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Purpose: We evaluated the characteristics of and treatment outcomes in patients with benign tracheobronchial tumors., Materials and Methods: We reviewed the records of patients with benign tracheobronchial tumors who underwent bronchoscopic intervention with mechanical removal and Nd: YAG laser cauterization, and evaluated the characteristics and treatment outcomes of 55 patients with hamartomas, leiomyomas, papillomas, typical carcinoids, or schwannomas seen between April 1999 and July 2012., Results: The most common tumors were hamartoma (n=24), leiomyoma (n=16), papilloma (n=7), typical carcinoid (n=5), and schwannoma (n=3). Forty-one patients (75%) had symptoms. On chest computed tomography, 35 patients (64%) had round or ovoid lesions, accompanied by atelectasis (n=26, 47%) or obstructive pneumonia (n=17, 31%). Fatty components (n=9, 16%) and calcifications (n=7, 13%) were observed only in hamartomas, leiomyomas, and typical carcinoids. At bronchoscopy, the typical findings were categorized according to tumor shape, surface, color, and visible vessels. Fifty (91%) patients underwent complete resection. Forty patients (73%) achieved successful bronchoscopic removal defined as complete resection without complications or recurrence. Recurrences occurred in four papillomas, one leiomyoma, and one typical carcinoid. The proportions of tumor types (p=0.029) differed between the successful and unsuccessful removal groups, and a pedunculated base (p<0.001) and no spontaneous bleeding (p=0.037) were more frequent in the successful removal group., Conclusion: We described clinical, radiological, and typical bronchoscopic findings in patients with benign tracheobronchial tumors; these findings might help to differentiate such tumors. Bronchoscopic intervention was a useful treatment modality, and tumor type, pedunculated base, and vascularity may influence successful tumor removal.

Objectives: The aim of our study was to assess whether repeated derecruitments induced by the repetitive withdrawal of high positive end-expiratory pressure could induce lung injury in a swine model., Design: Prospective, randomized, experimental animal study., Setting: University laboratory., Subjects: Specific pathogen-free pigs (Choong-Ang Laboratory Animals, Seoul, Korea) weighing around 30 kg., Interventions: After lung injury was induced by repeated saline lavage, pigs were ventilated in pressure-limited mode with the highest possible positive end-expiratory pressure with a tidal volume of 8 mL/kg and maximum inspiratory pressure of 30 cm H2O. With this initial ventilator setting, the control group (n = 5) received ventilation without derecruitments for 4 hours, and in the derecruitment group (n = 5), derecruitments were repeatedly induced by intentional disconnection of the ventilatory circuit for 30 seconds every 5 minutes for 4 hours., Measurements and Main Results: After the initial increase in positive end-expiratory pressure, the PaO2 increased to greater than 450 mm Hg in both groups. The PaO2 remained at greater than 450 mm Hg in the control group persistently, but in the derecruitment group, PaO2 significantly decreased to 427.7 mm Hg (adjusted p = 0.03) after 2 hours and remained significant for the rest of the study. PaCO2, oxygenation index, and alveolar-arterial oxygen gradient also significantly increased after 2 hours compared with the control group. However, the variables of respiratory mechanics except for minute volume at 2-hour point showed no difference between the two groups for the duration of the study. Histologically, significant bronchiolar injury was observed in the dependent portion of the derecruitment group compared with the controls (p = 0.03), but not in the nondependent area of the lung., Conclusions: Repeated derecruitments exacerbated lung injury, particularly at the bronchiolar level in the dependent portion. Strategies to minimize this type of injury should be incorporated when designing optimal ventilator strategies in acute respiratory distress syndrome patients.

Background: Although elongated morphological changes in the trachea are known to be related to lung function in chronic obstructive pulmonary disease (COPD), whether the tracheal morphological changes are associated with airflow limitations or overinflation of the lung in the early stages of COPD has not yet been determined. Thus, our aim was to investigate the association of tracheal index (TI) with lung function parameters, including lung volume parameters, in COPD patients with mild-to-moderate airflow limitations., Materials and Methods: A retrospective study was conducted in 193 COPD patients with GOLD grades 1-2 (post-bronchodilator forced expiratory volume in 1s [FEV1] ≥ 50% predicted with FEV1/forced vital capacity ratio ≤ 70%; age range, 40-81) and 193 age- and gender-matched subjects with normal lung function as a control group (age range, 40-82). Two independent observers measured TI at three anatomical levels on chest radiographs and CT scans., Results: Compared with the control group, TI was reduced significantly and "saber-sheath trachea" was observed more frequently in COPD patients. Patients with GOLD grade 2 disease had a lower TI than those with GOLD grade 1. TI had apparent inverse correlations with total lung capacity, functional residual capacity, and residual volume, regardless of the anatomical level of the trachea. Even after adjustments for covariates, this association persisted., Conclusions: TI is reduced even in mild-to-moderate COPD patients, and TI measured on chest CT shows significant inverse relationships with all lung volume parameters assessed, suggesting that tracheal morphology may change during the early stages of COPD., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background: Despite the key role of mutational analysis in targeted therapy, the difficulty in acquisition of adequate tumor tissues for molecular genotyping in advanced non-small cell lung cancer (NSCLC) has led to the need for a fast and efficient method for detecting genetic alterations for targeted therapy., Patients and Methods: We analyzed tissue specimens of advanced NSCLC. A mass spectrometry-based assay was used to investigate 471 oncogenic mutations. All tumor specimens were prepared from fresh-frozen tissues., Results: In total, there were 59 hotspot mutations in 67% of the entire patient group (41 out of 61 patients). The most frequent mutation was in TP53 (n=24, 39.3%), followed by EFGR (n=19, 31.1%). Others included MLH1, KRAS, PIK3CA, ERBB2, ABL1 and HRAS., Conclusion: Our results suggest that molecular genotyping using high-throughput technology such as OncoMap v4 is feasible, even with small biopsied specimens from patients with advanced NSCLC.

Purpose: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an accurate and minimally invasive technique used routinely for investigation of mediastinal and hilar lymphadenopathy. However, few studies have addressed its role in comparison to the traditional diagnostic approaches of transbronchial lung biopsy (TBLB), endobronchial biopsy (EBB), and bronchoalveolar lavage (BAL) in the diagnosis of sarcoidosis. We evaluated the usefulness of EBUS-TBNA in the diagnosis of sarcoidosis compared to TBLB, EBB, and BAL., Materials and Methods: Consecutive patients with suspected sarcoidosis (stage I and II) on chest radiography and chest computed tomography were included. All 33 patients underwent EBUS-TBNA, TBLB, EBB, and BAL during the same session between July 2009 and June 2011. EBUS-TBNA was performed at 71 lymph node stations., Results: Twenty-nine of 33 patients, were diagnosed with histologically proven sarcoidosis; two patients were compatible with a clinical diagnosis of sarcoidosis during follow-up; and two patients were diagnosed with metastatic carcinoma and reactive lymphadenopathy, respectively. Among 29 patients with histologically proven sarcoidosis in combination with EBUS-TBNA, TBLB, and EBB, only EBUS-TBNA and TBLB revealed noncaseating granuloma in 18 patients and one patient, respectively. The overall diagnostic sensitivities of EBUS-TBNA, TBLB, EBB, and BAL (CD4/CD8 ≥3.5) were 90%, 35%, 6%, and 71%, respectively (p<0.001). The combined diagnostic sensitivity of EBUS-TBNA, TBLB, and EBB was 94%., Conclusion: EBUS-TBNA was the most sensitive method for diagnosing stage I and II sarcoidosis compared with conventional bronchoscopic procedures. EBUS-TBNA should be considered first for the histopathologic diagnosis of stage I and II sarcoidosis.

Context: In patients with post-tuberculosis bronchial stenosis (PTBS), the severity of bronchial stenosis affects the restenosis rate after the silicone stent is removed. In PTBS patients with incomplete bronchial obstruction, who had a favorable prognosis, the timing of stent removal to ensure airway patency is not clear., Aims: We evaluated the time for silicone stent removal in patients with incomplete PTBS., Settings and Design: A retrospective study examined PTBS patients who underwent stenting and removal of a silicone stent., Methods: Incomplete bronchial stenosis was defined as PTBS other than total bronchial obstruction, which had a luminal opening at the stenotic segment on bronchoscopic intervention. The duration of stenting was defined as the interval from stent insertion to removal. The study included 44 PTBS patients and the patients were grouped at intervals of 6 months according to the duration of stenting., Results: Patients stented for more than 12 months had a significantly lower restenosis rate than those stented for less than 12 months (4% vs. 35%, P = 0.009). Multiple logistic regression revealed an association between stenting for more than 12 months and a low restenosis rate (odds ratio 12.095; 95% confidence interval 1.097-133.377). Moreover, no restenosis was observed in PTBS patients when the stent was placed more than 14 months previously., Conclusions: In patients with incomplete PTBS, stent placement for longer than 12 months reduced restenosis after stent removal.

Background: Flexible bronchoscopy with bronchial washing is a useful procedure for diagnosis of pulmonary tuberculosis (TB), when a patient cannot produce sputum spontaneously or when sputum smears are negative. However, the benefit of gaining serial bronchial washing specimens for diagnosis of TB has not yet been studied. Therefore, we conducted a retrospective study to determine the diagnostic utility of additional bronchial washing specimens for the diagnosis of pulmonary TB in suspected patients., Methods: A retrospective analysis was performed on 174 patients [sputum smear-negative, n = 95 (55%); lack of sputum specimen, n = 79 (45%)] who received flexible bronchoscopy with two bronchial washing specimens with microbiological confirmation of pulmonary TB in Samsung Medical Center, between January, 2010 and December, 2011., Results: Pulmonary TB was diagnosed by first bronchial washing specimen in 141 patients (81%) out of 174 enrolled patients, and an additional bronchial washing specimen established diagnosis exclusively in 22 (13%) patients. Smear for acid-fast bacilli (AFB) was positive in 46 patients (26%) for the first bronchial washing specimen. Thirteen patients (7%) were positive only on smear of an additional bronchial washing specimen. Combined smear positivity of the first and second bronchial washing specimens was significantly higher compared to first bronchial washing specimen alone [Total cases: 59 (34%) vs. 46 (26%), p < 0.001; cases for smear negative sputum: 25 (26%) vs. 18 (19%), p = 0.016; cases for poor expectoration: 34 (43%) vs. 28 (35%), p = 0.031]. The diagnostic yield determined by culture was also significantly higher in combination of the first and second bronchial washing specimens compared to the first bronchial washing. [Total cases: 163 (94%) vs. 141 (81%), p < 0.001; cases for smear negative sputum: 86 (91%) vs. 73 (77%), p < 0.001; cases for poor expectoration: 77 (98%) vs. 68 (86%), p = 0.004]., Conclusions: Obtaining an additional bronchial washing specimen could be a beneficial and considerable option for diagnosis of TB in patients with smear-negative sputum or who cannot produce sputum samples.

Backgroud: Procurement of tumor tissue is mandatory for a mutation analysis in patients with non-small cell lung cancer. The purpose of this study was to evaluate the usefulness of bronchoscopic biopsy and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy for detecting epidermal growth factor receptor (EGFR) and KRAS mutations in routine practice., Methods: Tumor DNA was extracted from formalin-fixed paraffin-embedded tissues, and amplifications of exons 18-21 of EGFR and codons 12, 13 and 61 of KRAS were performed using polymerase chain reaction (PCR). PCR products were subjected to direct sequencing in both directions., Results: Of 211 consecutive specimens, 201 (95.3%) were available for EGFR mutation analysis, and 196 (92.9%) were adequate for KRAS mutation analysis. EGFR and KRAS mutations were detected in 14.9% and 5.4%, respectively. A median of 16 days was spent from biopsy to the final report for either EGFR or KRAS mutation status. The detection rates for both mutations were similar between bronchoscopic biopsy and EBUS-TBNA (P > 0.05). Female gender (53.3%), never smoker (63.3%), and adenocarcinoma (96.7%) were predominant in patients with EGFR mutations. Among patients with adenocarcinoma (n = 104), the frequencies of EGFR and KRAS mutations were 27.9% and 10.6%, respectively., Conclusions: Small tissue samples obtained by bronchoscopic biopsy and EBUS-TBNA are sufficient for detecting EGFR and KRAS mutations in routine practice. Therefore, concurrent mutational analyses of small tissue samples should be considered at the time of initial diagnosis., (© 2012 Tianjin Lung Cancer Institute and Wiley Publishing Asia Pty Ltd.)

Purpose: Tracheal restenosis due to excessive granulation tissue around a silicone stent requires repeated bronchoscopic interventions in patients with post-tuberculosis tracheal stenosis (PTTS). The current study was conducted to identify the risk factors for granulation tissue formation after silicone stenting in PTTS patients., Materials and Methods: A retrospective study was conducted between January 1998 and December 2010. Forty-two PTTS patients with silicone stenting were selected. Clinical and radiological variables were retrospectively collected and analyzed., Results: Tracheal restenosis due to granulation tissue formation were found in 20 patients (47.6%), and repeated bronchoscopic interventions were conducted. In multivariate analysis, tracheal wall thickness, measured on axial computed tomography scan, was independently associated with granulation tissue formation after silicone stenting. Furthermore, the degree of tracheal wall thickness was well correlated with the degree of granulation tissue formation., Conclusion: Tracheal wall thickening was associated with granulation tissue formation around silicone stents in patients with post-tuberculosis tracheal stenosis.

The two-stage system of limited and extensive disease has been widely employed for small cell lung cancer (SCLC). However, the International Association for the Study of Lung Cancer has proposed that the TNM classification should be incorporated into clinical practice. The purpose of this study was to evaluate the applicability of the Union for International Cancer Control (UICC) 7th TNM staging system to SCLC. We retrospectively reviewed the medical records of consecutive patients with newly diagnosed histologically proven SCLC between March 2005 and January 2010. Patients who had other concurrent malignancies or had combined-type SCLC were excluded. We assessed overall survival (OS) according to the T descriptor, N descriptor, M descriptor, and TNM stage grouping. In total, 320 SCLC patients were included. Median age was 65 years and 286 patients (89.4%) were male. Median OS was 12.7 months. There were no significant differences in OS according to the T descriptor (P = 0.880). However, there were significant differences in OS according to the N (P < 0.001) and M (P < 0.001) descriptors and TNM stage grouping (P < 0.001). Hazard ratios for OS, adjusted for known prognostic factors, differed significantly according to the N and M descriptor, and TNM stage grouping, but not according to the T descriptors. The UICC 7th TNM staging system may contribute to a more precise prognosis in SCLC patients. Further studies are required to evaluate the applicability of the TNM staging system to SCLC., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Purpose: Acute respiratory failure that requires invasive mechanical ventilation is a leading cause of death in critically ill cancer patients. The aim of this study was to evaluate the outcome and prognostic factors of patients requiring invasive mechanical ventilator for acute respiratory failure, within 1 month of ambulatory chemotherapy for solid cancer., Methods: A retrospective observational study of patients who underwent ambulatory chemotherapy at Samsung Medical Center, between January of 2007 and April of 2009, was employed for this study., Results: A total of 51 patients met the inclusion criteria and were included in the study. The median age was 65 years (25-87) and the majority of the patients were male (n = 38, 74.5%). There were 42 patients (82.3%) with lung cancer. The most common cause of acute respiratory failure was pneumonia (n = 24, 47.1%), followed by acute respiratory failure due to extra-pulmonary infection, drug-induced pneumonitis, alveolar hemorrhage, and cancer progression. The intensive care unit (ICU) mortality was 68.6% and the most common cause of death in the ICU was uncorrected cause of acute respiratory failure. Before adjustment for others factors, prechemotherapy Eastern Cooperative Oncology Group (ECOG) Performance Scale (PS) (P = 0.03), Sequential Organ Failure Assessment score (P = 0.01), and anemia (P = 0.04) were significantly associated with ICU mortality. However, when adjusted for age, sex, and Acute Physiologic and Chronic Health Evaluation II score, only poor ECOG PS (≥2) was significantly associated with ICU mortality [OR 6.36 (95% CI (1.02-39.5))]., Conclusions: The outcome of patients with acute respiratory failure needing invasive mechanical ventilation during ambulatory chemotherapy for solid cancer is poor. Prechemotherapy performance status is an independent predictor of mortality.

Background and Objective: We evaluated effective treatments of broncholithiasis based on its radiographical and bronchoscopic features., Methods: This retrospective study conducted at Samsung Medical Center, Korea enrolled patients who were suspected of having broncholithiasis based on chest computed tomography (CT). The broncholiths were classified as intraluminal, mixed (both intraluminal and extraluminal) and extraluminal based on chest CT and bronchoscopic findings., Results: The study enrolled 46 patients between 1995 and 2009. Symptoms included cough (n = 21, 45.7%), hemoptysis (n = 19, 41.3%) and purulent sputum (n = 11, 23.9%). Cough was more common in intraluminal boncholiths than in other type of broncholiths (P = 0.03). Based on chest CT, there were 15 (32.6%) intraluminal, 15 (32.6%) mixed and 16 (34.8%) extraluminal broncholiths. All 15 intraluminal broncholiths were removed completely via flexible (n = 2) or rigid (n = 13) bronchoscopy. For the 15 mixed broncholiths, seven (46.7%) bronchoscopic interventions were performed, but complete removal of the broncholiths was not accomplished. Six (40%) mixed and four (25%) extraluminal broncholiths were treated by surgical resection for symptom control. None of the patients who underwent surgical resection suffered morbidity or postoperative mortality., Conclusions: The treatment of broncholithiasis should be based on chest CT and bronchoscopic findings. Intraluminal broncholiths can be removed via bronchoscopy, while surgery should be considered for symptomatic mixed or extraluminal broncholiths., (© 2013 The Authors. Respirology © 2013 Asian Pacific Society of Respirology.)

Purpose: The purpose of this study was to evaluate the usefulness of convex probe endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for detecting malignancy in parenchymal pulmonary lesions located adjacent to the central airways., Materials and Methods: We retrospectively reviewed the diagnostic performance of EBUS-TBNA in consecutive patients with high clinical suspicion of a centrally located primary lung cancer who had undergone EBUS-TBNA at the Samsung Medical Center between May 2009 and June 2011., Results: Thirty-seven patients underwent EBUS-TBNA for intrapulmonary lesions adjacent to the central airways. Seven lesions were located adjacent to the trachea and 30 lesions were located adjacent to the bronchi. Cytologic and histologic samples obtained via EBUS-TBNA were diagnostic in 32 of 37 (86.4%) of patients. The final diagnosis was lung cancer in 30 patients (7 small cell lung cancer, 23 non-small cell lung cancer), lymphoma in one and malignant fibrous histiocytoma in one patient. The diagnostic sensitivity of EBUS-TBNA in detecting malignancy and detecting both malignancy and benignity was 91.4% and 86.5%, respectively. Two patients experienced minor complications., Conclusion: EBUS-TBNA is an effective and safe method for tissue diagnosis of parenchymal lesions that lie centrally close to the airways. EBUS-TBNA should be considered the procedure of choice for patients with centrally located lesions without endobronchial involvement.

We report a 54-year-old woman who presented with a well-defined, homogeneous, and non-enhancing mass in the retrobronchial region of the bronchus intermedius. The patient underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for histological confirmation. Serous fluid was aspirated by EBUS-TBNA. Cytological examination identified an acellular smear with negative microbiological cultures. The patient was finally diagnosed with bronchogenic cysts by chest computed tomography (CT) and EBUS-TBNA findings. However, 1 week after EBUS-TBNA, the patient developed bronchogenic cyst rupture and pneumonia. Empirical antibiotics were administered, and pneumonia from the bronchogenic cyst rupture had resolved on follow-up chest CT. To our knowledge, this is the first reported case of pneumonia from bronchogenic cyst rupture after EBUS-TBNA.

Context: Bronchoscopic intervention can provide immediate relief from suffocation and an opportunity for additional treatment in patients with malignant airway obstruction. However, few studies have specifically identified prognostic factors affecting the survival of advanced lung or esophageal cancer patients receiving bronchoscopic intervention., Aims: We aimed to investigate prognostic factors influencing survival in these patients., Study Design: We conducted retrospective study., Methods: The clinical parameters were retrospectively reviewed in 51 patients (lung cancer: n = 35; esophageal cancer: n = 16) who underwent palliative bronchoscopic interventions due to malignant airway., Results: Bronchoscopic interventions, such as mechanical removal (n = 26), stenting (n = 31), laser cauterization (n = 19), and ballooning (n = 16), were performed on intraluminal (n = 21, 41%), extrinsic (n = 8, 16%), and combined lesions (n = 22, 43%). Tracheal invasion was found in 24 patients (47%). Successful palliation was achieved in 49 patients (96%). After the intervention, additional anti-cancer treatment was followed in 24 patients (47%). The median survival time and overall survival rate were 3.4 months and 4%. Survival was increased with selected conditions, including a treatment-naïve status (hazard ratio [HR], 0.359; confidence interval [CI], 0.158-0.815; P = 0.01), an intact proximal airway (HR, 0.265; CI, 0.095-0.738; P = 0.01), and post-procedural additional treatment (HR, 0.330; CI, 0.166-0.657; P < 0.01)., Conclusions: Brochoscopic intervention could provide immediate relief and survival improvement in advanced lung or esophageal cancer patients with selected conditions such as a treatment-naïve status, an intact proximal airway, and available post-procedural additional treatment.

The aim of this study was to investigate antifactor Xa (aFXa) levels after once daily dose of 40 mg of enoxaparin and to evaluate factors influencing aFXa levels among Korean intensive care unit (ICU) patients. This prospective observational study was conducted between August and December 2011 in medical ICUs at Samsung Medical Center. AFXa levels between 0.1 and 0.3 U/mL were considered to be effective for antithrombotic activity. Fifty-five patients were included. The median aFXa levels were 0.22 (IQR 0.17-0.26) at 4 hr, 0.06 (IQR 0.02-0.1) at 12 hr, and 0 U/mL (IQR 0-0.03) at 24 hr. The numbers of patients showing effective antithrombotic aFXa levels were 48 (87.3%), 18 (32.7%), and 0 (0%) at 4, 12 and 24 hr, respectively. At 12 hr, higher sequential organ failure assessment (SOFA) scores and hyperbilirubinemia were significantly associated with low aFXa levels (OR, 0.58; 95% CI, 0.36-0.93; P = 0.02 and 0.06; 0.003-0.87; 0.04, respectively). Once daily dose of 40 mg of enoxaparin is inadequate for maintaining effective antithrombotic aFXa levels, and the inadequacy is more salient for patients with high SOFA scores and hyperbilirubinemia.

Setting: Patients with new pulmonary infiltrates on chest computed tomography (CT) scans at a tertiary centre in South Korea., Objective: To demonstrate associations among radiological changes, blood eosinophilia (E) and Toxocara (T) seropositivity., Design: We retrospectively reviewed blood eosinophilia, Toxocara seropositivity, history of raw meat intake and radiological features, and divided study patients into four groups according to blood eosinophilia and Toxocara seropositivity., Results: Among 150 patients, 62 were E- and T-positive (E+T+), 45 were E-negative and T-positive (E-T+), 7 were E-positive and T-negative (E+T-), and 36 were E- and T-negative (E-T-). History of raw meat intake was found in 95 (63%) patients. The type and number of lesions on CT did not show any significant differences among the four groups. Among 119 patients who were not diagnosed with a specific disease, transient or migrating lesions were seen in 93% of E+T+, 93% of E-T+, 80% of E+T- and 52% of E-T- patients (P < 0.0001). Furthermore, the frequencies of migrating or new lesions and improvement were significantly higher in the Toxocara-positive group (88/95, 93%) than in the Toxocara-negative group (14/24, 58%; P = 0.002)., Conclusion: Transient and migratory pulmonary infiltrates on chest CT scans were associated with blood eosinophilia and Toxocara seropositivity. Clinicians should consider asymptomatic toxocariasis as a cause of unexplained new pulmonary infiltrates in countries with dietary habits of raw meat intake.

Background: There are limited data on the performance of the pneumonia severity index (PSI) and CURB-65 (confusion, urea, respiratory rate, blood pressure, age ≥65) score, which were originally developed for community-acquired pneumonia (CAP), for patients with healthcare-associated pneumonia (HCAP)., Methods: The performances of PSI and CURB-65 were retrospectively evaluated in patients with HCAP compared to patients with CAP using prospectively collected data between January 2008 and December 2010., Results: In total, 938 patients hospitalized with pneumonia were eligible for this study, consisting of 519 (55%) with CAP and 419 (45%) with HCAP. The PSI and CURB-65 scores had similar trends of increasing mortality with worsening risk class in both the HCAP and CAP groups. In the HCAP group, however, the low-risk patients identified using CURB-65 had a higher aggregate 30-day mortality compared with the low-risk patients identified using PSI. Although the performances of PSI and CURB-65 in the HCAP group showed similar trends to those observed in the CAP group, the estimated areas under the receiver operating characteristic curve for PSI (0.679, 95% confidence interval [CI], .619-.739) and CURB-65 (0.599, 95% CI, .522-.675) in the HCAP group were significantly lower than those in the CAP group (0.835, 95% CI, .768-.759 for PSI and .686-.832 for CURB-65)., Conclusions: The performances of PSI and CURB-65 for predicting 30-day mortality in patients with HCAP were comparable to those in patients with CAP. However, the discriminatory powers of PSI and CURB-65 for 30-day mortality were significantly lower in the HACP group than those in the CAP group.

Epidermal growth factor receptor (EGFR) mutation in non-small cell lung cancer (NSCLC) is a strong predictive factor for a favorable response to EGFR tyrosine kinase inhibitors, however, its prognostic role in locally advanced stage is unclear. The aim of this study was to analyze the association of EGFR mutational status and clinical outcome after neoadjuvant chemoradiotherapy (CRT) followed by surgical resection in mediastinoscopically proven N2(+) NSCLC patients. We retrospectively identified 168 patients diagnosed between 1998 and 2006. EGFR mutational status was identified in 107 patients. Response and survival after neoadjuvant CRT followed by surgery were compared according to EGFR mutational status. 83 patients (77.6%) were found to have wild type EGFR, while exon 19 deletions or L858R missense mutations in the EGFR gene were detected in 19 patients. There was no significant difference in overall survival; however, the 5-year PFS rate in EGFR mutant patients (8.4%) were significantly lower than in the EGFR wild-type patients (33.6%; p=0.005). In multivariate analysis, EGFR mutation was a significant prognostic factor for a higher risk of distant recurrence/progression than the EGFR wild type (HR=7.183, p=0.005). In locally advanced mediastinoscopic N2-positive NSCLC, EGFR mutation was associated with more frequent distant relapses and worse 5-year PFS rate after neoadjuvant CRT followed by surgery, which might suggest that systemic control might be important in patients with the EGFR mutation. Therefore, the role of TKI for adjuvant EGFR TKI to decrease disease recurrence in distant sites should be further investigated., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: To evaluate the prognostic significance and predictive performance of volume-based parameters of F-fluorodeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) in early-stage non-small cell lung cancer (NSCLC)., Background: Although surgical resection remains the optimal treatment for early-stage NSCLC, approximately 40% of patients with stage I and 60% of patients with stage II NSCLC relapse and die within 5 years after curative resection. Therefore, identification of additional prognostic biomarkers is needed to develop risk-adapted treatment strategies., Methods: We retrospectively reviewed 529 consecutive patients with pathologically proven early-stage NSCLC who underwent preoperative F-FDG PET/CT. Maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) for the primary tumors were measured. Overall survival (OS) and disease-free survival (DFS) were assessed by the Kaplan-Meier method. The prognostic significance of PET parameters and other clinicopathological variables was assessed by Cox proportional hazards regression analysis. To evaluate and compare the predictive performance of PET parameters, time-dependent receiver operating characteristic (ROC) curve analysis was used., Results: In the multivariate analyses, volume-based parameters of PET (MTV and TLG) that were analyzed as continuous variables were significantly associated with an increased risk of recurrence (P = 0.001 for MTV, P < 0.001 for TLG) and death (P = 0.009 for MTV, P = 0.007 for TLG), after adjusting for age, sex, histology, tumor stage, and type of surgery. SUVmax analyzed as a continuous variable was not a significant prognostic factor for both DFS (P = 0.056) and OS (P = 0.525). In the time-dependent ROC curve analysis, the volume-based parameter of PET showed better predictive performance than SUVmax (P < 0.001)., Conclusions: The volume-based parameter of PET is an independent prognostic factor for survival in addition to pathological tumor-node-metastasis stage and a promising tool for better prediction of outcome in patients with early-stage NSCLC.

Objective: Obtaining an accurate histopathological diagnosis is mandatory for the optimal treatment of patients who are suspected of having recurrent lung cancer. The purpose of this retrospective study was to investigate the usefulness of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the diagnosis of recurrent non-small cell lung cancer (NSCLC) among patients who undergo curative surgical resection., Methods: Consecutive patients who underwent convex probe EBUS-TBNA for mediastinal or hilar lymph node and peribronchial lung parenchymal lesions between May 2009 and May 2011 were included. The diagnostic sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) were calculated on a per-lesion and per-patient basis., Results: Forty-two patients who were suspected of having recurrent NSCLC underwent EBUS-TBNA to assess 53 mediastinal and hilar lymph nodes and seven peribronchial lung parenchymal lesions. Among the 60 lesions, recurrence of malignancy was confirmed in 41 lesions on EBUS-TBNA (36 lymph nodes and five peribronchial lung lesions). On a per-lesion basis, the diagnostic sensitivity, specificity, accuracy, PPV and NPV of EBUS-TBNA for confirming recurrence were 95.3%, 100%, 96.6%, 100% and 88.9%, respectively. On a per-person basis, the diagnostic sensitivity, specificity, accuracy, PPV and NPV were 94.3%, 100%, 95.2%, 100% and 77.8%, respectively. No serious complications related to the procedures were observed., Conclusion: Convex probe EBUS-TBNA is a sensitive method for diagnosing recurrent NSCLC in patients with lymph node and peribronchial lung parenchymal lesions. Therefore, EBUS-TBNA should be considered first for the cytopathological diagnosis of recurrent NSCLC.

Background: Although focal ground-glass opacity (GGO) lung nodules are generally reported to grow slowly, their natural course is unclear. The purpose of this study was to elucidate the natural course of screening-detected pure GGO lung nodules in patients with no history of malignancy., Methods: We retrospectively reviewed the database of subjects who had undergone screenings involving low-dose CT scans. We included patients with pure GGO lung nodules who were followed for > 2 years after the initial screening., Results: Between June 1997 and September 2006, 122 pure GGO nodules were found in 89 patients. The median nodule size was 5.5 mm (range, 3-20 mm) in the largest diameter on initial low-dose CT scan. The median follow-up period per patient was 59 months. On a per-person basis, the frequency of growth was 13.5% (12 of 89 patients). On a per-nodule basis, the frequency of growth was 9.8% (12 of 122 nodules). Nodule growth was significantly associated with initial size and new development of an internal solid portion. The median volume doubling time was 769 days for growing pure GGO nodules. A total of 11 growing nodules were surgically validated, and all lesions were confirmed as primary lung cancer., Conclusions: About 90% of the screening-detected pure GGO lung nodules did not grow during long-term follow-up in subjects with no history of malignancy and most growing nodules had an indolent clinical course. A strategy of long-term follow-up and selective surgery for growing nodules should be considered for pure GGO lung nodules.

Objective: The purpose of this study was to discern differences in the clinical and radiologic presentations of intrathoracic tuberculous lymphadenitis in adult patients with and those without HIV infection., Materials and Methods: Between 2000 and 2010, 66 patients (28 men, 38 women; mean age, 45 ± 13.9 years) were found to have intrathoracic tuberculous lymphadenitis. Of these patients, 17 (26%) (15 men, two women; mean age, 47 ± 9.9 years) were HIV-seropositive. Thoracic CT scans were evaluated for involved lymph node stations, long-axis diameter of involved lymph nodes, presence of central necrosis in enlarged nodes, and other associated findings., Results: In HIV-positive patients, tuberculous lymphadenitis had more multifocal (mean number of involved nodal stations, 8.4 versus 3.6; p < 0.001) nodal involvement, had smaller nodes (mean long-axis diameter, 17 mm versus 21 mm; p = 0.004), and was more frequently associated with lung parenchymal lesions and extrathoracic lymph node and organ involvement (p < 0.05) than in HIV-negative patients. Tuberculous lymphadenitis was the sole manifestation of tuberculous infection in 22 of 49 (45%) HIV-negative patients and in 2 of 17 (12%) HIV-positive patients (p = 0.018)., Conclusion: Tuberculous lymphadenitis in patients with HIV infection is characterized by multiple-station lymphadenitis with extensive lung parenchymal, extrathoracic lymph node, and extrathoracic organ involvement.

This study was designed to investigate the incidence, causes, and outcomes of new-onset thrombocytopenia (NOT) in Korean intensive care units (ICUs). A prospective cohort study was conducted in medical ICUs of Samsung Medical Center between August 2010 and February 2011. All newly admitted patients were included if they stayed in the ICU for more than 48 hr and did not have thrombocytopenia upon admission. A total of 186 patients were included. NOT developed in 37.1%. Most common cause of NOT was sepsis with disseminated intravascular coagulation (66.7%), followed by drug-induced thrombocytopenia (18.8%), and heparin-induced thrombocytopenia (2.9%). IgG-specific antibody to platelet factor 4/heparin was positive in 2.4% among patients treated with heparin, and thrombosis occurred in two patients. Twenty eight-day mortality was higher in patients that developed NOT compared to those that did not develop NOT (39.1% vs 12%, P < 0.001). NOT increased the odds ratio of 28-day mortality and was an independent risk factor for mortality (OR 3.52; 95% CI 1.32-9.38; P = 0.012). In conclusion, NOT is common and is an independent risk factor for mortality in Korean ICU patients. Therefore, clinicians should make every effort to correct the causes of NOT.

Background:   Melanoma antigen (MAGE) genes are expressed in tumor cells, the testis and the placenta. The purpose of this prospective study was to investigate the sensitivity, specificity, and accuracy of the carcinoembryonic antigen (CEA), MAGE reverse transcriptase-nested polymerase chain reaction (RT-nested PCR), and cytology of pleural fluid in the diagnosis of malignant pleural effusion., Methods:   Patients in whom unilateral pleural effusion was identified on chest radiography from January to December 2009 were included in the study. MAGE genes were analyzed by RT-nested PCR using MAGE A1-6 common primers., Results:   Of 81 enrolled patients, 46 were diagnosed as malignant pleural effusion, and 24 were diagnosed as benign pleural effusion. The diagnoses of 11 patients were not confirmed in this study. The diagnostic sensitivity, specificity, and accuracy of MAGE RT-nested PCR were 61.4%, 95.7%, and 73.1%, respectively. The diagnostic sensitivities of cytology and CEA (>5 ng/mL) were 61.4% and 75.0%, respectively. Among 17 patients with negative cytology who had malignant pleural effusion, 12 and 10 patients were positive for CEA (>5.0 ng/mL) and MAGE RT-nested PCR, respectively. However, of five patients with malignant pleural effusion that was not recognized by cytology and CEA, MAGE RT-nested PCR correctly predicted a malignant etiology in only one additional patient (20%)., Conclusions:   MAGE RT-nested PCR seems to add little on the combination of conventional methods in the diagnosis of malignant effusion., (© 2012 Tianjin Lung Cancer Institute and Wiley Publishing Asia Pty. Ltd.)

Surgery is a well-recognized modality of treatment for benign tracheobronchial stenosis. However, in some benign disease groups, such as tuberculosis, sarcoidosis, war gas exposure, and inhalation burns, multiplicity of involvement or long length of stenosed segment heightens surgical challenge. We investigated the outcomes and long-term tolerability of the Natural stent (N-stent) in such patients with post-tuberculosis tracheobronchial stenosis. A retrospective review was done for 17 patients who underwent silicone stenting (N-stent) for post-tuberculosis tracheobronchial stenosis during January 2000-December 2003 but needed persistent stent placement and still require the stent. Significant increase in the ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC), expressed as FEV1%, as well as in forced percentual vital capacity (FVC%) (Δ24% and Δ11%, respectively) in the short term and sustained increase in the FEV1% and FVC% (Δ26.5% and Δ16.5%, respectively) in the long term were noted at a median (range) interval of 1 (0.5-72) month and 72 (12-114) months, respectively, along with symptomatic relief. No procedure-related death occurred. Stent-related late complications included granulation tissue formation (76%), migration (70%), and mucostasis (17%). The median duration for which N-stents were tolerated was 7.9 (range, 3-11) years. N-stents are well-tolerated for a prolonged period. Stent-related complications occur, but are easily managed. These results might carry medical implications for those who have airway lesions difficult to correct surgically.

Background: There is controversy regarding palliative chemotherapy for large cell neuroendocrine carcinoma (LCNEC). We evaluated whether advanced LCNEC should be treated similarly to small cell lung cancer (SCLC) or non-small cell lung cancer (NSCLC)., Patients and Methods: The clinical reports and tumor specimens of 45 consecutive patients who were diagnosed with advanced LCNEC were reviewed. They were divided into SCLC (n=11) and NSCLC regimen groups (n=34) according to first-line chemotherapeutic regimens., Results: Most patients were male (96%) and smokers (93%) with a median age of 64 years. Neuroendocrine differentiation was established in 42 (93%) tumors by immunohistochemical analyses. Regarding the efficacy of first-line chemotherapy in the SCLC and NSCLC regimen groups, the response rates were 73% and 50% (P=0.19), and the median progression-free survival times were 6.1 and 4.9 months (P=0.41), respectively. The difference in overall survival between the two treatment groups was 7.3 months (16.5 vs. 9.2 months, P=0.10). There was also a considerable difference in the type and efficacy of salvage chemotherapeutic regimens between the two groups: salvage regimens with irinotecan, platinum, or taxanes were commonly used with relatively high objective responses in the SCLC regimen group, whereas frequently used agents in the NSCLC regimen group such as pemetrexed, gefitinib, or erlotinib were associated with no objective response., Conclusion: Regarding palliative chemotherapy for advanced LCNEC, treatment similar to SCLC is more appropriate than NSCLC., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objectives: To investigate the role of bronchoscopic intervention in the management of postoperative tracheobronchial stenosis, a retrospective study was performed at a tertiary referral hospital., Methods: Thirty patients who underwent 106 bronchoscopic interventions between January 2000 and July 2010, including ballooning, bouginage, Nd:YAG laser resection, and stent insertion, were included and followed up for a median of 34 months., Results: Silicone stents were required in 19 of 30 patients (63%) to maintain airway patency. Bronchoscopic intervention provided improvement of dyspnea in 97% of the patients. After airway stabilization, the stents were removed successfully in 7 of 19 patients (37%) a median of 7 months after insertion. In 3 patients (10%), the intervention failed to widen the airway. There were no procedure-related deaths or cases of pneumonia, although additional interventions were needed in 9 patients (30%) within 30 days. Stent-related late complications (70%), such as restenosis (43%), overgrowth of granulation tissue (33%), stent migration (32%), mucostasis (30%), and malacia after stent removal (16%), were controllable at follow-up bronchoscopy., Conclusions: Bronchoscopic intervention could be a useful treatment modality for patients with postoperative tracheobronchial stenosis when surgery is not feasible., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Purpose: To evaluate whether air pockets (tracheobronchial air columns in the space between the outer surface of the stent and the adjacent airway wall) discernible at computed tomography (CT) can help optimize the time of stent removal in patients with posttuberculosis tracheobronchial stenosis (PTTS)., Materials and Methods: The study was approved by the institutional review board, and informed consent was obtained from all patients. Data from 41 patients (five men, 36 women) with a median age of 39 years (range, 21-64 years) who underwent silicone stent placement owing to PTTS, followed by CT and stent removal 6-12 months after clinical stabilization, were investigated retrospectively. Two radiologists determined whether the extent of air pockets on CT scans was associated with clinical success, which was defined as maintenance of a prosthesis-free airway for more than 2 years after stent removal. Radiologic features were compared for outcome by using a Wilcoxon two-sample test or Fisher exact test., Results: Stents were removed successfully in 31 patients (76%). Air pockets longer than 1 cm or longer than 2 cm were associated with successful stent removal (P = .04 and P = .006, respectively). The sensitivity and specificity of air pocket length in the prediction of successful stent removal were 84% and 50%, respectively, for air pockets longer than 1 cm and 68% and 70% for air pockets longer than 2 cm., Conclusion: The extent of air pockets at chest CT shows correlation with the success of stent removal, indicates regression of stenosis, and may help guide the optimal time for stent removal.

Purpose: Stenting has been developed to deal with airway stenosis and is applicable in patients with post-intubation tracheal stenosis (PITS) in whom surgery would not be indicated. The purpose of this study was to investigate the prognostic factors in inoperable patients in whom a silicone stent was inserted due to PITS., Materials and Methods: We retrospectively evaluated 55 PITS patients undergoing silicone stenting between January 2001 and December 2009., Results: Silicone stent was inserted to narrowed trachea after the combination of pre-dilatation including laser cauterization, mechanical bougienation and ballooning. Following airway stabilization, the stent could be removed successfully in 40% (22/55) of the patients after median 12 months of stenting. However, in 60% (33/55) of patients, the stent could not be removed successfully and surgical management was needed after initial stabilization. Multivariate analysis revealed that the stent could be successfully removed more frequently in those who do not have cardiovascular disease [odds ratio (OR)=12.195; p=0.036] and the intervention was performed within 6 months after intubation (OR=13.029; p=0.031)., Conclusion: Among those patients undergoing silicone stenting due to PITS, the stent could be successfully removed when patients do not have cardiovascular disease and stented within 6 months after intubation.

Purpose: Vascular endothelial growth factor (VEGF) and angiopoietin-2 (Ang-2) are major mediators of angiogenesis and are induced by tissue inflammation and hypoxia. The purpose of this study was to investigate whether serum VEGF and Ang-2 are associated with the presence of hemoptysis and the extent of systemic inflammation in patients with inflammatory lung diseases., Materials and Methods: We prospectively enrolled 52 patients with inflammatory lung disease between June 2008 and October 2009., Results: The median values of VEGF and Ang-2 were 436 pg/mL and 2383 pg/mL, respectively. There was a significant positive correlation between serum Ang-2 and VEGF levels. VEGF levels were not significantly different according to the presence of hemoptysis. C-reactive protein (CRP) and Ang-2 level were significantly higher in patients without hemoptysis (n=26) than in those with hemoptysis (n=26; p<0.001 and p<0.001, respectively). CRP and arterial oxygen tension (PaO₂) were significantly correlated with both serum VEGF (p=0.032 and p=0.016, respectively) and Ang-2 levels (p<0.001 and p=0.041, respectively), after adjusting for other factors. Age and the absence of hemoptysis were factors correlated with serum Ang-2 levels., Conclusion: Our study suggests that serum VEGF and Ang-2 levels are associated with PaO₂ and the severity of inflammation rather than the presence of hemoptysis in patients with inflammatory lung diseases. Thus, hemoptysis may not be mediated by increased serum levels of VEGF and Ang-2 in patients with inflammatory lung diseases, and further studies are required to determine the mechanisms of hemoptysis.

There are no accurate data on the relationship between nodal station and diagnostic performance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). We evaluated the impact of nodal station and size on the diagnostic performance of EBUS-TBNA in patients with non-small cell lung cancer (NSCLC). Consecutive patients who underwent EBUS-TBNA of mediastinal or hilar lymph nodes for staging or diagnosis of NSCLC were included in this retrospective study. Between May 2009 and February 2010, EBUS-TBNA was performed in 373 mediastinal and hilar lymph nodes in 151 patients. The overall diagnostic sensitivity, specificity, accuracy and negative predictive value (NPV) of EBUS-TBNA were 91.6%, 98.6%, 93.8%, and 84.3%, respectively. NPV of the left side nodal group was significantly lower than those of the other groups (P = 0.047) and sensitivity of the left side nodal group tended to decrease (P = 0.096) compared with those of the other groups. Diagnostic sensitivity and NPV of 4L lymph node were 83.3% and 66.7%, respectively. However, diagnostic performances of EBUS-TBNA did not differ according to nodal size. Bronchoscopists should consider the impact of nodal stations on diagnostic performances of EBUS-TBNA.

The purpose of this study was to evaluate the prognostic significance of classification of patients with septic shock into different critical illness-related corticosteroid insufficiency subgroups. A retrospective observational study was conducted in patients with septic shock who underwent a short corticotropin stimulation test within 72 h of the onset of shock. Patients were classified into normal adrenal function (NOM), low basal cortisol (LBC) (basal cortisol, <10 μg/dL), or low Δ cortisol (LDC) (basal cortisol, ≥10 μg/dL; cortisol, <9 μg/dL) groups. A total of 168 septic shock patients were recruited. Forty-two patients (25%) were assigned to the NOM group, 39 (23.2%) to the LBC group, and 87 (51.8%) to the LDC group. All of the patients received hydrocortisone therapy. Patients in the LDC group had significantly higher Simplified Acute Physiology Score 3 (P < 0.001) and Sequential Organ Failure Assessment score (P < 0.001) than did patients in the NOM group. The 28-day mortalities of the NOM, LBC, and LDC groups were 40.5%, 38.5%, and 63.2%, respectively (P = 0.007). Classification into the LDC group significantly increased the odds of 28-day mortality (odds ratio, 2.717; 95% confidence interval, 1.452-5.082; P = 0.002) and remained an independent risk factor for mortality even after controlling for all the other potential risk factors identified (odds ratio, 3.638; 95% confidence interval, 1.418-9.028; P = 0.006). Classification into the LDC group is an independent risk factor for mortality in hydrocortisone-treated septic shock patients.

Background and Objective: Silicone airway stents are used to widen narrowed airways in patients with post-tuberculosis tracheobronchial stenosis (PTTS). After mechanical stabilization, stents can be removed from the majority of patients leaving restored airway patency. However, in a significant minority re-stenosis develops post-sten removal thus necessitating surgical intervention or long-term stenting. In this study, we sought to establish prognostic factors for successful airway intervention in PTTS., Methods: We retrospectively investigated 71 patients who underwent silicone stenting due to PTTS. After stenting, bronchoscopic toileting and/or repositioning was performed during follow up. At 6-12 months after clinical stabilization, stents were planned to be removed. Patients with patent airways were followed if no further intervention was required. If restenosis developed, patients underwent re-stenting or operation. Clinical parameters were analysed to determine favourable prognostic factors., Results: Stents were successfully removed in 40 patients at a median 12.5 months after insertion. In 27 patients, stent re-insertion was carried out and four patients underwent surgical management. Multivariate logistic regression analysis revealed that successful stent removal was independently associated with atelectasis <1 month before bronchoscopic intervention, and absence of complete lobar atelectasis., Conclusions: Airway intervention, including silicone stenting, can be successful in patients with PTTS, when the intervention is performed within 1 month of atelectasis and before complete lobar atelectasis., (© 2011 The Authors. Respirology © 2011 Asian Pacific Society of Respirology.)

Introduction: The development of synchronous multiple primary non-small cell lung cancer (NSCLC) is not rare. Nevertheless, the diagnosis, treatment and outcome are controversial. The purposes of this study were to assess the treatment outcomes for patients with synchronous multiple primary NSCLC and to analyze the factors related to this outcome., Methods: We retrospectively analyzed clinical characteristics and treatment outcomes of 32 patients with synchronous multiple primary NSCLC who underwent surgical resection between 1995 and 2008., Results: A total of 68 separate tumors were identified in 32 patients. Fifteen (46.9%) patients underwent lobectomy or pneumonectomy with mediastinal lymph node dissection, and 17 (53.1%) patients underwent at least one limited resection or photodynamic therapy. The rate of immediate postoperative mortality was 9.4% (N=3). The five-year progression-free survival (PFS) and overall survival (OS) rates were 46.0% and 60.9%, respectively. Small tumor size, similar histology, pN0, and pT1 were associated with better PFS in univariable analyses. Female gender, young age, non-smoker, FEV1/FVC ≥70%, small tumor size, similar histology, and highest pT1 were associated with better OS in univariable analyses., Conclusions: An aggressive surgical approach offers the greatest chance for long-term survival in patient with synchronous multiple primary NSCLC and several clinical factors were associated with survivals. However, the decision of aggressive surgical treatments for synchronous MPLC should be made carefully in the patients with old age and underlying comorbidities due to poor OS and increased surgical mortality., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: Adenoid cystic carcinoma (ACC) of the airway is a slowly growing tumor and airway narrowing is one of the main causes of death. The purposes of this study were to investigate treatment outcomes, prognostic factors, and the indications and outcomes of bronchoscopic interventions in patients with ACC of the airway., Methods: We retrospectively analyzed the clinical characteristics, treatment modalities, and clinical outcomes of patients with histologically-proven ACC of the airway treated between January 1995 and June 2009 at Samsung Medical Center., Results: A total of 30 patients were included in the study. Sixteen patients were male and the median age was 45 years. Multiple treatment modalities were required for the patients; 17 for surgery, 13 for definitive radiation therapy, 10 for adjuvant radiation therapy, and 1 for adjuvant chemotherapy. Bronchoscopic interventions were required to improve airway narrowing in 20 patients. After bronchoscopic intervention, 19 patients (95%) showed immediate improvement of airway narrowing and suffered no serious complications. The 5- and 10-year overall survival (OS) rates in these patients were 84% and 70%, respectively. The prognostic factors associated with OS were tumor size, tumor location, clinical T stage, surgery as an initial treatment, and bronchoscopic intervention., Conclusions: ACC of the airway had a good long-term prognosis but bronchoscopic interventions were frequently required during the course of the disease due to the development of airway narrowing. Bronchoscopic interventions may be considered as a bridge therapy before surgery or radiation therapy and as a palliative therapy for airway narrowing., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective and Design: To determine how pulmonary paragonimiasis may be confused with lung cancer, we retrospectively analysed the clinical and radiological characteristics of 47 patients (27 males, median age 55 years; interquartile range 49-61) with serologically or histopathologically confirmed pulmonary paragonimiasis seen between October 2004 and December 2009., Results: Respiratory symptoms were present in 29 (62%) patients; the remaining 18 (38%) were asymptomatic. Chest radiography (CXR) revealed intrapulmonary parenchymal lesions (n = 35, 75%) more frequently than pleural lesions (n = 11, 23%). Of the 47 patients, 28 (60%) were referred for suspected lung cancer. The majority of these patients had no symptoms, and 22 (79%) patients with suspected lung cancer had nodular or mass lesions on CXR. As a result, additional diagnostic procedures were performed to make an accurate diagnosis in these patients, including bronchoscopy in 20, transthoracic lung biopsy in 11 and fluorodeoxyglucose positron emission tomography in seven. Surgical lung resection was performed unnecessarily in six patients., Conclusions: Pulmonary paragonimiasis presenting with nodular or mass lesions on CXR is common. Clinicians should therefore include pulmonary paragonimiasis in the differential diagnosis of asymptomatic nodular lesions in the lung in patients who have lived in or travelled to paragonimiasis-endemic areas.

Purpose: The Simplified Acute Physiology Score (SAPS) 3 was recently proposed to reflect contemporary changes in intensive care practices. SAPS 3 features customized equations for the prediction of mortality in different geographic regions. However, the usefulness of SAPS 3 and its customized equation (Australasia SAPS 3) have never been externally validated in Korea. This study was designed to validate SAPS 3 and Australasia SAPS 3 for mortality prediction in Korea., Materials and Methods: A retrospective analysis of the prospective intensive care unit (ICU) registry was conducted in the medical ICU of Samsung Medical Center. Calibration and discrimination were determined by the Hosmer-Lemeshow test and area under the receiver operating characteristic (aROC) curve from 633 patients., Results: The mortalities (%) predicted by SAPS 3, Australasia SAPS 3, and SAPS II were 42 ± 28, 39 ± 27 and 37 ± 31, respectively. The calibration of SAPS II was poor (p = 0.003). SAPS 3 and Australasia SAPS 3 were appropriate (p > 0.05). The discriminative power of all models yielded aROC values less than 0.8., Conclusion: In Korea, mortality rates predicted using general SAPS 3 and Australasia SAPS 3 exhibited good calibration and modest discrimination. However, Australasia SAPS 3 did not improve the mortality prediction. To better predict mortality in Korean ICUs, a new equation may be needed specifically for Korea.

Objective: The determination of mediastinal lymphadenopathy is important in the management of extrapulmonary malignancy. The purpose of this study was to determine the diagnostic performance of EBUS-TBNA in the diagnosis of mediastinal and hilar lymphadenopathy in patients with proven or suspicious extrapulmonary malignancy., Patients and Methods: Retrospective analysis was performed in 57 patients (81 lesions) with proven (n=51) or suspicious (n=6) extrapulmonary malignancies who underwent EBUS-TBNA between May 2009 and January 2011., Results: There were 37 male and 20 female patients, with a median age of 64 years. Thirty-five (61.4%) patients were confirmed as malignancy (34 extrapulmonary malignancy and 1 primary lung cancer) and 22 (38.6%) patients were confirmed as benign. EBUS-TBNA identified malignancy in 30 patients. One patient who was diagnosed as primary lung cancer was excluded from diagnostic performance analysis. Overall cancer prevalence was 61% in 56 study patients. The diagnostic sensitivity, accuracy, and negative predictive value of EBUS-TBNA per patient were 88%, 93%, and 85%. The diagnostic sensitivity, accuracy, and negative predictive value of PET/CT scan per patient were 81%, 82%, and 71%, respectively. There were no serious complications related to EBUS-TBNA., Conclusion: Since mediastinal and hilar lymphadenopathy do not always result from metastases in patients with extrapulmonary malignancy, histopathologic confirmation is mandatory. EBUS-TBNA is a sensitive modality and can be considered as the initial test for the histopathological diagnosis of mediastinal and hilar lymphadenopathy in patients with extrapulmonary malignancy.

Background: Health care-associated pneumonia (HCAP) has been proposed as a new category of respiratory infection. ATS/IDSA guidelines state that all patients with HCAP should receive empirical therapy directed at multidrug-resistant pathogens. However, recent data from other countries have reported a different picture of HCAP., Methods: We conducted a retrospective observational study of patients with HCAP and CAP who were hospitalized through the emergency department in January-December 2008 at Samsung Medical Center, Seoul, Korea, and compared clinical characteristics, severity, distribution of pathogen, and outcomes., Results: In total, 345 patients hospitalized with pneumonia were eligible, 182 (52.8%) with HCAP and 163 (47.2%) with CAP. Patients with HCAP had greater comorbidity and higher Pneumonia Severity Index (PSI) score (P < 0.001). Although Streptococcus pneumoniae was the most frequently isolated pathogen in HCAP and CAP patients, the occurrence of potentially drug-resistant pathogens (29.3% vs. 13.0%; P = 0.044) and inappropriate initial antimicrobial treatment (24.6% vs. 8.7%; P = 0.032) were significantly higher in HCAP patients. Patients with HCAP had a longer duration of hospital stay (13 [8-18] vs. 8 [6-12] days; P < 0.001), and higher in-hospital mortality (19.2% vs. 7.4%; P = 0.001). In a multiple logistic regression analysis, however, in-hospital mortality was independently associated with higher PSI class (OR 2.82, 95% CI 1.19-6.70) and ICU admission (OR 15.37, 95% CI 3.58-66.05)., Conclusions: Severity of illness, rather than type of pneumonia, was the main predicting factor for in-hospital mortality among patients with pneumonia hospitalized through the emergency department., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Background and Objective: The introduction of ¹⁸F-FDG PET/CT has enhanced the diagnostic accuracy of nodal staging for non-small cell lung cancer (NSCLC). We analysed risk factors for occult nodal metastasis in patients with clinical stage IA NSCLC as determined by ¹⁸F-FDG PET/CT., Methods: Data for 147 patients diagnosed as clinical stage IA NSCLC by PET/CT from 2005 to 2007 were retrospectively reviewed. All study patients underwent ¹⁸F-FDG PET/CT for lung cancer staging. They also underwent cervical mediastinoscopy or systematic lymph node dissection., Results: Cervical mediastinoscopy was performed in 78 patients (53.1%), and N2 involvement was detected in 3.8% (3/78) of these patients. Thoracotomy with systematic lymph node dissection was done in 144 patients. Four patients (2.8%, 4/144) were diagnosed with N2 disease after systematic lymph node dissection. Total N2 involvement was 4.8% (7/147). As 9.5% (14/147) of study patients had N1 disease, 14.3% (21/147) of patients had occult nodal (N1 or N2) metastasis. In univariate analyses, larger tumour size and a higher primary tumour maximum standardized uptake value >7.3 (SUV(max)) were associated with occult nodal metastasis. Multivariate analysis demonstrated that a primary tumour SUV(max) >7.3 was an independent predictor of occult nodal metastasis (odds ratio: 7.574; P = 0.001)., Conclusions: Preoperative PET/CT scans contribute to reduce the frequency of occult nodal metastasis compared with those reported in the pre-PET/CT era. The higher SUV(max) in primary tumour was an independent predictor of occult nodal metastasis in patients with clinical stage IA NSCLC by PET/CT., (© 2010 The Authors. Journal compilation © 2010 Asian Pacific Society of Respirology.)

Endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) offers a minimally invasive option for staging the mediastinum in suspected lung cancer but also in the diagnosis of mediastinal lesions accessible from the airways. EBUS-TBNA has been widely used for the evaluation of mediastinal and hilar lesions for several reasons, such as its minimally invasive nature, high diagnostic accuracy, needle aspiration under real-time visualization and excellent safety profile. Several recent studies have demonstrated that EBUS-TBNA have diagnostic accuracy equivalent to mediastinoscopy and in fact higher for certain lymph node stations. The present case report presents endobronchial inflammatory polyp as a complication after EBUS-TBNA in patients with tuberculous lymphadenitis and discusses the possible etiology of this complication, as well as implications for further application of this technology in patients with tuberculous lymphadenitis.

Objectives: Chronic necrotizing pulmonary aspergillosis (CNPA) is uncommon, and the optimal therapeutic regimen has not been established. In a retrospective cohort study, we investigated the clinical characteristics and treatment outcomes of patients with CNPA., Methods: We reviewed the medical records of all patients who had been diagnosed with CNPA at our institution over the last 10 years., Results: Forty-three patients were identified. Their median age was 60 years (interquartile range (IQR) 45-65 years), and 34 (79%) of the patients were men. The most common underlying lung disease was pulmonary tuberculosis (n=40, 93%). After CNPA was diagnosed, all patients were treated with antifungal drugs, including oral itraconazole (n=39, 91%) or intravenous amphotericin B (n=4, 9%). Seventeen (40%) patients discontinued therapy early (<3 months), 14 patients due to death and three to loss of follow-up. Twenty-six (60%) patients received oral itraconazole at a daily dose of 200-400mg for more than 3 months. The median treatment duration was 6 months (IQR 6-12 months). In these 26 patients, clinical improvement was observed in 15 (58%) and radiological improvement was observed in 11 (42%). Ten (38%) patients showed no improvement. Twenty-two (51%) patients died, including 18 (42%) CNPA-related deaths, during a median follow-up of 15 months (IQR 2.5-32 months). The median survival time was 62 months., Conclusions: CNPA is difficult to treat and often has a poor outcome. Further studies with more patients are needed to identify the optimal therapy for patients with CNPA., (Copyright 2009 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Background: The aim of this study was to evaluate treatment outcomes in patients with thoracic actinomycosis and identify patient characteristics associated with unfavorable responses to antibiotic therapy., Methods: A retrospective analysis was performed on 40 patients with pathologically confirmed thoracic actinomycosis., Results: Initial surgical treatment was performed on 17 patients to control severe symptoms such as hemoptysis or rule out lung cancer. Sixteen (94%) patients were successfully treated, including three patients who did not receive postoperative antibiotics, and one patient died of a postoperative complication. The median duration of oral antibiotic therapy after surgery was 3 months. After the diagnosis of actinomycosis, 23 patients began antibiotic therapy. The median duration of oral antibiotic therapy was 5 months. Favorable treatment outcomes were achieved in 18 of these 23 patients (78%), while five (22%) showed unfavorable responses to antibiotic therapy. Surgery was successfully performed in these five patients. The patients with unfavorable responses to antibiotic therapy had a longer duration of symptoms prior to treatment (median, 10 months) as compared to patients with favorable responses (median, 2 months; P = 0.012)., Conclusions: Medical treatment failure is possible in patients with thoracic actinomycosis, and close monitoring is necessary in those who begin antibiotic therapy. In addition, surgical resection may be a valid option for patients who do not respond to antibiotic therapy, with the consideration of the age and comorbid conditions.

Few studies have compared the clinical and radiographic findings of tuberculomas to those of solitary pulmonary nodules (SPNs) caused by Mycobacterium avium complex (MAC). We retrospectively analyzed clinical and radiographic findings from 26 patients with tuberculomas and 15 patients with SPNs caused by MAC. Median SPN size was 22 mm. In 26 patients (63%), the SPN was detected during a routine health checkup or evaluation of organs other than lungs. Patients with SPNs due to MAC were slightly older (median = 59 years) compared with those with tuberculomas (median = 50 years; P = 0.044). When we compared computed tomography (CT) features between patients with tuberculomas and patients with MAC, no significant differences were found in SPN location or the presence of calcification, cavitation, central low attenuation, and the satellite lesions. Although the maximum standardized uptake values were slightly higher in patients with SPNs due to MAC (median = 8.5) compared with those with tuberculomas (median = 2.2), this difference was not significant (P = 0.053). Of the 15 patients with SPNs due to MAC, 10 were initially diagnosed with "tuberculoma" and administered antituberculosis medication. MAC pulmonary disease should be considered in the differential diagnosis of SPNs, even when encountered in geographic regions with a high prevalence of pulmonary tuberculosis.

Sarcoidosis is an inflammatory disease of unknown cause which is characterized by the presence of noncaseating granulomas. The association of sarcoidosis with malignancy has been an issue and remains controversial. We herein report endobronchial carcinoid tumor in a patient with sarcoidosis diagnosed by nasal mucosal biopsy, excisional biopsy of cervical lymph nodes and mediastinal lymph node dissection.

Mycobacterium abscessus (M. abscessus) is the second most common nontuberculous mycobacteria (NTM) in South Korea. Nevertheless, the diagnosis and treatment of M. abscessus lung disease can be problematic. Surgical resection has been tried for patients with localized M. abscessus lung disease refractory to medical treatment. Here, we report on a 25-year-old woman with M. abscessus lung disease who had been diagnosed and treated three times for pulmonary tuberculosis. She was initially diagnosed as having M. intracellulare lung disease; however, M. abscessus was isolated after several months of medication. She had multiple bronchiectatic and cavitary lesions bilaterally, and M. abscessus was repeatedly isolated from her sputa despite prolonged treatment with clarithromycin, ethambutol, moxifloxacin, and amikacin. She improved only after sequential bilateral lung resection. Based on the experience with this patient, we suggest that, if medical treatment fails, surgical resection of a diseased lung should be considered even in patients with bilateral lesions.

Background and Objective: Bronchoscopic resection of endobronchial hamartomas has been reported to have a favourable outcome. This study describes the bronchoscopic features of endobronchial hamartoma and reports the clinical outcome of bronchoscopic intervention., Methods: A retrospective analysis was conducted of patients with histologically proven endobronchial hamartomas, diagnosed in the 10-year period 1999-2009 to elucidate the clinical, radiological and bronchoscopic features of hamartoma and to describe the clinical outcomes., Results: Seventeen of the 135 patients with pulmonary hamartomas were diagnosed as having endobronchial hamartomas. CXR was abnormal in 11 of the 17 patients. On chest CT (n = 16), the median diameter of the lesion was 15.6 mm. Calcification and areas of focal fat in the lesion, the diagnostic CT findings of pulmonary hamartoma, were found in two of 16 (12.5%) patients. At bronchoscopy (n = 16), all tumours had a mass appearance and most were smooth surfaced round masses (50.0%) with 18.8% having a 'stalk'. Bronchoscopic forceps biopsies were performed in 13 patients, which resulted in five patients (38.5%) being diagnosed with endobronchial hamartoma. Fifteen patients were treated with rigid or flexible bronchoscopic resection, one had lobectomy, and one had no intervention. No procedure-related mortalities or late complications developed., Conclusions: Bronchoscopic intervention appears to be a safe and effective method to resect endobronchial hamartomas.