Search

Background Determinates of tumor treating fields (TTFields) usage in patients receiving combined modality therapy for primary IDH wild-type glioblastoma are currently unknown. Methods Ninety-one patients underwent maximal debulking surgical resection, completed external beam radiotherapy with concurrent Temozolomide (TMZ), and initiated adjuvant TMZ with or without TTFields. We performed a retrospective analysis of patient, tumor, and treatment-related factors that affected TTFields usage. Results We identified three TTFields usage subgroups: 32 patients that declined TTFields, 40 patients that started, but had monthly compliance of less than 75% or used it for less than 2 months, and 19 patients who used TTFields for 2 or more months and maintained average monthly compliance greater than 75%. With 26.5 months median follow-up for surviving patients, the 1- and 3-year actuarial overall survival for all patients was 80% and 18%, respectively. On multivariate analysis TTFields use (P = .03), extent of surgical resection (P = 0.02), and MGMT methylation status (P = .01) were significantly associated with overall survival. TTFields usage was explored as a continuous variable and higher average usage was associated with longer overall survival (P = .03). There was no relationship between patient, tumor, or treatment-related factors and a patient’s decision to use TTFields. Conclusions No subgroup of patients was more or less likely to initiate TTFields therapy and no subgroup was more or less likely to use TTFields as prescribed. The degree of TTFields compliance may be associated with improved survival independent of other factors.

Rationale: Less invasive, nonsurgical approaches are needed to treat severe emphysema. Objectives: To evaluate the effectiveness and safety of the Spiration Valve System (SVS) versus optimal medical management. Methods: In this multicenter, open-label, randomized, controlled trial, subjects aged 40 years or older with severe, heterogeneous emphysema were randomized 2:1 to SVS with medical management (treatment) or medical management alone (control). Measurements and Main Results: The primary efficacy outcome was the difference in mean FEV1 from baseline to 6 months. Secondary effectiveness outcomes included: difference in FEV1 responder rates, target lobe volume reduction, hyperinflation, health status, dyspnea, and exercise capacity. The primary safety outcome was the incidence of composite thoracic serious adverse events. All analyses were conducted by determining the 95% Bayesian credible intervals (BCIs) for the difference between treatment and control arms. Between October 2013 and May 2017, 172 participants (53.5% male; mean age, 67.4 yr) were randomized to treatment (n = 113) or control (n = 59). Mean FEV1 showed statistically significant improvements between the treatment and control groups—between-group difference at 6 and 12 months, respectively, of 0.101 L (95% BCI, 0.060–0.141) and 0.099 L (95% BCI, 0.048–0.151). At 6 months, the treatment group had statistically significant improvements in all secondary endpoints except 6-minute-walk distance. Composite thoracic serious adverse event incidence through 6 months was greater in the treatment group (31.0% vs. 11.9%), primarily due to a 12.4% incidence of serious pneumothorax. Conclusions: In patients with severe heterogeneous emphysema, the SVS shows significant improvement in multiple efficacy outcomes, with an acceptable safety profile. Clinical trial registered with www.clinicaltrials.gov (NCT01812447).

Splenic hematoma is a known complication of blunt force abdominal trauma. Traditional management of splenic hematomas has been primarily surgical. However, more recently, spleen-sparing management has been favored over surgical management for cases that meet certain criteria, with surgery now reserved for patients with complications. In this report, we present a case of a massive splenic hematoma that was managed conservatively and analyze the challenges faced in clinical decision making.

Introduction: COVID-19 has a variable clinical presentation ranging from flu-like symptoms to respiratory failure. Most patients have a mild form of disease and often recover at home over a period of weeks. For some, the highest morbidity of COVID-19 may not be associated with the acute phase of the disease, but rather the longstanding post-viral pulmonary fibrosis. Case Description: A 49-year-old man with a past medical history of coronary artery disease, obstructive sleep apnea, hypertension, and type two diabetes mellitus presented to the emergency department with a four-day history of fever, nausea, and diarrhea. He denied cough or dyspnea. Chest radiograph revealed bibasilar ground glass opacifications. He was positive for severe acute respiratory syndrome coronavirus 2 by polymerase chain reaction testing. His oxygen saturation was 95% on room air and he was discharged home without treatment. Over the following days, he developed a dry cough and mild dyspnea, but he did not desaturate on room air. He was prescribed a short course of steroids by his outpatient pulmonologist. He gradually improved over the course of two weeks and he was never hospitalized. Computed tomography (CT) of the chest 10 weeks after diagnosis revealed bilateral patchy ground glass opacities in all lobes and interstitial components with architectural distortion in the lower lobes (Image 1). A pulmonary function test performed 12 weeks after diagnosis showed an FVC 83%, FEV1 85%, TLC 75%, RV 37%, and DCLO 88%. The patient continued to experience mild dyspnea with exertion 2 months after the resolution of the infection. Conclusion: Pulmonary fibrosis is not a post-viral phenomenon limited to severe cases of COVID-19 and can occur following mild presentations managed at home. Thus far, risk factors for the development of pulmonary fibrosis secondary to COVID-19 have been reported to be advanced age, disease severity, length of intensive care unit stay, smoking, and alcoholism. Our case report calls for a re-evaluation of these risk factors. While pharmaceutical treatments are typically only administered to hospitalized patients, there may be basis for treating mild cases with the intent of preventing post-viral pulmonary fibrosis. Further, outpatient clinicians may consider monitoring for changes in pulmonary architecture with pulmonary function tests or high-resolution CT scans in all recovered COVID-19 patients regardless of symptom severity.

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: As the COVID-19 pandemic progresses, genetic variants have been identified globally, including the UK, South Africa, and Brazil strains. These variants exhibit genetic mutations in spike proteins and open reading frame regions. Rising cases of COVID-19 strains call to question the accuracy of current polymerase chain reaction (PCR) testing in detecting genetic variants. CASE PRESENTATION: A 76-year-old male nursing home resident was brought to the emergency department (ED) by ambulance due to progressively worsening dyspnea. His past medical history was remarkable for COPD and diabetes mellitus type II. On initial presentation, his respiratory rate was 30 breaths per minute, heart rate was 128 beats per minute, blood pressure was 135/64 mmHg, and oxygen saturation was 92% on supplemental oxygen via bilevel positive airway pressure (BIPAP). Physical exam was remarkable for bilateral rhonchi with accessory muscle use. Labs were remarkable for a white blood cell count of 16.5 109/L with lymphopenia, lactic acid of 2.2 mmol/L, and a d-dimer of 5250 ng/mL. Chest CT showed bilateral patchy ground glass infiltrates, fibrotic changes, and small bilateral pleural effusions (Image 1). He tested negative for influenza A and B, Mycoplasma pneumoniae, Streptococcus pneumonia, and Legionella. Sputum cultures showed no growth. The patient tested negative for COVID-19 twice by RT-PCR analysis (Abbott Laboratory, Chicago, IL). He was treated with intravenous steroids and broad-spectrum antibiotics. He was unable to be weaned from BIPAP to a lower level of supplemental oxygen. Eight days after hospital admission, the patient tested positive for COVID-19 IgM and IgG antibodies. After 12 days of treatment, the patient suffered a fatal cardiac arrest. DISCUSSION: We present an elderly man with a clinical symptoms and imaging findings highly suggestive of COVID-19, despite multiple negative RT-PCR tests. The patient did not improve despite treatment with broad spectrum antibiotic and intravenous corticosteroids. Patients had positive COVID-19 IgM antibodies, despite no known recent prior infection. Although the lab utilized for COVID-19 RT-PCR analysis asserts that testing is not impacted by genetic variants, these cases challenge the true sensitivity of this testing in detecting emerging strains. CONCLUSIONS: There are potentially many patients in the community hospitals presenting with COVID-19 variants that are not detected by existing RT-PCR testing. The genetic diversity of COVID-19 may diminish the sensitivity of RT-PCR testing, as labs across the country utilize different primers and probes with variable sensitivities in detecting variants. Clinicians should maintain a high suspicion for COVID-19, despite negative PCR testing. REFERENCE #1: Wang R, Hozumi Y, Yin C, Wei G-W. Mutations on COVID-19 diagnostic targets. Genomics. 2020;112(6):5204-5213. REFERENCE #2: Sapoval N, Mahmoud M, Jochum MD, et al. SARS-CoV-2 genomic diversity and the implications for qRT-PCR diagnostics and transmission. Genome Res. 2021;31(4):635-644. DISCLOSURES: No relevant relationships by Gustavo Avila, source=Web Response No relevant relationships by Jessica Baek, source=Web Response No relevant relationships by Renuka Reddy, source=Web Response No relevant relationships by Claudia Tejera Quesada, source=Web Response no disclosure on file for Adam Wellikoff

A 63-year-old man presented with intermittent, progressively worsening dyspnoea associated with cough and blood-tinged sputum. Initial work-up showed left axis deviation on ECG, chest X-ray with an elevated left hemidiaphragm and a non-contrast CT chest that showed a multilobulated mass in the proximal trachea. Bronchoscopy showed a whitish-appearing lesion, which was then sampled and partially resected with pathology showing a schwannoma with no malignant cells. He felt partial relief post procedure; however, he presented a month later with similar symptoms of dyspnoea and a repeat CT scan showed enlargement of the mass in the same location. The patient underwent another flexible bronchoscopy and resection with argon plasma coagulation (APC)/electrocautery snare. APC/electrocautery is an effective interventional bronchoscopy technique that can be used to resect endoluminal lesions or extraluminal lesions that have infiltrated into the airway using flexible/rigid bronchoscopy. It is more cost-effective, safe, works well with vascular lesions and achieves excellent haemostasis as compared with Nd:YAG lasers.

Background and objective The development of novel technologies has increased the yield from transbronchial biopsies while preserving patient safety by guiding biopsies to the area of interest. Other technologies have helped identify pre-cancerous or sessile lesions in the endobronchial space by utilizing interactions between tissue and light at varying wavelengths. Probe-based confocal laser endomicroscopy (pCLE) is a new technology that encompasses the benefits of both guided biopsies and novel optical imaging in one device. This project compares pCLE images to the findings of light microscopy in non-small cell lung cancer (NSCLC). Methods Patients who underwent bronchoscopies between July 2012 and January 2013 for evaluation of pulmonary lesions (transbronchial and endobronchial) were recruited. Histopathological images from malignant lesions were compared with the pCLE images obtained from the same area. The microscopic and pCLE images were reviewed side by side with the microscopic findings. Results Images from pCLE correlate with some histopathological findings. pCLE changes seen in NSCLC consist of mottled elastin, septal studding and disorganization/fragmentation with increased friability. These changes also seem to correlate with degrees of differentiation. Conclusions pCLE can identify changes to the elastin composition of the airways and alveoli in lung cancer. These changes correlate with histopathology and may help indicate the presence of malignant changes in vivo.

Dystrophic calcification of hilar lymph nodes is a common response to chronic inflammation related to several etiologies and rarely is associated with any clinical findings. A clinical scenario related to these calcified lymph nodes can thus be delayed by the low clinical suspicion associated with such a presumably innocuous finding. Normal respiratory movements however, can cause erosion into adjacent bronchi leading to a broncholith, complications of which can result in morbidity. We illustrate one of these complications, a partial obstruction with subsequent recurrent infection due to normal oral flora - actinomyces.

The development of novel technologies has increased the yield from transbronchial biopsies while preserving patient safety by guiding biopsies to the area of interest. Other technologies have helped identify pre-cancerous or sessile lesions in the endobronchial space by utilizing interactions between tissue and light at varying wavelengths. Probe-based confocal laser endomicroscopy (pCLE) is a new technology that encompasses the benefits of both guided biopsies and novel optical imaging in one device. This project compares pCLE images to the findings of light microscopy in non-small cell lung cancer (NSCLC).Patients who underwent bronchoscopies between July 2012 and January 2013 for evaluation of pulmonary lesions (transbronchial and endobronchial) were recruited. Histopathological images from malignant lesions were compared with the pCLE images obtained from the same area. The microscopic and pCLE images were reviewed side by side with the microscopic findings.Images from pCLE correlate with some histopathological findings. pCLE changes seen in NSCLC consist of mottled elastin, septal studding and disorganization/fragmentation with increased friability. These changes also seem to correlate with degrees of differentiation.pCLE can identify changes to the elastin composition of the airways and alveoli in lung cancer. These changes correlate with histopathology and may help indicate the presence of malignant changes in vivo.

Relapsing Polychondritis (RP) is a systemic condition characterized by chronic, episodic inflammation, especially of cartilaginous and proteoglycan-rich structures. The etiology of this rare autoimmune disease is unknown, and so far, there is very little data available for non-Caucasians. RP presents with a constellation of non-specific inflammation, which sometimes appear in characteristic locations. Radiology is important in supporting the diagnosis, and this paper presents a case of a non-Caucasian patient monitored radiologically from early onset to the terminal stages.

Malignancy of the parietal pleural is a therapeutic challenge; current therapies largely target patient's regional symptoms related to effusions/tumor burden and restrictive physiology. Seldom are tumor ablation procedures considered. If alternatives to the current standard approaches could promote tumor ablation, address symptoms and be cost effective, studies to assess clinical impact of these alternatives may be warranted. We present a novel cryo- based technology for treating pleural malignant disease with a dramatic reduction in a tumor biomarker. We present a case of a 67-year-old man with mucinous adenocarcinoma of the pleura with elevated Carcinoembryonic Antigen (CEA) level who had an inadequate response to standard treatment. He underwent cryospray ablation of the parietal pleura with tumor destruction being documented both visually and with a significant decrease in his CEA level. This case demonstrates tumor necrosis, a rapid drop in serum CEA, as well as ease of treatment and continued evidence of safety and the feasibility of cryospray ablation in the pleural space. This case demonstrated that spray cryotherapy promoted tumor ablation and addressed symptoms within the pleura thereby indicating the need for further study. The degree of tumor necrosis in multiple clinical presentations (bulky, flat, studding, etc) awaits definition, as does the rate and timing of post-treatment pleurodesis and the possibility of an immunoregulatory or mortality effect.

Background Probe-based confocal laser endomicroscopy (pCLE) is a new FDA approved tool used for in vivo microscopic imaging of proximal and distal airways including bronchial and alveolar walls, microvessels, and inflammatory cells. Light at 488 nm wavelength is focused via a pinhole-sized aperture incorporated into a flexible probe that fits into the working channel of a standard bronchoscope and reflected back through that aperture to produce an image that can aid in the identification of neoplastic processes. Studies have demonstrated elastin and collagen fibers as having endogenous fluorescence by pCLE. No studies have correlated in vivo imaging by pCLE to pathologic samples obtained during bronchoscopy. This combination could prove diagnostically advantageous to both clinician and pathologist. Design Selected patients undergoing bronchoscopy from 7/17/ 12 to present are subjected to pCLE followed by biopsy. pCLE and bronchoscopy are performed to help determine abnormal bronchial or alveolar changes that warrant a biopsy. We correlate pCLE images with biopsies obtained during bronchoscopy. Patients ranged from 47 to 82 years of age, and biopsies include adeno, squamous cell, poorly differentiated, small cell and metastatic carcinomas. When necessary, immunohistochemistry (IHC) and electron microscopy (EM) are performed for further tumor classification. Studies are ongoing to add additional tumor types. Results/findings By pCLE, differences between normal, inflammation and neoplasia can be recognized. Normal findings consist of organized connective tissue fibers. Inflammatory cells, mostly macrophages, can be recognized within tissue spaces. In neoplastic tissue, a ragged surface can be observed along with disorganization of the collagen/elastin fibers within the bronchi/ alveoli. Differences between squamous (SCC) and adenocarcinomas (ADC) can be suggested on the basis of imaging patterns. SCC shows friability and dense areas of auto fluorescence with dark spots representing tumor groups. ADC shows less fluorescence and gives a mottled appearance to the tissue. ADC with bronchioloalveolar differentiation and a lepidic pattern of growth can be suspected when a studded appearance is noted by pCLE. Disarray of fibers increases with more poorly differentiated carcinomas. Biopsies and pCLE images can be correlated by comparing tissue patterns with images. The use of IHC and ultrastructural evaluation (EM) further support our pCLE and microscopic findings. Conclusions pCLE allows the distinction between benign and malignant tissues, assists in obtaining diagnostic tissue, and recognizes tumor growth patterns. Correlation between biopsies and pCLE can help aid sampling and diagnostic techniques. Larger studies can enhance our understanding of how pCLE can help differentiate tumor types.