[Solitary Mixed Squamous and Glandular Papilloma of the Peripheral Lung:Report of a Case].

A 76-year-old woman was admitted because of a 25 mm solitary nodule in right S10 on chest computed tomography (CT). 18 fluoro deoxyglucose-positron emission tomography (FDG-PET) indicated accumulation with standardized uptake value( SUV) max 5.2. The serum carcinoembryonic antigen( CEA) and squamous cell carcinoma antigen( SCC) level was elevated. Although the diagnosis was not established by bronchofiberscopy, lung cancer was suspected and the video assisted thoracoscopic surgery (VATS) was carried out. Since no malignant cells were detected by intra-operative pathology, partial resection of the right lower lobe was performed. The postoperative pathological examination revealed features of mixed squamous and glandular papilloma.

[Vagal Schwannoma in the Middle Mediastinum Found by Atelectasis on Chest X-ray:Report of a Case].

An 70-year-old woman was reffered to our hospital to examine for a left lower lobe atelectasis on chest X-ray. Chest computed tomography (CT) showed the mass in middle mediastinum. The video-assisted thoracoscopic surgery( VATS) was performed to establish diagnosis and treat. 50 mm mass was found in the area surrounded by the descending thorasic aorta, esophagus, left atrium, left lower lobe, and mesiastinal pleura, and was regarded as a neurogenic tumor originating from the pulmonary branch of the vagal nerve. The histopathological diagnosis was benign schwannoma. She was dischraged on the seventh postoperative day, without any neurological complications.

Secure intravariceal sclerotherapy with red dichromatic imaging decreases the recurrence rate of esophageal varices: A propensity score matching analysis.

BACKGROUND: Red dichromatic imaging (RDI) is next-generation image-enhanced endoscopy technique released in July 2020. We previously reported that RDI can predict esophageal varices (EV) depth and decrease their recurrence rate by accurate intravariceal injections during endoscopic injection sclerotherapy (EIS) using unreleased prototype RDI endoscope. In this study, we analyzed whether RDI improves the overall survival (OS) rate and whether it is more accurate independent predictor of EV recurrence than white light imaging (WLI), using propensity score matching. METHODS: A total of 179 patients were enrolled. Patients were matched for age, platelet count, liver function, EV size, luminal diameter, and EV depth using propensity score matching, and 78 patients (RDI, 39; WLI, 39) were finally matched. Primary endpoints were OS and recurrence rates. Secondary endpoints were success rate of intravariceal injection, operating time, incidence of adverse events (AEs), and predictors associated with OS and recurrence rates. RESULTS: There was no difference in OS (P = .193), but the cumulative recurrence rate in the RDI group was significantly lower than in the WLI group (P = .002). Success rates of intrainjection, operating time, and incidence of AEs were better in the RDI group (p = 0.035, .026, and .0019, respectively). Independent predictors associated with recurrence rate by Cox proportional regression were RDI function and luminal diameter (P < .001 and .017, respectively). CONCLUSION: RDI did not improve OS but decreased the recurrence rate. Independent predictors of recurrence rate were RDI and luminal diameter, resulting from secure intravariceal injections in EIS.

The Thrombopoietin Receptor Agonist Lusutrombopag Is Effective for Patients with Chronic Liver Disease and Impaired Renal Function.

BACKGROUND: The thrombopoietin (TPO) receptor agonist lusutrombopag was developed to treat thrombocytopenia in chronic liver disease (CLD). However, its effectiveness remains unclear. The purpose of this study was to assess the efficacy of lusutrombopag and identify predictors associated with increase in platelet count. METHODS: Eighty CLD patients with thrombocytopenia were enrolled. The primary endpoint was a satisfactory increase in platelets (greater than 1.0 × 104/µL from baseline) in the absence of platelet transfusion. The secondary endpoints were response rate (an increase of greater than 1.0 × 104/µL from baseline), independent predictors of increase in platelets, and the superiority of lusutrombopag over platelet transfusion. RESULTS: The primary endpoint was achieved in 93.8% (75 of 80) patients. The response rate was 96.2% (77 of 80). Renal function parameters (blood urea nitrogen, creatinine, eGFR) were significantly negatively associated with platelet count (p = 0.033, 0.049, and 0.0014, respectively) and were identified as independent predictors by multiple regression analysis (p = 0.049, 0.0023, and 0.0016, respectively). The median increase in platelet count was significantly higher after lusutrombopag than after platelet transfusion (41,000 vs. 12,000/µL, p = 0.015). CONCLUSION: Lusutrombopag was more effective than platelet transfusion for CLD patients, and renal function independently predicted increase in platelet count. Renal function parameters were significantly associated with platelet count.

Usefulness of Modified CEUS LI-RADS for the Diagnosis of Hepatocellular Carcinoma Using Sonazoid.

The Contrast-Enhanced Ultrasound Liver Imaging Reporting and Data System (CEUS LI-RADS) was introduced for classifying suspected hepatocellular carcinoma (HCC). However, it cannot be applied to Sonazoid. We assessed the diagnostic usefulness of a modified CEUS LI-RADS for HCC and non-HCC malignancies based on sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Patients with chronic liver disease at risk for HCC were evaluated retrospectively. Nodules ≥1 cm with arterial phase hyperenhancement, no early washout (within 60 s), and contrast defects in the Kupffer phase were classified as LR-5. Nodules showing early washout, contrast defects in the Kupffer phase, and/or rim enhancement were classified as LR-M. A total of 104 nodules in 104 patients (median age: 70.0 years; interquartile range: 54.5-78.0 years; 74 men) were evaluated. The 48 (46.2%) LR-5 lesions included 45 HCCs, 2 high-flow hemangiomas, and 1 adrenal rest tumor. The PPV of LR-5 for HCC was 93.8% (95% confidence interval (CI): 82.8-98.7%). The 22 (21.2%) LR-M lesions included 16 non-HCC malignancies and 6 HCCs. The PPV of LR-M for non-HCC malignancies, including six intrahepatic cholangiocarcinomas, was 100% (95% CI: 69.8-100%). In conclusion, in the modified CEUS LI-RADS for Sonazoid, LR-5 and LR-M are good predictors of HCC and non-HCC malignancies, respectively.

Thrombopoietin receptor agonist is more effective than platelet transfusion for chronic liver disease with thrombocytopenia, shown by propensity score matching.

AIM: The thrombopoietin receptor agonist, lusutrombopag, was recently adapted for treatment of thrombocytopenia in chronic liver disease. However, no studies have compared the effects of lusutorombopag and platelet transfusion. Therefore, we aimed to clarify the efficacy and proportion of responders of lusutrombopag compared with platelet transfusion, by propensity score matching. METHODS: A total of 200 patients (90 lusutrombopag, 110 platelet transfusion) with thrombocytopenia were enrolled, and matched for age, liver function, renal function, platelet count, peripheral blood count, and spleen size, using the propensity score-matching method. Finally, 52 patients (26 lusutrombopag, 26 platelet transfusion) were included. The primary end-point was an increase in platelet count. Secondary end-points were the proportion of responders, duration of the sustained effect, incidence of adverse events, and predictors associated with an increase in platelet count. RESULTS: The median increase in platelets from baseline was 48 × 103 /µL versus 9.5 × 103 /µL (lusutrombopag vs. transfusion, P < 0.0001). The proportion of responders (increase of >10 × 103 /µL) was 100% versus 50.0% (P < 0.0001). Median duration of the sustained effect (increase of >50 × 103 /µL) was 10 versus 2 days (P < 0.0001). The incidence of adverse events was 7.7% versus 50.0% (P = 0.036). Predictors associated with an increase in platelets were hemoglobin and spleen size by multiple regression analysis. CONCLUSION: Lusutrombopag was more effective in chronic liver disease patients than platelet transfusion. The proportion of responders, effect duration, and non-incidence rate of adverse events were higher in the lusutrombopag group.

The Role of Multiparametric US of the Liver for the Evaluation of Nonalcoholic Steatohepatitis.

Background Nonalcoholic steatohepatitis (NASH) is diagnosed with histopathologic testing, but noninvasive surrogate markers are desirable for screening patients who are at high risk of NASH. Purpose To investigate the diagnostic performance of dispersion slope, attenuation coefficient, and shear-wave speed measurements obtained using two-dimensional (2D) shear-wave elastography (SWE) in assessing inflammation, steatosis, and fibrosis and in the noninvasive diagnosis of NASH in patients suspected of having nonalcoholic fatty liver disease (NAFLD). Materials and Methods This prospective study collected data from 120 consecutive adults who underwent liver biopsy for suspected NAFLD and were enrolled between April 2017 and March 2019. Three US parameters (dispersion slope [(m/sec)/kHz], attenuation coefficient [dB/cm/MHz], and shear-wave speed [in meters per second]) were measured using a 2D SWE system immediately before biopsy. The biopsy specimens were scored by one expert pathologist according to the Nonalcoholic Steatohepatitis Clinical Research Network criteria (119 participants underwent a histologic examination). Diagnostic performance was assessed using the area under the receiver operating characteristic curve (AUC) for the categories of inflammation, steatosis, and fibrosis. Results One hundred eleven adults (mean age, 53 years ± 18 [standard deviation]; 57 men) underwent a US examination. Dispersion slope enabled the identification of lobular inflammation, with an AUC of 0.95 (95% confidence interval [CI]: 0.91, 0.10) for an inflammation grade greater than or equal to A1 (mild), 0.81 (95% CI: 0.72, 0.89) for an inflammation grade greater than or equal to A2 (moderate), and 0.85 (95% CI: 0.74, 0.97) for an inflammation grade equal to A3 (marked). Attenuation coefficient enabled the identification of steatosis, with an AUC of 0.88 (95% CI: 0.80, 0.97) for steatosis grade greater than or equal to S1 (mild), 0.86 (95% CI: 0.79, 0.93) for steatosis grade greater than or equal to S2 (moderate), and 0.79 (95% CI: 0.68, 0.89) for steatosis grade equal to S3 (severe). Shear-wave speed enabled the identification of fibrosis, with an AUC of 0.79 (95% CI: 0.69, 0.88) for fibrosis stage greater than or equal to F1 (portal fibrosis), 0.88 (95% CI: 0.82, 0.94) for fibrosis stage greater than or equal to F2 (periportal fibrosis), 0.90 (95% CI: 0.84, 0.96) for fibrosis stage greater than or equal to F3 (septal fibrosis), and 0.95 (95% CI: 0.91, 0.99) for fibrosis stage equal to F4 (cirrhosis). The combination of dispersion slope, attenuation coefficient, and shear-wave speed showed an AUC of 0.81 (95% CI: 0.71, 0.91) for the diagnosis of NASH. Conclusion Dispersion slope, attenuation coefficient, and shear-wave speed were found to be useful for assessing lobular inflammation, steatosis, and fibrosis, respectively, in participants with biopsy-proven nonalcoholic fatty liver disease. © RSNA, 2020 Online supplemental material is available for this article.

Irreversible electroporation of hepatocellular carcinoma: the role of ultrasonography.

Irreversible electroporation (IRE) is a novel form of soft tissue ablation therapy that uses highcurrent electrical pulses to induce the formation of pores in the cell membrane, leading to cell death. Although outcome data for the ablation of hepatocellular carcinoma (HCC) by IRE are limited, early results are encouraging and may suggest equivalency to the outcomes achieved by thermal ablation methods such as radiofrequency ablation (RFA) and microwave ablation (MWA). However, IRE can be a challenging and very time-consuming procedure compared to RFA and MWA. In this review article, we not only evaluate the efficacy and safety of IRE for the treatment of HCC, but also discuss imaging guidance, ablation monitoring, and endpoint assessment, with a particular focus on ultrasonography.

Clinical utilization of shear wave dispersion imaging in diffuse liver disease.

Shear wave (SW) dispersion imaging is a newly developed imaging technology for assessing the dispersion slope of SWs, which is related to tissue viscosity in diffuse liver disease. Our preclinical and preliminary clinical studies have shown that SW speed is more useful than dispersion slope for predicting the degree of fibrosis and that dispersion slope is more useful than SW speed for predicting the degree of necroinflammation. Thus, dispersion slope, which reflects viscosity, may provide additional pathophysiological insight into diffuse liver disease.

[Basaloid Squamous Cell Carcinoma;Report of a Case].

We report a resected case of basaloid squamous cell carcinoma (BSC). BSC is a rare type of malignant lung tumor. A 79-year-old woman had a 13 mm tumor in the left upper lobe on chest computed tomography (CT). On fluorodeoxyglucose-position emission tomography (FDG-PET), the tumor showed the accumulation of FDG with an SUVmax of 14.7. A left upper lobectomy with lymph node dissection was performed by video-assisted thoracoscopic surgery. The pathological diagnosis was BSC (pT2aN0M0, stage IB). There was no recurrence following lung cancer resection for 12 months. BSC is generally poor prognosis.

Predictive factors for hepatocellular carcinoma occurrence or recurrence after direct-acting antiviral agents in patients with chronic hepatitis C.

BACKGROUND AND AIMS: Direct-acting antiviral agents (DAAs) and the risk of hepatocellular carcinoma (HCC) is controversially reported in the literature. The primary endpoints of this study were to clarify the cumulative incidence and recurrence rate of HCC after DAA treatment. The secondary endpoints were to identify the factors associated with the occurrence or recurrence of HCC after DAAs treatment. METHODS: Of 234 HCV patients, 211 with no history of HCC (no-HCC-history group) and 23 with previous treated HCC history (HCC-history group) were treated with DAAs and followed for more than 24 weeks to determine the incidence of HCC. Platelet count, albumin, α-fetoprotein (AFP) level, L3%, the FIB-4 index and APRI scores were analyzed as possible factors associated with HCC occurrence and recurrence. An intergroup comparison was made of the cumulative incidence of HCC. Cox proportional hazards regression was used to determine associations between blood test values and risk of HCC. RESULTS: The median observation period was 21 months. Cumulative incidence of HCC was higher in the HCC-history group than in the no-HCC-history group (p < 0.0001, 19.0 and 0.52 per 100 patient-years, respectively). Univariate analysis revealed platelet count, albumin, α-fetoprotein (AFP) level, AFP-L3%, and FIB-4 index and APRI scores at the end of DAA treatment as being significantly associated with occurrence/recurrence of HCC. Multivariate analysis revealed that AFP levels before and after the administration of DAAs and AFP-L3% after DAA were independently associated with the occurrence/recurrence of HCC (p = 0.045, 0.043, 0.005, respectively). CONCLUSION: The HCC occurrence rate after DAA treatment was very low, and the recurrence rate lower than that in previous interferon reports. The AFP level and AFP-L3% were identified as important factors in predicting occurrence/recurrence of HCC. Careful observation is needed when increased levels of AFP or AFP-L3% after DAAs treatment are observed.

[Fetal Adenocarcinoma of the Lung].

We report a resected case of fetal adenocarcinoma. Fetal adenocarcinoma is a rare type of malignant lung tumor. A 53-year-old man had a 25 mm tumor in the right upper lobe on chest computed tomography. On fluorodeoxyglucose-positron emission tomography( FDG-PET), the tumor showed the accumulation of FDG with a standardized uptake value( SUV) max of 5.63. He underwent bronchoscopic examination, but a diagnosis was not established. We suspected that the tumor was primary lung cancer or metastatic lung tumor of rectal cancer which was resected prior to the treatment for pulmonary lesion. A right upper lobectomy with lymph node dissection was performed and the pathological diagnosis was high-grade fetal adenocarcinoma, stage IB (pT2aN0M0). The patient was treated with postoperative adjuvant chemotherapy. There has been no recurrence after surgery resection for 9 months.

Viscoelasticity Measurement in Rat Livers Using Shear-Wave US Elastography.

To investigate the usefulness of shear-wave speed and dispersion slope measurements obtained, using an ultrasound elastography system in rat livers with various degrees of necroinflammation and fibrosis. A total of 25 male Sprague Dawley rats were randomly divided into 5 groups of 5 rats each: G0 (control), G1 (CCl4 injected twice a week for 1 wk), G2 (CCl4 injected four times a wk for 1 wk), G3 (CCl4 injected twice a wk for 6 wk) and G4 (CCl4 injected twice a wk for 10 wk). The shear-wave speed (m/s) and the dispersion slope ([m/s]/kHz) were measured. Histologic features (inflammation, necrosis and fibrosis) were used as reference standards. In multivariable analysis with histologic features as independent variables, the fibrosis grade was significantly related to shear-wave speed (p < 0.05) and the necrosis grade was significantly related to dispersion slope (p < 0.05). Dispersion slope is more useful than shear-wave speed for predicting the degree of necroinflammation.

[Growth Process of Cystic Lung Cancer Followed with Computed Tomography Findings Over 5 Years].

An estimated 2~16% of primary lung cancers form cavities with cases that form thin-walled cavities being comparatively rare. We treated a patient with squamous cell carcinoma of the lung with a small cystic shadow that showed no changes for 3 years. The cyst then suddenly grew larger, after which the cyst wall thickened over time and a thin-walled cavity was seen. Here we report this important case showing the development process of lung cancer that formed a thin-walled cavity, together with a discussion of the literature.

A case of severe stenosis of hepatic veins and inferior vena cava with stomal variceal bleeding induced by oxaliplatin-based chemotherapy.

A 27-year-old woman with colon cancer and liver metastasis was referred to our hospital. Colectomy and colostomy were performed to improve her ileus. Following 13 sessions of oxaliplatin-based chemotherapy (OC) with mFOLFOX6 + bevacizumab, thrombocytopenia and frequent peristomal bleeding occurred. Computed tomography showed severe ascites, splenomegaly, significant collateral veins around the stoma, and severe stenosis of the hepatic veins (HV) and inferior vena cava (IVC). Ultrasound elastography showed high liver (and spleen) stiffness values. Repeated OC appeared to cause IVC stenosis as a result of worsening sinusoidal obstruction syndrome (SOS), and peristomal variceal bleeding. After ultrasound-guided percutaneous embolization, bleeding did not recur. Unfortunately, the patient died of liver dysfunction caused by severe SOS. The incidence of OC-induced SOS is reported to be about 50%; however, there is apparently no report of OC-induced HV and IVC stenosis, and in most cases, portal hypertension is improved after OC cessation. This is the first report of OC-induced severe HV and IVC stenosis resulting in refractory peristomal variceal bleeding and eventual death.

Liver fibrosis: noninvasive assessment using supersonic shear imaging and FIB4 index in patients with non-alcoholic fatty liver disease.

PURPOSE: Shear wave elastography (SWE) has been validated in chronic hepatitis C and B; however, limited data are available in non-alcoholic fatty liver disease (NAFLD). This study aimed to evaluate the accuracy of SWE and FIB4 index for the diagnosis of fibrosis in a cohort of consecutive patients with biopsy-proven NAFLD, and to evaluate the effects of other histologic parameters on SWE measurement. METHODS: Written informed consent was obtained from all patients, and this study was approved by our internal review board and ethics committee. Seventy-one patients with histologically proven NAFLD (mean age 50.8 years ± 15.7) were examined. All patients underwent SWE (Aixplorer™; SuperSonic Imagine) and FIB4 index (based on age, aspartate aminotransferase and alanine aminotransferase levels, and platelet counts) measurements. SWE measurements were compared with the histologic features based on the NAFLD activity score and FIB4 index. RESULTS: The area under the ROC curve for the diagnosis of hepatic fibrosis stage 3 or higher was 0.821 (optimal cut-off value 13.1 kPa, sensitivity 62.5%, specificity 57.4%) for SWE and 0.822 (optimal cut-off value 1.41, sensitivity 71.9%, specificity 53.9%) for FIB4 index. The median liver stiffness values measured using SWE showed a stepwise increase with increasing hepatic fibrosis stage (P < 0.001), inflammation score (P = 0.018), and ballooning score (P < 0.001), and showed a stepwise decrease with increasing hepatic steatosis stage (P = 0.046). CONCLUSIONS: SWE and FIB4 index are useful noninvasive tools for estimating the severity of fibrosis in NAFLD patients. However, the presence of severe steatosis may affect the liver stiffness measurement, resulting in underestimations of liver fibrosis.

Role of dual red imaging to guide intravariceal sclerotherapy injection of esophageal varices (with videos).

BACKGROUND AND AIMS: Dual red imaging (DRI) is a novel image-enhanced endoscopy technique that can increase the visibility and predict the depth of esophageal varices (EVs). The recurrence rate of EVs after endoscopic injection sclerotherapy (EIS) reportedly decreases by intravariceal injection of a sclerosant. We evaluated prospectively whether the EIS success rate was increased by DRI compared with the white-light imaging (WLI) mode. METHODS: A total of 79 patients with EVs were randomly divided into the DRI (n = 40) and WLI (n = 39) groups. The primary endpoint was the success rate of intravariceal injection on the first EIS puncture. The secondary endpoint was the recurrence rate. A variable puncture needle was used, and the length was adjusted according to the EV visibility change by DRI. In the WLI group, DRI was not used. RESULTS: The success rate of the first puncture was significantly higher in the DRI group than in the WLI group (80.0% vs 46.2%; P = .0018). The cumulative recurrence rate was significantly lower in the DRI group (P = .031). The sum of the depth and luminal diameter of EVs was investigated by EUS. The Pearson correlation coefficient between this value and the needle length was higher in the DRI group than in the WLI group (r = 0.878 vs 0.603). CONCLUSIONS: DRI increased the EIS success rate and decreased the recurrence rate. This resulted from the puncture needle adjustment to the appropriate length via EV depth prediction by DRI.

Narrow-band imaging can increase the visibility of fibrin caps after bleeding of esophageal varices: a case with extensive esophageal candidiasis.

A 58-year-old man with hepatitis B cirrhosis noticed black stools and underwent an endoscopy at a community hospital. The presence of esophageal varices (EVs) was confirmed, but the bleeding point was not found. He was referred to our institution and underwent a second endoscopy. Extensive white patches of esophageal candidiasis were visible on endoscopy by white-light imaging (WLI), but it was difficult to find the fibrin cap of the EVs. This was easier under narrow-band imaging (NBI), however, as the color turned red from absorption by hemoglobin adhered to it. We retrospectively measured the color differences (CD) between the fibrin cap and the surrounding mucosa 10 times using the CIE (L*a*b*) color space method. The median value of CD increased after NBI (13.9 â†’ 43.0, p < 0.001), with increased visibility. However, the median CD between the white patch and surrounding mucosa decreased after NBI (44.8 â†’ 30.3, p < 0.001). The fibrin cap was paler than the white patch of candidiasis, but the increased visibility of the fibrin cap by NBI enabled it to be found more easily. This is the first report of a case in which NBI was helpful in locating a fibrin cap of EVs.

Dual red imaging (novel advanced endoscopy) can increase visibility and can predict the depth in diagnosing esophageal varices.

BACKGROUND: Dual red imaging (DRI) is a new technology that can increase the visibility of deeper veins compared with narrow band imaging (NBI). As esophageal varices (EVs) are a vascular disease occurring in the submucosal layer, their visibility might be increased by DRI. We prospectively clarified whether the visibility of EVs with red color sign (RCS) can be increased by DRI, and clarified the relation between the visibility scores and the obtained endoscopic ultrasound (EUS) images. METHODS: Forty patients were enrolled. The visibility of the EVs on DRI and NBI endoscopic images was evaluated by five observers in a blinded manner and was compared with a white light image (bad, 0; equal, 1; good, 2). The diameter of the lumen and the depth of the EVs and RCS from the epithelium were measured by EUS. The relation between the visibility scores and the EUS findings was investigated. RESULTS: The DRI scores were 1.66 ± 0.34 for the EV substance and 1.79 ± 0.28 for the RCS, whereas the NBI scores were 0.68 ± 0.38 and 0.41 ± 0.28, respectively. A significant negative correlation was found between the depth and the visibility score (r = -0.505, p = 0.001 for EVs; r = -0.458, p = 0.003 for RCS). CONCLUSIONS: DRI increased the visibility of the EVs and RCS. The visibility of the EVs or RCS in the shallower position was more enhanced by DRI. Visual recognition of the changing degrees of visibility by DRI enables the prediction of the depth of EVs.

Relationship between dose-volume parameters and pulmonary complications after neoadjuvant chemoradiotherapy followed by surgery for lung cancer.

PURPOSE: This study evaluated the relationship between dose-volume histogram (DVH) parameters and pulmonary complications after neoadjuvant chemoradiotherapy (NACRT) followed by surgery for lung cancer. We also examined a new DVH parameter, because the unresected lung should be more spared than the later resected lung. PATIENTS AND METHODS: Data from 43 non-small cell lung cancer patients were retrospectively analyzed. The DVH parameters of the lung were calculated from the total bilateral lung volume minus (1) the gross tumor volume (DVHg) or (2) the later resected lung volume (DVHr). Radiation pneumonitis (RP) and fistula, including bronchopleural and pulmonary fistula, were graded as the pulmonary complications. Factors affecting the incidences of grade 2 or higher RP (≥G2 RP) and fistula were analyzed. RESULTS: Sixteen patients (37 %) experienced ≥G2 RP and a V20 value of the total lung minus the later resected lung (V20r) ≥ 12 % was a significant factor affecting the incidence of ≥G2 RP (p = 0.032). Six patients (14 %) developed a fistula and a V35 value of the total lung minus the gross tumor (V35g) ≥ 19 % and a V40g ≥ 16 % were significant factors affecting the incidence of fistula (p = 0.002 and 0.009, respectively). CONCLUSION: These DVH parameters may be related to the incidences of ≥G2 RP and fistula.