Efficacy of Combining Multiple Electromagnetic Navigation Bronchoscopy Modalities for Diagnosing Lung Nodules.

Electromagnetic navigation bronchoscopy (ENB) is one of the non-invasive methods used for lung nodule biopsy. We evaluated the efficacy of combining radial endobronchial ultrasound (R-EBUS)-guided transbronchial lung biopsy (TBLB) with ENB-guided TBLB or transbronchial needle aspiration (TBNA) for diagnosing lung nodules. Forty patients with a lung nodule underwent ENB-TBLB or TBNA, followed by R-EBUS-TBLB if available. The final diagnosis was benign or malignant, depending on the surgical pathology or 24-month follow-up computed tomography (CT). We compared the sensitivity, negative predictive value, and accuracy between combinations of procedures. The mean nodule size was 21.65 mm, and 60.0% of the nodules were solid. The bronchus was within the nodule in 67.5% and 65.0% of cases examined using CT and R-EBUS, respectively. The accuracies of ENB-TBLB alone, ENB-TBLB/TBNA, and R-EBUS-TBLB plus ENB-TBLB/TBNA were 74.4%, 82.5%, and 90.0%, respectively. The sensitivity levels of the aforementioned procedures were 69.8%, 78.8%, and 87.9%, respectively. Among 21 patients who underwent both ENB-TBLB and R-EBUS-TBLB, the latter revealed malignant cells in three of nine patients (33.3%) with benign ENB-TBLB results. Combined ENB-TBLB/TBNA and R-EBUS-TBLB had increased sensitivity and diagnostic accuracy for lung nodules. ENB and R-EBUS are complementary; using both modalities improves the sensitivity and accuracy of lung nodule diagnoses.

Comparison of clinical outcomes of pulmonary sequestration in adults between surgery and non-surgery groups.

Background: Pulmonary sequestration (PS) is a rare congenital lung malformation that can be incidentally diagnosed in adulthood. The natural course of PS in adults is scarcely known. Methods: In this retrospective cohort study, medical records and imaging results of adult patients diagnosed with PS between 1994 and 2019 were reviewed. Diagnoses of PS were confirmed by histopathological findings in resected cases, while non-resected cases were diagnosed based on the presence of anomalous systemic arterial supply and abnormal lung parenchyma on enhanced chest computed tomography (CT). Results: Among 104 patients with PS, the median age at diagnosis was 40.5 years, and 69 (66.3%) patients were asymptomatic. Patients in the surgery group were significantly younger (38.6 vs. 45.3 years, respectively, P=0.016), were more likely to be symptomatic initially (51.6% vs. 28.6%, respectively, P=0.015), and had larger PS (90.0 vs. 66.3 mm, respectively, P<0.001) than the non-surgery group. Of the patients in the surgery group, 29.0% (18/62) experienced postoperative complications. In the surgically resected cases, infections were only detected in intralobar PS, not in extralobar PS. Among 25 subjects without initial symptoms in the non-surgery group, 24 (96.0%) remained asymptomatic at the last follow-up. Conclusions: Adults with PS tended to undergo resection if they were young, symptomatic, and had large PS (a median diameter of 90.0 mm). Almost all subjects who were initially asymptomatic and did not undergo surgery remained asymptomatic at the last follow-up. Therefore, considering the indolent course of PS, initially asymptomatic adults with PS could be followed up without surgery.

Change in individual chronic obstructive pulmonary disease assessment test item scores after short-term bronchodilator therapy and its impact on exacerbation in treatment-naïve patients with chronic obstructive pulmonary disease.

Background: The chronic obstructive pulmonary disease (COPD) assessment test (CAT) measures the health status of patients with COPD. We aimed to investigate the change in individual CAT scores after short-term bronchodilator therapy among treatment-naïve patients with COPD. Methods: Data from 148 patients newly diagnosed with COPD between January 2016 and April 2020 were retrospectively analyzed. We compared the CAT score, modified Medical Research Council (mMRC) dyspnea grade, and forced expiratory volume in 1 s (FEV1) before and after short-term (6 ± 2 months) bronchodilator therapy. We analyzed the change trends using generalized estimating equations. Results: The mean patient age was 70.9 years, and 92.6% were male. The total CAT score did not significantly improve. However, among the CAT items, phlegm [adjusted difference: -0.22 (-0.48, -0.002)], chest tightness [-0.30 (-0.56, -0.05)], and breathlessness [-0.45 (-0.66, -0.23)] scores significantly improved after bronchodilator therapy. The patients were divided into two groups: CAT score improved (n = 69) and not improved group (n = 79). The development of moderate-to-severe exacerbations during follow-up was significantly lower (2.9% versus 17.7%, p = 0.004) in the CAT score improved group. Conclusion: The improvement in CAT items indicating respiratory symptoms was more evident than the CAT total score after short-term bronchodilator therapy. Despite the significant increase in FEV1 after bronchodilator therapy, fewer than half of the patients achieved meaningful improvement in CAT, and this group showed significantly lower development of exacerbation during follow-up.

Association Between Vitamin D Level and Respiratory Symptoms in Patients with Stable Chronic Obstructive Pulmonary Disease.

Purpose: Vitamin D insufficiency or deficiency is prevalent in patients with chronic obstructive pulmonary disease (COPD). However, the association between vitamin D levels and respiratory symptoms in patients with stable COPD has not been fully investigated. This study evaluated the association between vitamin D levels and respiratory symptoms in patients with stable COPD. Patients and Methods: Patients with COPD who had their serum 25-hydroxyvitamin D (25-OH vitamin D) level measured within 6 months of spirometry between January 2016 and April 2020 were retrospectively included. Respiratory symptoms were assessed using the modified Medical Research Council (mMRC) scale and COPD assessment test (CAT) score. Results: Of the 329 included patients, 193, 88, and 48 were categorized as having vitamin D deficiency (<20 ng/mL), insufficiency (20-29 ng/mL), and sufficiency (≥30 ng/mL), respectively. The mean serum 25-OH vitamin D level of each group was 13.45 ng/mL, 24.61 ng/mL, and 38.90 ng/mL, respectively. Patients with vitamin D insufficiency/deficiency showed higher CAT scores than those with vitamin D sufficiency (p = 0.004). In multivariable adjusted models, vitamin D insufficiency/deficiency was significantly associated with a CAT score of 10 or more (adjusted odds ratio [aOR] = 2.41, 95% confidence interval [CI] = 1.20-4.82, p = 0.013) and mMRC ≥ 2 (aOR = 2.39, 95% CI = 1.08-5.32, p = 0.032). Among CAT items, the amount of phlegm (p = 0.008), chest tightness (p = 0.030), breathlessness walking upstairs (p < 0.001), home activity limitations (p = 0.002), and lack of energy (p = 0.003) were significantly associated with vitamin D insufficiency/deficiency after adjustment for age, sex, body mass index, smoking history, Charlson comorbidity index, post-bronchodilator forced expiratory volume in 1 second, and season of blood draw. Conclusion: Vitamin D insufficiency/deficiency were associated with worse respiratory symptoms in patients with stable COPD.

Association between 16S rRNA gene mutations and susceptibility to amikacin in Mycobacterium avium Complex and Mycobacterium abscessus clinical isolates.

We evaluated the association between 16S rRNA gene (rrs) mutations and susceptibility in clinical isolates of amikacin-resistant nontuberculous mycobacteria (NTM) in NTM-pulmonary disease (PD) patients. Susceptibility was retested for 134 amikacin-resistant isolates (minimum inhibitory concentration [MIC] ≥ 64 µg/ml) from 86 patients. Amikacin resistance was reconfirmed in 102 NTM isolates from 62 patients with either Mycobacterium avium complex-PD (MAC-PD) (n = 54) or M. abscessus-PD (n = 8). MICs and rrs mutations were evaluated for 318 single colonies from these isolates. For the 54 MAC-PD patients, rrs mutations were present in 34 isolates (63%), comprising all 31 isolates with amikacin MICs ≥ 128 µg/ml, but only three of 23 isolates with an MIC = 64 µg/ml. For the eight M. abscessus-PD patients, all amikacin-resistant (MIC ≥ 64 µg/ml) isolates had rrs mutations. In amikacin-resistant isolates, the A1408G mutation (n = 29) was most common. Two novel mutations, C1496T and T1498A, were also identified. The culture conversion rate did not differ by amikacin MIC. Overall, all high-level and 13% (3/23) of low-level amikacin-resistant MAC isolates had rrs mutations whereas mutations were present in all amikacin-resistant M. abscessus isolates. These findings are valuable for managing MAC- and M. abscessus-PD and suggest the importance of phenotypic and genotypic susceptibility testing.

Tracheobronchopathia osteochondroplastica (TPO) associated with tracheobronchial amyloidosis (TBA).

Tracheobronchopathia osteochondroplastica (TPO) is an idiopathic disease involving the cartilage rings of the large airway, characterized by submucosal calcified nodules. Localized tracheobronchial amyloidosis (TBA) is another rare disease with localized amyloid deposits in the tracheobronchial tree. The two diseases rarely coincide, and only a few case reports and series have been reported. A patient with dyspnea was referred to our clinic for suspicion of TBA. Chest computed tomography (CT) scan showed marked thickening of the tracheobronchial wall with calcified endobronchial submucosal nodules. The nodules were resected with a Diode Laser under rigid bronchoscopy, and results from the biopsy showed both osteochondroid metaplasia on microscopy in Hematoxylin and Eosin staining and apple-green birefringence on polarized microscopy in Congo red staining. This is a rare case in which microscopic findings of both TPO and TBA were observed on one slide. These findings suggest that localized TBA could be a cause of TPO.

Tracheobronchopathia osteochondroplastica (TPO) associated with tracheobronchial amyloidosis (TBA).

Tracheobronchopathia osteochondroplastica (TPO) is an idiopathic disease involving the cartilage rings of the large airway, characterized by submucosal calcified nodules. Localized tracheobronchial amyloidosis (TBA) is another rare disease with localized amyloid deposits in the tracheobronchial tree. The two diseases rarely coincide, and only a few case reports and series have been reported. A patient with dyspnea was referred to our clinic for suspicion of TBA. Chest computed tomography (CT) scan showed marked thickening of the tracheobronchial wall with calcified endobronchial submucosal nodules. The nodules were resected with a Diode Laser under rigid bronchoscopy, and results from the biopsy showed both osteochondroid metaplasia on microscopy in Hematoxylin and Eosin staining and apple-green birefringence on polarized microscopy in Congo red staining. This is a rare case in which microscopic findings of both TPO and TBA were observed on one slide. These findings suggest that localized TBA could be a cause of TPO.

S-100-Negative malignant pulmonary granular cell tumor: A case report.

Malignant pulmonary granular cell tumor (GCT) is extremely rare and difficult to distinguish from benign GCT. Most GCTs are neural-type and express S-100. However, a small subset of tumors sub-classified as the non-neural type do not express S-100. We report a case of malignant non-neural-type GCT in the lungs. A 77-year-old woman felt chest discomfort and dyspnea in July 2019. She had never smoked and had no medical history other than hypertension and diabetes mellitus. She was initially evaluated at a local hospital. Flexible bronchoscopy showed total occlusion of the right main bronchus by a mass-like lesion. Biopsy of the mass lesion revealed chronic inflammation. The patient visited for re-evaluation in September 2019. Rigid bronchoscopy showed worsening of the total obstruction of the right main bronchus by a tumor mass, such that the carina was not visible. Additionally, endobronchial nodules were observed on the medial side of left main bronchus. The tumor masses of both main bronchi were removed by bronchoscopic intervention, but the right main bronchus was not opened. Biopsy revealed malignant GCT, favoring the non-neuronal type (S-100-negative). We report an extremely rare case of malignant pulmonary GCT negative for S-100 in immunohistochemistry. In this case, surgical resection was not possible because the tumor was diagnosed at a fairly advanced stage and had spread to involve the contralateral main bronchus. The patient chose to be treated at another hospital and was thereafter lost to follow-up.

Surgically intractable bronchopleural fistula treated with endobronchial valve insertion by isolating the tract with indigo carmine: A case report.

Bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree. Herein, we report a patient with persistent air leak after necrotizing pneumonia, where tract of BPF was not apparent in computed tomography (CT). Despite control of infection, watchful observation, repetitive procedures, and surgery, air leak was not resolved. This led to consideration of the endobronchial valve (EBV) placement. After identifying the bronchial segment leading to the fistula with indigo carmine, precise occlusion of the lingular division of the left upper lobe (LUL) was performed using an EBV. Subsequently, the air leak was resolved. During 6 months of follow-up, neither recurrence of BPF nor any procedure-related complications were noted. We concluded that precise EBV placement by identifying bronchial segment leading to the BPF, could be an effective treatment for persistent air leak.