An amalgamation of vision transformer with convolutional neural network for automatic lung tumor segmentation.

Lung cancer has the highest mortality rate. Its diagnosis and treatment analysis depends upon the accurate segmentation of the tumor. It becomes tedious if done manually as radiologists are overburdened with numerous medical imaging tests due to the increase in cancer patients and the COVID pandemic. Automatic segmentation techniques play an essential role in assisting medical experts. The segmentation approaches based on convolutional neural networks have provided state-of-the-art performances. However, they cannot capture long-range relations due to the region-based convolutional operator. Vision Transformers can resolve this issue by capturing global multi-contextual features. To explore this advantageous feature of the vision transformer, we propose an approach for lung tumor segmentation using an amalgamation of the vision transformer and convolutional neural network. We design the network as an encoder-decoder structure with convolution blocks deployed in the initial layers of the encoder to capture the features carrying essential information and the corresponding blocks in the final layers of the decoder. The deeper layers utilize the transformer blocks with a self-attention mechanism to capture more detailed global feature maps. We use a recently proposed unified loss function that combines cross-entropy and dice-based losses for network optimization. We trained our network on a publicly available NSCLC-Radiomics dataset and tested its generalizability on our dataset collected from a local hospital. We could achieve average dice coefficients of 0.7468 and 0.6847 and Hausdorff distances of 15.336 and 17.435 on public and local test data, respectively.

Pulmonary artery resection and reconstruction in locally advanced lung cancer with moderate hemoptysis

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.

SMARCA4-DEFICIENT UNDIFFERENTIATED TUMOR: A RARE THORACIC MALIGNANCY

SESSION TITLE: Rare Malignancies SESSION TYPE: Case Reports PRESENTED ON: 10/17/2022 03:15 pm - 04:15 pm INTRODUCTION: SMARCA4 deficient undifferentiated tumors (SMARCA4-DUT) are rare and aggressive neoplasms that are most commonly encountered in young male smokers and portend a poor prognosis (1,2). They are characterized by loss of SMARCA4, a subunit of chromatin remodeling complexes, and loss of the tumor suppressor brahma-related gene 1 (BRG1). We present a case of an elderly female with an extensive smoking history who was diagnosed with SMARCA4-DUT. CASE PRESENTATION: An 84 year old female with approximately 70 pack year smoking history, emphysema, ischemic cardiomyopathy, and coronary artery disease, presented to the emergency room with upper abdominal pain which started one day prior to admission. She endorsed an unintentional 10 pound weight loss in the past two months. The patient was admitted for an incarcerated ventral hernia for which she underwent repair. Of note, one and a half years ago, she was found to have a right lower lobe 7mm nodule but was unable to follow up due to the COVID pandemic. On this admission, a CT chest revealed a 4.2 x 3.8 x 3.7cm mediastinal mass and subcarincal lymphadenopathy. She underwent an EBUS with biopsy of the mediastinal mass and subcarinal lymph node. Cytology showed highly atypical epitheloid cells, concerning for a neoplasm with neuroendocrine differentiation and granulomas. Given the high suspicion for malignancy, she had a PET CT (figure 1) which showed FDG activity (SUV 11) in the mass with areas of necrosis and was referred to thoracic surgery. She underwent thoracoscopy with mediastinal mass resection and lymph node dissection and pathology showed diffuse sheets of epithelioid cells with large foci of necrosis. Neoplastic cells showed preserved INI (SMARCB1) expression, non-reactivity for NUT, and complete loss of BRG1 (SMARCA4) expression, consistent with a SMARCA4-DUT with positive margins (figure 2). She was referred to Radiation Oncology with plans to pursue further therapy thereafter. DISCUSSION: SMARCA4-DUT is a new and distinctive clinicopathological entity of aggressive thoracic tumors (1). The novelty of this class of tumors poses challenges in terms of treatment. Immune checkpoint inhibitors have shown compelling outcomes in case reports (3), however larger studies are needed to delineate optimal treatment regimens. CONCLUSIONS: SMARCA4-DUT are are rare but highly aggressive thoracic neoplasms. They present as large tumors and are smoking related. Prompt recognition may aid in early diagnosis. No definitive therapy exists but immunotherapy has shown promising results. Reference #1: Chatzopoulos, K., Boland, J.M. Update on genetically defined lung neoplasms: NUT carcinoma and thoracic SMARCA4-deficient undifferentiated tumors. Virchows Arch 478, 21–30 (2021). Reference #2: Roden AC. Thoracic SMARCA4-deficient undifferentiated tumor-a case of an aggressive neoplasm-case report. Mediastinum. 2021;5:39. Published 2021 Dec 25. Reference #3: Henon C, Blay JY, Massard C, Mir O, Bahleda R, Dumont S, Postel-Vinay S, Adam J, Soria JC, Le Cesne A. Long lasting major response to pembrolizumab in a thoracic malignant rhabdoid-like SMARCA4-deficient tumor. Ann Oncol. 2019 Aug 1;30(8):1401-1403. DISCLOSURES: No relevant relationships by Sathya Alekhya Bukkuri No relevant relationships by Erin Meier No relevant relationships by Mangalore Amith Shenoy No relevant relationships by Alexandra Zavin

Pulmonary benign metastasizing leiomyoma (PBML) - A rare cause of lung tumor

Introduction: Benign metastasizing leiomyoma (BML) is a rare disorder that usually occur in premenopausal women with uterine leiomyoma. The commonest metastasis site is the lungs. Diagnosis and treatment are challenging and there is no standardized treatment for BML. Case Description: We report a case of a 66-year-old menopausal lady who presented to Sarawak General Hospital in October 2021 for Covid-19 infection, with incidental finding of pulmonary benign metastasizing leiomyoma (PBML). She experienced one-year history of weight loss. Chest X-ray on admission revealed a solitary right lung nodule (2 x 2cm). CT thorax revealed a right perihilar lesion with multiple smaller lung nodules. Tuberculosis was excluded. The histopathology result of lung biopsy surprisingly showed spindle cell neoplasm with smooth muscle differentiation. There was no palpable abdominal mass. Ultrasound showed irregular endometrial mass about 3.9 x2 cm. Repeated CT thorax and abdomen in April 2022 showed the lung lesion has enlarged to 4 x 4 cm. Patient is planned for a hysterectomy and bilateral salpingo-oophorectomy following a multidisciplinary meeting among Respiratory Physician, Oncologist and Gynae-oncologist. Discussion: Benign metastasizing leiomyoma is rare and not well understood. It usually occurs in premenopausal women with history of myomectomy or hysterectomy. Only few cases have been reported among postmenopausal women without prior history of leiomyoma. Lung biopsy is crucial in excluding serious causes such as malignancy and achieving the correct diagnosis. As there is no established treatment and monitoring guideline, treatment should be individualized and guided by a multidisciplinary team.

The impact of COVID-19 on thoracic surgical procedures in Japan: Analysis of data from the National Clinical Database.

OBJECTIVE: The COVID-19 pandemic has far-reaching collateral health impacts on the ongoing delivery of surgical care worldwide. The current study was designed to analyze the impact of the COVID-19 pandemic on the number of surgeries of general thoracic surgery in Japan. METHODS: Changes in the number of surgeries for total and three representative tumors were analyzed using the National Clinical Database data with reference to the pandemic infection rate and lung cancer screening. RESULTS: In 2020, the number of surgeries in total and for primary lung cancer and mediastinal lung tumor decreased by 4.9, 5.1, and 5.0 %, respectively. Considering the five-year trend towards a 5 % annual increase, there was a potential 10 % decrease in the number of primary lung cancer surgeries. The number of primary lung cancer surgeries bottomed in July 2020 but recovered towards the end of the year. In contrast, the number of metastatic lung tumor surgeries in 2020 increased by 3.2 %, following a similar trend observed over the previous five years. The number of lung cancer screening examinees decreased markedly with the lowest number in May. Our findings indicate that surgical triage had a limited impact on the decrease in primary lung cancer surgeries during the pandemic; rather, the decrease in lung cancer screening, which was a few months preceding, is most likely responsible. CONCLUSIONS: The decrease in primary lung cancer was mainly caused by the decrease in lung cancer screening, indicating that continuing screening is vital even during a pandemic.

Incidental Finding of a Tracheal Lipoma

Introduction: Primary tracheal tumors are rare with an incidence of 0.2/100,000 persons, accounting for 0.6% of all pulmonary tumors. Only 10-20% of these tumors are benign with the most common being recurrent respiratory papillomatosis. Other benign tracheobronchial tumors include hamartoma, fibroma, lipoma and hemangioma among others. Due to the slow growing nature of these tumors, patients may present with progressive exertional dyspnea, cough and recurrent pneumonia, though rarely these tumors are identified incidentally in asymptomatic patients. This case describes a patient with an who underwent successful resection with flexible bronchoscopy and snare electrocautery. Case Report: A 66-year-old male with a history of former tobacco use was admitted to the medical intensive care unit (ICU) in 11/2020 with COVID-19 pneumonia, and incidentally found to have a tracheal tumor noted on CT imaging. His ICU course was complicated by submassive pulmonary embolism, pneumothorax requiring chest tube, and acute hypoxemic respiratory failure requiring heated high-flow nasal cannula. He was successfully discharged to home after 4 weeks and evaluated in the ambulatory clinic for follow-up 2 months later. Review of his imaging from an outside facility demonstrated a 1-cm polypoid lesion arising from the right tracheal wall (Figure 1A). Pulmonary function testing demonstrated a moderate restrictive defect with normal flow-volume loops. He was referred to interventional pulmonology for further evaluation and management. Flexible bronchoscopy revealed a 50% partially obstructing polypoid mass 6-cm distal to the vocal cords (Figure 1B). The mass was excised using snare electrocautery with subsequent cryotherapy for destruction of abnormal tissue at the base of the lesion and argon plasma coagulation for hemostasis. Pathology revealed tracheal lipoma. Repeat flexible bronchoscopy 12 weeks later revealed no evidence of recurrence at the site of the previously resected tracheal lipoma (Figure 1C). Discussion: Among benign tracheobronchial tumors, lipoma is an extremely rare diagnosis representing only 3-9% of cases. Airway lipomas very rarely involve the trachea and are infrequently found incidentally in asymptomatic patients. Epidemiological risk factors are thought to include male gender, obesity, middle age, and smoking. Flexible tracheobronchoscopy remains the gold standard for diagnosis, also allowing for excisional treatment with electrocautery, cryotherapy, or laser therapy. Given the rare incidence of these tumors, follow-up evaluation is recommended, though to-date there are no reports of local recurrence after bronchoscopic treatment. This case highlights the importance for diagnostic evaluation of incidental tracheobronchial tumors given the rare incidence of benign diagnoses.

Rare case of cystic schwannoma presenting as right upper lobe lung cyst

Background: Schwannomaare benign tumors arising from Schwann cells of nerve root sheaths. Schwannomasare mostly solid / heterogeneous solid tumours, rarely cystic. Presentation of cystic schwannomainthorax is extremely rare. Case Study: A 62-year-old female came to our hospital withthe complaint of right sided chest pain for 2 months, which is dull, non-radiating. She had history of fever 4 months back, diagnosed to have covid and took treatment at home. Chest x-ray showed a homogenous opacity in the right upper lobe extending up to 1stintercostal space. Ct reported well-defined thick-walled cyst, hypodensewith central low attenuation, forming acute angles with lung parenchyma in apical segments of right upper lobe towards mediastinum. Mild perilesional atelectasis is seen.On contrast, cyst is non enhancing. Patient is evaluated for the possibilities of Foregut duplication cyst, Hydatidcyst, Neoplasm. Endoscopic ultrasonography revealed a 5cms×5cms cyst, which is not communicating, infiltrating to esophagus. Patient was referred to ctvswhere excision of cyst is done by right thoracotomy .A 6cms×6cms×2cms unilocularcyst with wall thickness ranging from 0.1- 0.4cms. Its outer surface is congested, inner surface showed dark-brown hemorrhagic contents. Histopathological examination revealed cystic schwannoma. Discussion: Schwannomasare mostly benign in nature .Treatment includes excision of Bronchogenic cyst, Brachial cyst, neurogenic tumours, apical lung tumour, hydatid cyst, foregut duplication cyst are to be considered as differential diagnosis. It is important to consider cystic schwannomasin the differential diagnosis of thoracic cystsince the best surgical outcome is strongly related to earlier diagnosis and total resection of the lesion.

A Systematic Review and Analysis on Deep Learning Techniques Used in Diagnosis of Various Categories of Lung Diseases

One of the record killers in the world is lung disease. Lung disease denotes to many disorders affecting the lungs. These diseases can be identified through Chest X-Ray, Computed Tomography CT, Ultrasound tests. This study provides a systematic review on different types of Deep Learning (DL) designs, methods, techniques used by different researchers in diagnosing COVID-19, Pneumonia, Tuberculosis, Lung tumor, etc. In the present research study, a systematic review and analysis is carried by following PRISMA research methodology. For this study, more than 900 research articles are considered from various indexing sources such as Scopus and Web of Science. After several selection steps, finally a 40 quality research articles are included for detailed analysis. From this study, it is observed that majority of the research articles focused on DL techniques with Chest X-Ray images and few articles focused on CT scan images and very few have focused on Ultrasound images to identify the lung disease. © 2021, Brno University of Technology. All rights reserved.

The 15 Year Long-Term Survival of Patients with Chronic Myeloid Leukaemia from 35 Regions of Russian Federation: A Follow up of a Multicenter Observation Study Eutos Osp Initiated By European Leukemia NET

The results of long-term follow-up of patients (pts) with chronic myeloid leukemia (CML) do not lose their importance. Data from routine clinical practice are of particular interest. The use of 1 st (imatinib, IM) and 2nd generation TKI (2G TKI) led to a significant increase in survival, so the probability of death associated with CML could be significantly lower than the probability of death due to common causes of death other than CML. To analyze the overall survival (OS) and causes of mortality in CML pts treated in routine clinical practice in Russian Federation for a long period (>15 years) of time. The long-term follow-up data of the Russian part of the European LeukemiaNet (ELN) OSP EUTOS multicenter observational study were evaluated. The analyzed cohort consisted of 678 Ph/BCR-ABL-positive CML pts from 35 regions of Russia diagnosed in 2002-2006 with IM therapy initiation ≤6 months (mo) after diagnosis. Median (Me) age was 47(range 18-81) years (y), 47% males. Chronic phase, accelerated phase and blast crisis at diagnosis was in 631 (93%), 41(6%) and 6(1%) pts, respectively. The annual number of newly diagnosed pts was as follows: 2002 - 15 pts, 2003 - 38 pts, 2004 - 46 pts, 2005 - 206 pts, 2006 - 302 pts. The last update for 209 pts was done in Jun. 2021;last contact for 100 pts - in 2020, for 39pts - in 2019, for the other - before 2018. The date of the last contact/death could not be established for 14 pts. Statistical analysis included 661 pts, the OS was evaluated by Kaplan-Mayer method using the SAS 9.4 package. In total, 331 (50%) pts of the analyzed cohort were alive with the Me follow-up of 180 (range 2-232) mo or 15 y (range 2 mo-19,3 y). All pts started therapy with IM with 25% switched to 2G TKI in subsequent therapy lines. In total, 218 (66%) pts achieved MR4, 183 (55%) pts got MMR;46 (21%) of these pts with deep molecular response (DMR) were observed in hematology centers of Moscow. The 15-y OS in the total cohort was 63% (CI 59-70%)(fig.1). The OS by age groups was as follows: 18-40yy-75% (CI 73-82%), 40-60yy- 63% (CI 59-70%), 60-80yy- 37% (CI 30-45%). The most complete information was provided by Moscow centers (2 centers, 113 pts). The 15-y OS of pts receiving treatment in Moscow was significantly higher vs pts from other regions (32 centers, 548 pts): 75% vs 60%, p=0,0030 (fig.2). The mortality in the whole cohort of 661 pts was 35% (233 pts). Of these 233 pts, 112(48%) pts deaths were due to CML progression to AP or BP (including non-compliant cases);3pts (1,5%) died after allogenic stem cell transplantation (infection complications);the cause of death was unknown in 50 (21,5%) pts. The highest death rate from CML progression was at 4-9 y of follow-up. Deaths caused by concomitant diseases were in 68 (29%) pts: coronary artery disease/myocardial infarction/heart failure in 42 (62%) of 68 pts, acute ischemic stroke in 10 (15%) pts, second malignancies (Cr- cancer) in 10 (15%) pts (lung tumor, metastatic esophageal Cr, stomach Cr, brain tumor, sigmoid colon Cr, rectal colon Cr, melanoma, renal Cr, breast tumor, other hematological malignancies), accidents - 1 pt, liver cirrhosis - 2 pts, in 2 cases - respiratory virus infections complicated with pneumonia, 1 pt died due to Covid-19. Conclusions. The long-term follow-up of the multicenter study EUTOS OSP in 35 regions of Russian Federation allows not only to characterize the 15-y OS in CML pts but also provides the long-term outlook of the routine clinical practice. Probably, better OS of CML patients receiving treatment in Moscow (2 centers) may be related to organizational issues of interaction with the federal center, better monitoring and timely switching to 2G TKI therapy. The organization and support of multicenter studies may improve the situation with the treatment of diseases of the blood system. [Formula presented] Disclosures: Chelysheva: Novartis Pharma: Speakers Bureau;Pfizer: Speakers Bureau;Pharmstandart: Speakers Bureau;Bristol Myers Squibb: Speakers Bureau. Vinogradova: Pharmstandart: Speakers Bureau;Novartis Phar a: Speakers Bureau;Pfizer: Speakers Bureau;Bristol Myers Squibb: Speakers Bureau. Lomaia: Novartis: Honoraria;Pfizer: Honoraria;BMS: Honoraria;Pharmstandard: Honoraria. Voloshin: Abbvie: Consultancy, Speakers Bureau;Novartis: Consultancy, Speakers Bureau;Astra Zeneca: Consultancy, Speakers Bureau;Pfizer: Consultancy;Biacad: Consultancy, Speakers Bureau. Turkina: Pharmstandart: Speakers Bureau;Pfizer: Speakers Bureau;Bristol Myers Squibb: Speakers Bureau;Novartis Pharma: Speakers Bureau.