes mellitus, coronary artery disease or myocardial infarction, and FEV1%. Variables of interest were compared utilizing Student's t-test, Wilcoxon rank-sum test, and Chi-square (or Fisher's exact) test, with significance at p<=0.05. Multivariable generalized linear regression was used to investigate predictors of the presence of postoperative complications and report odds ratios (OR). RESULT(S): COVID-19-Era patients had higher incidences of preoperative atrial fibrillation (p=0.027), peripheral vascular disease (p=0.0425), and pancreatitis (p=0.0349) compared to PreCOVID-19 patients. Differences in tumor size and histology, nodal status, and AJCC v8 pathologic stage were statistically insignificant. COVID-19-Era patients experienced a high incidence of effusion or empyema postoperatively (p< 0.0001). The PreCOVID-19 and COVID-19-Era cohorts had comparable odds for developing a postoperative complication. Older age, longer intraoperative skin-to-skin duration, and preoperative COPD are all predictive of an increased risk of developing a postoperative complication (Table 1). CONCLUSION(S): Despite our COVID-19-Era patients having greater indices of preoperative comorbidities, our analysis showed that they had a similar risk of developing a postoperative complication when compared to our PreCOVID-19 patients. Risk factors for development of postoperative effusion should be determined to minimize risk of empyema in COVID-19-Era patients. Patient age, skin-to-skin duration of the procedure, and preoperative COPD should be considered when planning for complication risk following RAPL.
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Over the course of a clinical trial, changes in the practice environment have the potential to reduce internal and external validity and impact change in patient outcomes. Such ''history effects''1 can take the form of changes in standard of care, clinical guidelines and recommendations, new drug/device availability in the marketplace, testing and screening procedures, and, as recently experienced, a global pandemic. Clinical trials conducted over many years are particularly susceptible to history effects. Such effects can impact foundational ability to continue a trial, including clinician equipoise and ability to implement trial interventions, necessitating awareness and action planning. For example, Curtis et al.2 acknowledged challenges with clinical guideline history effects and issued recommendations for addressing them such as consideration of participant wellbeing, stakeholder engagement, safety monitoring, review of guideline and policy changes, and development of rules for protocol changes. This session will explore how four multisite clinical trials conducted with VA Cooperative Studies Program sponsorship and coordination have weathered history effects during prolonged periods of enrollment. Topics to be covered include the implementation of pragmatic designs, monitoring of clinical guidelines, assessing control group treatment conditions, modifying protocols, adjusting quality assurance procedures, refining recruitment pathways, and training site investigators. The speakers, Study Chairs, will describe best practices and provide recommendations for navigating history effects in prolonged multisite clinical trials that can ensure outcomes remain relevant and compelling to inform public health at trial commencement. The CSP 2008/PTXRx study is a pragmatic, randomized, double-blind, placebo-controlled, multicenter clinical trial of Veteran patients with diabetic kidney disease (DKD) examining whether pentoxifylline (PTX), when added to usual care, can delay time to end-stage renal disease or death. Enrollment for the study began in 2019, and it is anticipated that 9 years of follow-up will be required to observe the required number of primary events. Given the long duration of the study, changes in clinical guidelines were anticipated and have occurred, including the approval of new DKD therapies and introduction of a new formula for estimated glomerular filtration rate (eGFR) calculation. In anticipation of these changes, the study design allows for whatever standard of care is extant at any time during the course of the study. PTXR's pragmatic trial design and protocol leverage the VA's research infrastructure and remote platforms allowing the study to be responsive to external changes and to safely continue during a global pandemic. The CSP 596/OPTION study is a randomized, double- blind, multicenter trial of Veteran patients with a first or second recurrent Clostridium difficile infection (CDI) comparing (1) fidaxomicin and (2) vancomycin, followed by a taper and pulse to (3) a standard vancomycin regimen. Since enrollment began in 2016, significant changes in CDI epidemiology and clinical management have impacted the study. The COVID-19 pandemic also resulted in an administrative hold on all trial activity followed by staggered reopening of sites due to variable COVID-19 activity and clinical priorities. Many clinical laboratories switched to algorithms that included free toxin assays in addition to polymerase chain reaction (PCR) tests out of concern for overdiagnosis based on PCR testing alone, reducing the number of potentially enrollable cases. There has been increased empirical vancomycin treatment for recurrent CDI without confirmation by stool testing, a requirement for enrollment, and a recruitment strategy for identifying potential cases. Finally, conflicting clinical guidelines for recurrent CDI has created potential equipoise when considering enrollment. Ongoing educational efforts have been made to clarify the protocol and emphasize the validity of the research question as well as protoco changes to allow safe enrollment and follow-up of participants in the face of the ongoing COVID-19 pandemic. The CSP 2005/VALOR is a phase III randomized, open label, multicenter clinical trial of Veteran patients with operable stage I non-small cell lung cancer that compares stereotactic radiotherapy and anatomic pulmonary resection with a primary outcome measure of overall survival. The study was activated in 2017 and recruitment to the trial has been affected by ongoing changes in public and clinician perceptions about stereotactic radiotherapy and surgery that have interfered with equipoise and willingness of participants to enroll. The study team perpetually addresses this challenge through group conversations with local site investigators, study coordinators, and other research personnel to preserve group equipoise across the study. Since the study's activation, new safety information about stereotactic radiotherapy has emerged necessitating protocol modifications while aiming to preserve internal and external validity. The includes modifying standard operating procedures for the study's centralized quality assurance program that has had to adapt its process to remain contemporary. STARPORT, funded by VA CSRD with CSP collaboration, is a randomized, open label, multicenter clinical trial of Veteran patients with oligorecurrent prostate cancer comparing the effects of standard systemic therapy (SST) alone or with PET-directed local therapy using surgery or radiation. Although enrollment was initiated in 2021, changes are already evident in clinical practice guidelines regarding the use of imaging in workup in this patient population. Shortly before the start of accrual, 18F-DCFPyL PSMA PET/CT received FDA-approval. Consequently, it is being rapidly adopted at the STARPORT VA medical centers and the use of conventional imaging using CT or bone scan prior to PET/CT imaging-part of the original eligibility criteria-quickly is falling out of favor. Furthermore, shortly after the start of enrollment, NCCN guidelines adopted the stance that conventional imaging was no longer required in the setting of PSMA PET/CT imaging, solidifying the transition away from conventional imaging. Thus, the protocol is being amended to remove the requirement for conventional imaging as part of workup for oligorecurrence. In addition, to be generalizable, the study is designed to integrate future PSMA radiotracers that are incorporated into practice as well as changes in SST regimens over the time of the study.
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The SARS-CoV-2 is the betacoronavirus responsible for the coronavirus disease 2019 (COVID-19) pandemic. Severe COVID-19 affects approximately 10-15% of patients and results in prolonged morbidity and mortality. Little is known about the immunophenotypic changes of the lung parenchyma driven by the viral infection in patients who die of severe COVID-19. Ultrasound-guided lung biopsies (LB) were collected (IRB approval#1561/21) within few hours from death in 15 severe COVID-19 patients between November 2020 and January 2021, in two patients who underwent lung transplantation after COVID-19 and in one patient who had surgery for bacterial superinfection during COVID-19 disease. All samples underwent histologic and immunohistochemistry evaluation and molecular profiling using the nCounter Host Response and Coronavirus Panel plus. As controls, lungs from end-stage usual interstitial pneumonia (UIP;n=9) and from lobectomy for lung cancer (Norm;n=5) were used. Eleven lungs (61%) were positive for SARS-CoV-2 RNA. Signs of diffuse alveolar damage (DAD) were observed in 6 patients (30%). COVID-19 lungs showed a marked macrophage infiltration with M2 polarization compared with controls. Globally, COVID-19 lungs showed distinct molecular profiles from UIP or Norm lungs. Specifically, a marked upregulation of interferon-genes that was directly correlated with SARS-CoV-2 genes was seen in COVID-19 lungs. COVID-19-specific genes signatures (Log2FC >1.5;adj p<0.05) obtained using VENN diagram showed impairment of the STAT3-pathway accompanied by the upregulation of the NFkB signaling. Results herein provide new insights into lung alterations induced by severe COVID-19 and suggest novel potential targets for therapeutic intervention.
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BACKGROUND: The COVID-19 outbreak had a massive impact on lung cancer patients with the rise in the incidence and mortality of lung cancer. METHODS: We evaluated whether a recent COVID-19 infection affected the outcome of patients undergoing thoracoscopic lobectomy for lung cancer using a retrospective observational mono-centric study conducted between January 2020 and August 2022. Postoperative complications and 90-day mortality were reported. We compared lung cancer patients with a recent history of COVID-19 infection prior to thoracoscopic lobectomy to those without recent COVID-19 infection. Univariable and multivariable analyses were performed. RESULTS: One hundred and fifty-three consecutive lung cancer patients were enrolled. Of these 30 (19%), had a history of recent COVID-19 infection prior to surgery. COVID-19 was not associated with a higher complication rate or 90-day mortality. Patients with recent COVID-19 infection had more frequent pleural adhesions (p = 0.006). There were no differences between groups regarding postoperative complications, conversion, drain removal time, total drainage output, and length of hospital stay. CONCLUSIONS: COVID-19 infection did not affect the outcomes of thoracoscopic lobectomy for lung cancer. The treatment of these patients should not be delayed in case of recent COVID-19 infection and should not differ from that of the general population.
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Purpose: Sirolimus (SIR), a mammalian target of rapamycin inhibitor (mTORi), may be used with or without a calcineurin inhibitor after heart transplant (HT). The antiproliferative properties & 72-hour half-life (T1/2) that make SIR desirable to provide uniform drug exposure & attenuate cardiac allograft vasculopathy add complications when surgical needs or toxicities arise.1,2 SIR-related wound healing impairment necessitates cessation before invasive procedures, yet managing long-acting SIR in these settings is complex due a large volume of distribution & vulnerability to interactions with CYP3A4 inhibitors, prolonging T1/2.2 Phenytoin (PHY), a potent inducer of CYP3A4, has been used to speed tacrolimus (FK) clearance.3 Interaction between PHY & SIR is reported.4 Strategic use of PHY to clear SIR is not described. Method(s): Case review leveraging PHY-inducing effects to expedite SIR & FK elimination while awaiting urgent thoracotomy for mucormycosis. Result(s): The patient developed invasive pulmonary mucormycosis 3 years post-HT. Supratherapeutic levels on admission were SIR 20 ng/mL & FK 15 ng/mL with mycophenolate 500 mg twice daily & prednisone 5 mg twice daily. Treatment was initiated with CYP3A4-inhibiting isavuconazonium sulfate (ISU) & amphotericin B irrigation. Infected lung segment resection was delayed for wound healing risks of SIR. To hasten SIR elimination via CYP3A4 induction, fosPHY load then PHY 100 mg orally thrice daily was initiated on day 5. To maintain infection treatment while inducing metabolism, ISU was converted to systemic amphotericin B. Figure 1 describes SIR, FK, ISU & PHY courses. The calculated T1/2 was shorted from 440 hours on ISU days 3-5 to 32 hours days 7-10 (allowing time for induction). On day 14 thoracotomy & left upper lobectomy were successfully performed with FK & SIR unquantifiable. Conclusion(s): This case illustrates effective induction SIR & FK metabolism using PHY. In the era of CYP 3A4-inhibiting nirmatrelvir-ritonavir availability for COVID-19, strategies to address inadvertent calcineurin inhibitor or mTORi toxicity are paramount. Employing this approach when needing to clear drugs quickly may be beneficial.
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SESSION TITLE: Case Reports of Procedure Treatments Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Broncholiths are calcifications in the tracheobronchial tree that are most commonly associated with indolent infections. Disease manifestations range from asymptomatic stones in the airway to major complications such as massive hemoptysis or post-obstructive pneumonias. Depending on severity of the disease, patient management can range from conservative strategies to surgical interventions. We report successful reduction of a large obstructive broncholith in the right middle lobe via Holmium-yttrium aluminum garnet (Ho:YAG) laser lithotripsy. CASE PRESENTATION: Patient is a 55 year old male who presented with on going purulent cough, fever and pleuritic chest pain for 3 months. He had associated weight loss (>10 lbs in 3 months), malaise, increased fatigue, and scant hemoptysis. Initial chest x-ray was evident of right middle lobe consolidation. Respiratory infection panel, COVID PCR, AFB cultures and fungal cultures were negative. Subsequent CT of his chest showed right middle lobe opacities with areas of obstruction with a broncholith. Subsequently, patient underwent rigid bronchoscopy to allow for left sided airway protection via direct tamponade if patient develops massive hemoptysis. A bronchoscopic inspection was performed through the rigid scope that confirmed the broncholith. Obliteration of broncholith was then performed via Ho:YAG. After multiple laser treatments, we noted improvement in the size of the broncholith. Patient admitted to significant improvement in chest pain, hemoptysis and cough since the procedure. DISCUSSION: Broncholithiasis refers to calcified material eroding the tracheobronchial tree and causing inflammation and obstruction. Etiology of broncholiths include calcified peribronchiolar lymph nodes that erode into the airway lumen. Lymph node calcifications in the thorax are associated with lymphadenitis from fungal or mycobacterial infections. Management depends on the size of broncholiths. For larger stones, flexible bronchoscopy is often used to confirm diagnosis. When forceps extraction is not feasible, stone fragmentation with Ho:YAG is generally utilized, but they carry the risk of massive hemoptysis or bronchial injury. Surgical interventions, such as lobectomy or pneumonectomy, are reserved for patients with recurrent pneumonias, bronchiectasis, bronchial stenosis or broncho-esophageal or aorto-tracheal fistulas. In our case, we demonstrate successful reduction of a non-mobile broncholith by protecting the airway using rigid bronchoscopy by interventional pulmonology and subsequently avoiding surgical intervention in a patient with repeated post-obstructive pneumonia. CONCLUSIONS: Management of broncholiths should be individualized for symptomatic patients. A comprehensive assessment with appropriate imaging and involvement of interventional pulmonology can result in successful reduction of the stone and minimizing complications. Reference #1: Dakkak, M., Siddiqi, F., & Cury, J. D. (2015). Broncholithiasis presenting as bronchiectasis and recurrent pneumonias. Case Reports, 2015, bcr2014209035. Reference #2: Krishnan, S., Kniese, C. M., Mankins, M., Heitkamp, D. E., Sheski, F. D., & Kesler, K. A. (2018).Management of broncholithiasis. Journal of thoracic disease, 10(Suppl 28), S3419. Reference #3: Olson, E. J., Utz, J. P., & Prakash, U. B. (1999). Therapeutic bronchoscopy in broncholithiasis. American journal of respiratory and critical care medicine, 160(3), 766-770 DISCLOSURES: No relevant relationships by Jalal Damani No relevant relationships by Joseph Gatuz No relevant relationships by Fereshteh (Angel) Yazdi
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SESSION TITLE: Lung Cancer Imaging Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The Coronavirus disease 2019 (COVID-19) pandemic affected millions of people globally, prompting the emergent need for an effective vaccine. Lymphadenopathy associated with COVID-19 vaccine is a recognized phenomenon that can present a diagnostic dilemma for staging thoracic malignancies. We present a case of post COVID-19 vaccination axillary lymphadenopathy complicating the staging process for a patient with newly diagnosed lung adenocarcinoma. CASE PRESENTATION: A 64-year-old-male with chronic obstructive pulmonary disease, former smoker with a 20-pack-year smoking history was found to have a 1.7 cm solid nodule in the left upper lobe with irregular margins on low dose computed tomography (CT) scan of the chest for lung cancer screening. Fine needle aspiration of the nodule was done, and histopathology results were consistent with the diagnosis of adenocarcinoma. Patient then underwent fluorodeoxyglucose-positron emission tomography (FDG-PET) scan that showed a 16 mm nodule in the left upper pulmonary lobe with maximum standardized uptake value (SUVmax) of 5.3 and left axillary nodes measuring up to 8 mm with SUVmax of 4.4 concerning for metastatic disease. On further history, patient had received the Pfizer mRNA vaccination booster three days prior to undergoing the FDG-PET scan. Patient was evaluated by oncology and decision was made to treat with a 7-day course of prednisone 20 mg daily and to repeat FDG-PET scan. FDG-PET scan done four weeks later showed resolution of axillary lymphadenopathy. Patient was clinically staged as T1bN0M0 stage 1A and underwent robotic left upper lobe lingular-sparing lobectomy. DISCUSSION: In patients with thoracic malignancies, lymphadenopathy related to COVID-19 vaccination with avid FDG uptake on PET scan was reported in 29% of patients (2). The presentation of FDG avid lymphadenopathy creates a clinical challenge by confounding accurate cancer staging and leading to unnecessary workup (3). More importantly, detection of lymphadenopathy while staging lung cancer has crucial implications in the process of triaging patients to oncologic management in terms of candidacy for surgical resection (3). Currently, no consensus is available to guide management for incidental lymphadenopathy associated with COVID-19 vaccination in lung cancer patients. For this patient, we chose to treat with steroids and to obtain repeat imaging within 4 weeks of the original FDG-PET to not delay treatment planning. Repeat imaging showed resolution of the axillary lymphadenopathy and patient was able to undergo definitive treatment promptly. CONCLUSIONS: This case highlights the diagnostic challenge posed by COVID-19 lymphadenopathy in patients with newly diagnosed lung cancer and delineates our approach to navigating this challenge to avoid malignancy up-staging and treatment delay. Reference #1: Polack FP, Thomas SJ, Kitchin N, et al. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N Engl J Med. 2020;383(27):2603-2615. doi:10.1056/NEJMoa2034577 Reference #2: Nishino M, Hatabu H, Ricciuti B, Vaz V, Michael K, Awad MM. Axillary Lymphadenopathy After Coronavirus Disease 2019 Vaccinations in Patients with Thoracic Malignancy: Incidence, Predisposing Factors, and Imaging Characteristics. J Thorac Oncol. 2022;17(1):154-159. doi:10.1016/j.jthoCH.2021.08.761 Reference #3: Lehman CD, D'Alessandro HA, Mendoza DP, Succi MD, Kambadakone A, Lamb LR. Unilateral Lymphadenopathy After COVID-19 Vaccination: A Practical Management Plan for Radiologists Across Specialties. J Am Coll Radiol. 2021;18(6):843-852. doi: 10.1016/j.jacr.2021.03.001 DISCLOSURES: No relevant relationships by Hadya Elshakh No relevant relationships by Stephen Karbowitz No relevant relationships by Gina Villani
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SESSION TITLE: Pneumothorax, Chylothorax, and Pleural Effusion Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: An alveolopleural fistula (APF) is a pathological communication between the pulmonary alveoli and the pleural space. If pneumothorax persists beyond five days, it is labeled as a prolonged air leak (PAL). Herein, we present a patient with respiratory failure, spontaneous pneumothorax with persistent air leak resulting in functional pneumonectomy despite CTS intervention. CASE PRESENTATION: A 60-year-old female with PMH of diabetes, hypertension was initially admitted for right lower extremity cellulitis. About ten days into the admission, patient started becoming progressively hypoxic and was noted to be saturating 82% on room air with crackles noted bilaterally. A CT angiogram showed findings suggestive of multifocal pneumonia. Covid-19 pneumonia was initially suspected despite negative testing and a course of remdesivir and steroids was administered. All other infectious workup returned negative. Patient's oxygenation requirements worsened over the next two weeks eventually requiring intubation. Bronchoscopy with bronchoalveolar lavage showed growth of stenotrophomonas and patient received a course of trimethoprim-sulfamethoxazole. Patient was subsequently extubated and transitioned to high flow nasal cannula. Two weeks later, she developed acute respiratory deterioration due to a right sided pneumothorax requiring emergent pigtail placement and subsequent intubation. She was noted to have a persistent airleak from the chest tube and imaging showed a persistent pneumothorax with possible malpositioning of the chest tube. Despite repositioning of the previous chest tube and a second chest tube insertion, patient's PAL persisted and she underwent video assisted thoracoscopic surgery (VATS) that showed a large bronchopleural fistula emanating from the right upper and middle lobes requiring stapling and surgical pleurodesis. Bronchoscopy prior to VATS did not show any signs of obstruction. Due to prolonged intubation, she underwent tracheostomy placement followed gradually by chest tube removal when no air leak was appreciated. After the removal of the chest tube, her lung gradually formed multiple bullae with no functional residual lung. Despite this, her respiratory status stabilized and she was discharged to a LTACH. DISCUSSION: The likely cause of APF here was the emergent chest tube insertion. APF and PALs are most seen following pulmonary resection or biopsy but can also be seen following spontaneous pneumothorax or traumatic chest tube insertions. Although an endobronchial valve was entertained, the lung damage was extensive enough to have no change in patient's outcome. CONCLUSIONS: Our case demonstrates a rare but complicated hospital course of a patient where a chest tube insertion resulted in non-resolving APF with PAL despite therapeutic interventions in an unfortunate case of "functional pneumonectomy". Underlying pneumonia may have also contributed to the APF resulting in PAL. Reference #1: 1. Liberman M, Muzikansky A, Wright CD, et al. Incidence and risk factors of persistent air leak after major pulmonary resection and use of chemical pleurodesis. Ann Thorac Surg 2010;89:891. Reference #2: 2. DeCamp MM, Blackstone EH, Naunheim KS, et al. Patient and surgical factors influencing air leak after lung volume reduction surgery: lessons learned from the National Emphysema Treatment Trial. Ann Thorac Surg 2006;82:197. Reference #3: 3. Rivera C, Bernard A, Falcoz PE, et al. Characterization and prediction of prolonged air leak after pulmonary resection: a nationwide study setting up the index of prolonged air leak. Ann Thorac Surg 2011;92:1062. DISCLOSURES: No relevant relationships by Mohammed Halabiya No relevant relationships by Rajapriya Manickam No relevant relationships by Rutwik Patel
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SESSION TITLE: Unusual Pneumonias SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Invasive pulmonary aspergillosis (IPA) commonly occurs in the setting of immunosuppression. Underlying lung disease is a well-known risk factor for IPA;however, interstitial lung disease (ILD) has not been recognized as a risk factor for IPA[1]. CASE PRESENTATION: A 40-year-old male with a history of a failed kidney transplant now on hemodialysis (HD), Juvenile Rheumatoid Arthritis, Mixed Connective Tissue Disease, Aspergilloma led to right lower lobectomy a year ago, COVID-19 infection three months ago, chronic lung disease (CLD) thought to be due to Nonspecific interstitial pneumonia (NSIP) presented with dyspnea. He had several hospitalizations for respiratory failure needing intubation or NIPPV, broad-spectrum antibiotics, steroids, and HD with improved respiratory status, eventually discharged. Bronchoalveolar lavage fluid culture grew aspergillus terreus but was negative for Pneumocystis (PCP), bacteria, acid-fast bacilli, and Nocardia. The transbronchial biopsies showed mixed inflammatory type and fungal forms in one specimen. Additionally, the initially negative galactomannan converted into a serial rise in galactomannan (>3.75 Index) along with a rise in beta d-glucan (>500 pg/ml). Unfortunately, he had gaps in antifungals and was readmitted similarly. Micafungin was added for dual fungal coverage and was planned for surgical lung biopsy to characterize ILD further once his respiratory status allows. DISCUSSION: He has multiple risk factors for developing IPA, such as high-dose steroids for ILD and recent COVID infection. Initially, respiratory failure was thought to be due to exacerbation of ILD, and suspicion for IPA was low because of lack of neutropenia, negative fungal biomarkers, lack of classic findings on lung imaging, and in-hospital clinical improvement with steroids. However, the eventual course of recurrent respiratory failure while on high-dose steroids, along with gaps in antifungal therapy and continued growth of Aspergillus, made IPA the most likely diagnosis. For IPA, the mainstay of treatment is both adequate antifungal therapy and reduction in immunosuppression to the extent possible[2];however, it is unclear if his underlying ILD can tolerate steroid taper. He will need a lung transplant after adequately treating IPA. CONCLUSIONS: There are no current guidelines on simultaneously treating IPA and NSIP. It is challenging to balance reduction in immunosuppression as tolerated for ILD and concurrently maintain antifungal therapy. During this patient's hospitalization, there have been considerations of using a steroid-sparing agent for his suspected NSIP, however, in the setting of active infection, its benefit is debatable.[3] Reference #1: Matsuyama H, Miyoshi S, Sugino K, et al. Fatal Invasive Pulmonary Aspergillosis Associated with Nonspecific Interstitial Pneumonia: An Autopsy Case Report. Intern Med. 2018;57(24):3619-3624. doi:10.2169/internalmedicine.1144-18 Reference #2: Thomas F. Patterson, George R. Thompson, III, David W. Denning, Jay A. Fishman, Susan Hadley, Raoul Herbrecht, Dimitrios P. Kontoyiannis, Kieren A. Marr, Vicki A. Morrison, M. Hong Nguyen, Brahm H. Segal, William J. Steinbach, David A. Stevens, Thomas J. Walsh, John R. Wingard, Jo-Anne H. Young, John E. Bennett, Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 63, Issue 4, 15 August 2016, Pages e1–e60, https://doi.org/10.1093/cid/ciw326 Reference #3: Mezger, M., Wozniok, I., Blockhaus, C., Kurzai, O., Hebart, H., Einsele, H., & Loeffler, J. (2008). Impact of mycophenolic acid on the functionality of human polymorphonuclear neutrophils and dendritic cells during interaction with Aspergillus fumigatus. Antimicrobial agents and chemotherapy, 52(7), 2644–2646. https://doi.org/10.1128/AAC.01618-07 DISCLOSURES: No relevant relationships by Nasir Alhamdan No relevant relati nships by Parth Jamindar No relevant relationships by Harshitha Mergey Devender No relevant relationships by Abira Usman No relevant relationships by Vishruth Vyata
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SESSION TITLE: Variety in Chest Infections Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Actinomyces is a Gram-positive anaerobic and micro aerophilic filamentous bacillus that normally colonize the human mouth and digestive and urogenital tracts. They most commonly cause cervical and abdominopelvic infections and rarely pulmonary actinomycosis. CASE PRESENTATION: 67-year-old female with past medical history of recurrent DVT with IVC filter placement, non- ischemic cardiomyopathy, atrial fibrillation, 40 pack year history, recent COVID19 infection, lung nodules & COPD presented with complaint of coughing up blood associated with chest pain for the past 2 days. She had a low-grade fever with stable vitals with preliminary labs showing she was anemic and had reactive leukocytosis. She was recommended to hold oral anticoagulation and follow-up outpatient during when her symptoms worsened. On admission she was started on tranexamic acid nebulization for hemostasis and underwent CTA chest which showed no evidence for pulmonary embolism but commented on a right lower lobe perihilar 12.5 mm mass which has increased in size compared to previous scans. Patient underwent bronchoscopy which showed generalized edema of the tracheobronchial tree with bleeding from superior segment of the right lower lobe bronchus with no visualization of mass. PET scan showed hyper-metabolic lung mass with concerns for malignancy. CT guided biopsy of nodule was done and was not staining for malignant cells, acid fast bacilli with no fungal or bacterial growth. Blood cultures and Karius Digital cultures were also negative. She began expectorating blood clots despite being on treatment and cardiothoracic surgery was consulted. A partial lobectomy with lysis of adhesions of the right lower lobe was done. Specimen sent to pathology showed no evidence for malignancy but instead elicited a contained pulmonary abscess containing filamentous bacteria with parenchymal inflammation with areas of chronic hemorrhagic fibrosing pleuritis and hilar thrombi. She was diagnosed with pulmonary actinomycosis and started on IV 24,000,000 IU penicillin. She underwent a panoramic dental x-ray which was read as suboptimal dentition with multiple missing teeth and did not identify a source. Patient symptoms resolved post lobectomy and since discharged on long course of antibiotics. She continued to have no more episodes of hemoptysis. DISCUSSION: Hemoptysis as a symptom of pulmonary actinomycosis is a rather rare presentation. Actinomycosis causes cavities, nodules, and pleural effusions. It is commonly mistaken for chronic suppurative lung disease and sometimes malignancy. Isolation and identification occur only a minority of cases with a high culture failure rate due to previous antibiotic therapy, inadequate incubation time or culture conditions. CONCLUSIONS: Due to it's variable presentation pulmonary actinomyces has a large overlap with other diseases but must be considered in the differential of unexplained hemoptysis. Reference #1: Hemoptysis secondary to actinomycosis: A rare presentation. PMID: 24778485 PMCID: PMC3999682 DOI: 10.4103/0970-2113.129864 DISCLOSURES: No relevant relationships by Victoria Famuyide No relevant relationships by rukhsaar khanam
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SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Since the start of Covid-19 pandemic, several respiratory microorganisms have been identified that cause coinfection with Sars-Cov-2. Bacteria like Staphylococcus aureus and viruses like influenza are some of the identified pathogens. Rarely, fungal infections from Aspergillus are also being reported. CASE PRESENTATION: 59-year-old male with past medical history of hypertension and hyperlipidemia was admitted for shortness of breath and was found to be positive for Covid-19. He received Remdesivir, dexamethasone & tocilizumab. He required non-invasive ventilation via continuous positive airway pressure but continued to remain hypoxemic with elevated procalcitonin, he was treated with cefepime for bacterial pneumonia. Patient required emergent intubation and eventually underwent tracheostomy. He developed methicillin-resistant Staphylococcus aureus pneumonia for which he received vancomycin. He was eventually discharged to long term acute care facility. Patient was readmitted after 2 months due to worsening respiratory status. Computed Tomography Angiography of chest was negative for pulmonary embolism but showed pleural effusion. He underwent thoracentesis which showed exudative effusion with negative cultures. Echocardiogram showed right heart failure. Patient's symptoms were believed to be due to Covid-19 fibrosis. He required home oxygen and also received pulmonary rehabilitation. One year after the initial Covid-19 infection, he developed pulmonary hypertension and was referred for lung transplant consultation. However, he developed severe hemoptysis requiring intubation and vasopressors. Galactomannan was positive, Karius digital culture revealed Aspergillus Niger for which he received voriconazole. He was not deemed a suitable candidate for lobectomy. Patient developed arrhythmia and had prolonged QT interval so voriconazole was switched to Isavuconazole. He continued to have hemoptysis and his condition did not improve so family requested to transition care and patient passed away. DISCUSSION: Several studies have proven co-infection of Aspergillus with Covid-19. This case highlights Aspergillus infection approximately 1 year after initial Covid-19 infection. Sars-Cov-2 causes damage to airway lining which can result in Aspergillus invading tissues. IL-6 is increased in severe Covid-19 infection. Tocilizumab is an anti-IL-6 receptor antibody that has been approved for treatment of Covid-19 pneumonia. However, IL-6 provides immunity against Aspergillus so use of tocilizumab decreases protection against Aspergillosis which is usually the reason for co-infection. However, in this case patient developed fungal infection later during Covid-19 fibrosis stage. CONCLUSIONS: Recognizing fungal etiology early on is important in Covid-19 patients as mortality is high and appropriate intervention can reduce morbidity and mortality. Some patient may eventually require lung resection. Reference #1: Kakamad FH, Mahmood SO, Rahim HM, Abdulla BA, Abdullah HO, Othman S, Mohammed SH, Kakamad SH, Mustafa SM, Salih AM. Post covid-19 invasive pulmonary Aspergillosis: a case report. International journal of surgery case reports. 2021 May 1;82:105865. Reference #2: Nasrullah A, Javed A, Malik K. Coronavirus Disease-Associated Pulmonary Aspergillosis: A Devastating Complication of COVID-19. Cureus. 2021 Jan 30;13(1). Reference #3: Dimopoulos G, Almyroudi MP, Myrianthefs P, Rello J. COVID-19-associated pulmonary aspergillosis (CAPA). Journal of Intensive Medicine. 2021 Oct 25;1(02):71-80. DISCLOSURES: No relevant relationships by Maria Haider Baig
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As the number of post-COVID-19 patients requiring surgery increases, it becomes pressing to develop guidelines outlining time requirements between active COVID-19 infection and surgery. We present a case of successful pulmonary segmentectomy 6 weeks following an acute COVID-19 infection in a 65-year-old female. The case patient was scheduled for a robotic assisted left upper lobectomy for radiologically diagnosed early-stage lung cancer. Unfortunately, prior to surgery she contracted Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2), resulting in the operation being rescheduled for 6 weeks' time. She was managed in the community for COVID pneumonitis and developed significant shortness of breath. At admission, with resolution of breathlessness, a repeat chest computed tomography scan showed the nodule had increased in size from 2 to 2.5cm, and widespread interstitial pneumonitis. The patient was saturating at 91% on air with no respiratory compromise. On balance of risk, surgery went ahead as planned due to concerns over tumour progression. A smaller lung resection was undertaken, with robot-assisted left upper division segmentectomy preferred to lobectomy. Post-operatively the patient received aggressive physiotherapy and high flow nasal oxygen to aid sputum expectoration. Chest tube was removed on day 2 post-operatively and the patient discharged 5 days following surgery without complication. Final histology confirmed a fully resected stage T1cN0M0 adenocarcinoma of the lung. This case highlights the importance of timing surgery correctly in post-COVID-19 patients to achieve the most favourable outcomes. We must balance clinical priority and the risk of disease progression against the severity of COVID-19 infection and the patient's comorbid status.
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Aim: Immune checkpoint inhibitors (ICIs) have been shown to prolong survival in patients that have locally advanced stage III/IV and metastatic non-small cell lung cancer (NSCLC). The role that salvages surgery plays in persistent localised disease and unresponsive synchronous cancer following treatment with a course of ICIs is not yet fully clear. We present a case series of nine patients with stage III/ IV NSCLC that underwent surgical resection after treatment with the ICI, pembrolizumab. Method: Six cases underwent salvage surgery after downstaging of the primary cancer following pembrolizumab treatment and three patients had resection of contralateral lung nodules that were unresponsive to ICI therapy. Three of the cases were open thoracotomies, 3 were robotic-assisted and 2 were video-assisted. One case was converted to open due to pulmonary artery involvement. Results: There was complete, successful macroscopic resection in all cases with each showing histological evidence for active cancer cells. One patient died of COVID pneumonitis in the community within 60 days of surgery. All other patients are alive with no evidence of localised disease or of any disease reoccurrence within 3-18 months of their surgery. Conclusions: Our case series demonstrates the potential for salvage pulmonary resection in select patients with advanced stage NSCLC who have persistent localised disease or unresponsive synchronous cancer after treatment with the ICI, pembrolizumab. Salvage surgery in this group of patients is safe and pragmatic despite high levels of post-immunotherapy hilar fibrosis. Further studies will be required in order to assess overall survival rates.
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Objective: COVID-19 pandemic required optimization of hospital institutional flow, especially regarding the use of intensive care unit (ICU) beds. The aim of this study was to assess whether the individualization of the indication for postoperative recovery from pulmonary surgery in ICU beds was associated with more perioperative complications. Method: retrospective analysis of medical records of patients undergoing anatomic lung resections for cancer in a tertiary hospital. The sample was divided into: Group-I, composed of surgeries performed between March/2019 and February/2020, pre-pandemic, and Group-II, composed of surgeries performed between March/2020 and February/2021, pandemic period in Brazil. We analyzed demographic data, surgical risks, surgeries performed, postoperative complications, length of stay in the ICU and hospital stay. Preventive measures of COVID-19 were adopted in group-II. Results: 43 patients were included, 20 in group-I and 23 in group-II. The groups did not show statistical differences regarding baseline demographic variables. In group-I, 80% of the patients underwent a postoperative period in the ICU, compared to 21% in group-II. There was a significant difference when comparing the average length of stay in an ICU bed (46 hours in group-I versus 14 hours in group-II-p<0.001). There was no statistical difference regarding postoperative complications (p=0.44). Conclusions: the individualization of the need for ICU use in the immediate postoperative period resulted in an improvement in the institutional care flow during the COVID-19 pandemic, in a safe way, without an increase in surgical morbidity and mortality, favoring the maintenance of essential cancer treatment.
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Introduction: Due to restrictions caused by the COVID-19 pandemic, elective procedures were canceled or postponed. This study aims to compare the epidemiological profile of cases from Brazilian’s Public Healthcare System (SUS) and Private Healthcare (PH) in a teaching single-center facility between 2019 and 2021. Methods: Data were gathered from patients who underwent lung resection (LR) by PUCRS’s Sao Lucas Hospital Thoracic Surgery team between 2019 and 2021. Data were obtained by retrospective review of electronic charts in March 2022. A retrospective analysis was made. Results: There were 212 procedures performed, being 80 in 2019, 66 in 2020 and 66 in 2021. In 2019, there were 45 (56.2%), in 2020, 43 (65.1%), and in 2021, 34 (51,5%) LR on SUS. Lobectomies on SUS in 2019 were 19 (42.2%), in 2020, 13 (30.2%), and in 2021, 17;on PH were 19 (54.2%) in 2019, 12 (52.1%) in 2020, and 18 in 2021. On SUS, in 2019 were performed 41 (91%) open thoracic surgeries and in 2020, there were 33 (76%);on PH, in 2019 video-assisted thoracic surgery (VATS) was done in 24 (68.5%) patients, 17 (73.9%) in 2020 and 29 (75%) in 2021. Procedures for oncological disease (primary or metastatic) on SUS in 2019 were performed in 27 (60%) patients, 23 (53.4%) in 2020, and 13 (44,8%) in 2021;on PH, in 2019, there were 23 (65.5%) patients, in 2020 were 15 (65.2%), and 16 (55,2%) in 2021. On SUS there were 24 women in 2019 (53%) and in 2020 (55%);on PH, there were 23 (65%) men in 2019 and 13 (56%) in 2020. The mean age of patients on SUS was 59, and 66 on PH. Clinical staging (CS) for primary lung cancer on SUS in 2019 was 12 (50%) CS I, 8 CS II, 3 CS III, and 1 CS IV;in 2020 was 8 (47%) CS I, 6 CS II, and 3 CS III. On PH, in 2019, there were 12 (66.6%) CS I, 4 CSII, and 2 CS IV;in 2020, 11 (84.6%) CS I and 2 CS II. Conclusions: We found maintenance in the numbers of procedures in 2020 and 2021, but a global reduction in the number of LR on SUS, mainly because the pandemic became worst in its second year, leading to the closure of surgery centers. And a reduction of 17.5% in the number of LR in 2020, compared with 2019. Lobectomies lowered 36.8% on PH and 31.5% on SUS between 2019 and 2020. Albeit there was a reduction in general incidence, LR for oncological reasons predominated. In 2021 it represented 82,8%, with 44,8% on SUS, and 52,2% on PH. There was a higher average age on PH. Open thoracic surgery was most frequent on SUS due to limitations on offered equipment, while VATS predominated on PH (difference: 44.5%). The predominant CS remained equal on both healthcare systems, CS I, which indicates maintenance of early-stage diagnoses. Nevertheless, the overall incidence has diminished (33.33% [SUS] and 8.3% [PH]), a probable reflection of the pandemic. Keywords: COVID-19, Thoracic Surgery, Lung Cancer
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Introduction: Definitive chemoradiaotherapy (dCRT) is an option for patients with lung cancer who are medically inoperable or have unresectable locally advanced disease. The local recurrence rate after dCRT is 30% and the prognosis is poor. Salvage surgery, or surgical resection of recurrent disease following dCRT, is one therapeutic option, however, optimal therapy for locoregional recurrences or residual disease is controversial. The purpose of this study was to determine the efficacy of salvage lung resection. Methods: This is a single centre retrospective database review. Patients eligible for the study received definitive chemotherapy, radiation therapy or both followed by salvage pulmonary resection for local recurrence or residual disease. Patient characteristics and outcomes were examined. Results: Sixteen patients (11 male, 5 female) out of 201 that met the inclusion criteria treated between January 2017 and August 2020 were identified with a median follow-up time of 21 months (Q1, Q3 8-37.5). The median patient age was 68. All 16 patients received radiation, 7 of whom received less than 59 Gy and 9 received greater than 59 Gy. The rationale for dCRT varied as 6 patients had disease considered to be unresectable, 5 patients were originally considered to be medically inoperable, 4 patients had a preference for non-surgical management initially, and 1 patient pursued dCRT due to uncertainty of surgical options due to the COVID-19 pandemic. The median time from radiotherapy to surgery was 22 months (Q1, Q3 14.25-27.5). The extent of salvage resections differed as 5 patients had wedge resections, 4 had lobectomies, and 5 patients had more than one lobe resected. No pneumonectomies were preformed. Two resections were aborted in the operating room due to upstaging at the time of resection. The final pathology was 9 adenocarcinomas, 5 squamous cell carcinomas, 1 adenosquamous carcinoma and 1 non-malignant (nodular fibroblastic scarring with surrounding focal organizing pneumonia). Median procedure time was 3h10.5m. Adhesions were noted in 12 cases (75%). Ninety-day mortality was 0%. Overall survival at most recent follow-up was 75% (12 patients). Conclusions: Salvage pulmonary resection after dCRT can be performed with low morbidity and mortality rates and is a good option for treatment of recurrent or residual disease after dCRT. Keywords: Early stage lung cancer treatment, Salvage pulmonary resection, Definitive chemoradiaotherapy
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Background: Serious infections are more frequently seen in patients with infam-matory rheumatic diseases, being treated with immunosuppressive or biologic disease-modifying antirheumatic drugs (b-DMARDs). Potential harmful effects of immunosuppressive drugs as well as b-DMARDs were a major concern during the early phases of the Coronavirus disease 2019 (COVID-19) pandemic, and preliminary data documented the worse outcome of COVID-19 associated with B cell depleting treatments (1). On the other hand, limited information has been shared about the course of COVID-19 in patients with monogenic autoinfamma-tory disorders using IL-1 inhibitors. Objectives: We herein aimed to evaluate the course of COVID-19 in adult patients with the most common form of infammasomopathy, Familial Mediterranean Fever (FMF), who were on biologic agents. Methods: In this cross-sectionally study, FMF patients were evaluated by screening their clinical and electronic records in our database in October 2021. The FMF patients with a record of PCR-confrmed COVID-19 were investigated in more detail in our hospital. Characteristics of FMF fndings as well as clinical and laboratory fndings associated with COVID-19 were recorded from the outpatient follow-up cards. Results: We identified 184 FMF patients using biologic agents, and their baseline characteristics are summarized in Table 1. Among them, 36 had PCR-confirmed COVID-19;32 of them were currently on b-DMARD along with colchicine (31 anti-IL-1, 1 anti-TNF), and 4 of them had a previous history of b-DMARD treatment. Data about the course of COVID-19 could be reached in 34 patients. Four (11%) patients had an asymptomatic course. Remaining patients with symptomatic COVID-19 had the following symptoms: cough (50%), headache (47.2%), fever (44.4%), loss of taste and smell (41.6%), myalgia (0.6%), dyspnoea (27.8%), diarrhea (25%) abdominal pain (5.6%). Thorax computed tomography was performed in 10 patients, and findings of pneumonia were documented in 6 (16.7%). The mean values of the laboratory parameters were as follows: C-reactive protein 99.48 ± 112.66 mg/L;ferritin 316 ± 208.3;D-Dimer 2445 ± 3917, Lactate Dehydroge-nase 253 ± 61, troponin T 26 ± 20, procalcitonin 0.348 ± 0.53. Lymphopenia was detected in 5 (13.9%) patients;mean lymphocyte count was 1080 ± 363. Data about the treatment could be reached in 34 patients. Antiviral therapy was prescribed in 25 (69.4%) patients (favipiravir, n=22;and oseltamivir, n=3). Antibiotics were given to 6 (16.7%) patients, and 6 (16.7%) received hydroxychloroquine. Parenteral steroids were administered to 2 patients during the hospitalization. Six (16.7%) patients required hospitalization, and 2 (5.6%) required oxygen support, non-invasive mechanical ventilation, and one of them followed in the intensive care unit. Twenty-two patients were on anakinra treatment, and none of them required additional dose. Only 1 patient, a 61-year-old male patient with a history of lung lobectomy and renal transplantation, received tocilizumab due to macrophage activation syndrome, and he later died of sepsis. This patient was on anakinra until 2 years before, and it was discontinued due to an allergic reaction. Only 4 patients had a history of vaccination before COVID-19, and none of them developed pneumonia and required hospitalization. Six patients had FMF attacks after recovering from COVID-19. None of the patients developed thromboembo-lism and secondary bacterial infections. Conclusion: This survey identified 36 biologic b-DMARD receiving FMF patients, who had COVID-19. All but 1 patient had complete recovery, and b-DMARD usage did not negatively affect the COVID-19 course. None of the patients currently on anti-IL-1 or anti-TNF had a worse outcome. Based on these observations, it can be suggested that refractory FMF patients can continue their b-DMARD treatments when they had COVID-19.