Lavage Cytology Research Articles

Prognostic factors for cytology-positive gastric cancer: a multicenter retrospective analysis.

The prognosis of patients with gastric cancer and positive peritoneal lavage cytology is poor, even after gastrectomy. Though the standard therapy for this population is radical gastrectomy followed by S-1 chemotherapy, treatments vary among institutions and eras. We conducted a multicenter retrospective study to investigate the prognostic factors for cytology-positive gastric cancer. We reviewed the medical records obtained from 6 institutions, covering 2000-2019. There were 128 patients with positive cytology and no other distant metastases that underwent R1 gastrectomy. Univariate and multivariate analyses to identify prognostic factors for overall survival were conducted using Cox's proportional hazards models. The median overall survival time was 18.6months. In univariate analyses, age (≥ 80years vs. < 70years), performance status (2, 3 vs. 0), prognostic nutritional index (< 35 vs. ≥ 40), the extent of lymphadenectomy (D1 vs. ≥ D2), macroscopic type (type 4 vs. non-type 4), and postoperative chemotherapy (none vs. S-1) were significantly correlated with worse survival. Multivariate analysis revealed that lymph node metastasis (pN3b vs. pN0, hazard ratio 4.46, 95% confidence interval 1.17-16.9, p = 0.03) and postoperative chemotherapy (none vs. S-1, hazard ratio 2.28, 95% confidence interval 1.16-4.45, p = 0.02) were independent risk factors for death. No postoperative chemotherapy regimen showed a survival benefit over S-1 monotherapy. Massive lymph node metastasis was an independent risk factor in cytology-positive gastric cancer. Postoperative chemotherapy was also an independent prognostic factor, though the most beneficial regimen was still uncertain.

Metastatic Adenocarcinoma of the Lung Mimicking Miliary Tuberculosis and Pott’s Disease

Tuberculous spondylitis (Pott’s disease) is among the frequent extra-pulmonary presentations of tuberculosis (TB). The global incidence of lung adenocarcinoma is on the rise, and it is a rare differential diagnosis of miliary shadows on chest imaging. It has a predilection to metastasize to ribs and spine in particular. There is a very close clinical and radiological resemblance in the presentation of spinal metastasis of lung cancer and Potts’s disease. It poses a diagnostic challenge to clinicians particularly in TB endemic areas to arrive at an accurate diagnosis, leading to disease progression and poor outcome. We report a 54-year-old female patient presented with constitutional symptoms of on and off fever and back pain. Her chest X-ray revealed miliary shadows, and acid-fast bacilli (AFB) sputum smear and TB polymerase chain reaction (PCR) test came negative; radiological diagnosis of tuberculous spondylitis was done on computerized tomography (CT) chest and magnetic resonance imaging (MRI) spine. Subsequent bronchoscopy and bronchoalveolar lavage (BAL) cytology showed malignant cells and CT-guided lung biopsy confirmed lung adenocarcinoma with spinal and brain metastasis. Despite being started on chemo-immunotherapy and radiotherapy her outcome was poor due to advanced metastatic disease. This case highlights the significance of considering metastatic adenocarcinoma of the lung a rare but ominous possibility in the differential diagnosis of miliary shadows on chest imaging. Early bronchoscopy and biopsy must be considered in all patients presenting with miliary pulmonary lesions and spinal lesions to make a correct diagnosis, preventing an unnecessary delay in starting proper treatment and poor outcome. It also emphasizes the importance of better understanding the different radiographic features of the two common mimics, spinal tuberculosis, and metastatic spinal tumors.

Concordance of Bronchoalveolar Lavage Cytology with Transbronchial Lung Biopsies in Non-neoplastic Pulmonary Diseases

Introduction: In many pulmonary diseases, despite radiological &amp; clinical investigations, laboratory tests and function studies, the diagnosis becomes difficult. Bronchoalveolar Lavage (BAL) is a minimally invasive method in which cells are collected from bronchial and alveolar spaces for cytology. This is facilitated by using a flexible bronchoscope with which a biopsy is taken following BAL. Bronchoscopy with BAL when used appropriately can offer correct diagnosis which in turn aids in proper management of the patient. Aim: To find the concordance of BAL findings with the histopathological features of Transbronchial Lung Biopsy (TBLB) in non-neoplastic lung diseases. Materials and Methods: It was a retrospective study conducted in Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka. A total of 40 patients presenting with clinico-radiological findings, suggesting a non-neoplastic lung disease in the year 2019, undergoing bronchoscopy with BAL and concurrent TBLB were chosen. The BAL fluid was processed and differential count of cells was done to classify according to the American Thoracic Society Guidelines. Concordance was checked between the diagnoses made on TBLB and BAL analysis. Results: In the present study, a total of 40 cases were included of which 13 (32.5%) cases showed neutrophilic, 16 (40%) cases showed lymphocytic, 5 (12.5%) cases showed eosinophilic and 6 (15%) cases showed normal cellular distribution on BAL cytology. Diagnoses on studying TBLB included nine cases of Nonspecific Interstitial Pneumonia, seven cases of Usual Interstitial Pneumonia, six cases of Bronchiolitis Obliterans Organising Pneumonia, three cases of Bronchiolitis, two cases each of pulmonary tuberculosis and granulomatous inflammation. There was one case each of actinomycosis, sarcoidosis, lung abscess and mucor mycosis. Normal histology was noted in seven cases. The sensitivity of BAL fluid analysis was found to be 84.84% and the concordance was 80%. The Kappa value obtained was 0.71 indicating good agreement/concordance between BAL cytology and TBLB. Conclusion: The data from the current study suggest that differential cell counts in BAL provide diagnostic information of fundamental importance in frequently occurring non-neoplastic lung diseases in the community.

378. E-cigarette or Vaping Associated Lung Injury in the Time of COVID-19

BackgroundPediatric providers have been caring for two new and similar respiratory illnesses: E-cigarette or vaping use associated lung injury (EVALI) beginning in 2019 and Coronavirus Disease 19 (COVID-19) in 2020. Similarities include prodrome, presentation, imaging, and laboratory testing. While EVALI often improves with steroid treatment, steroids can be detrimental early in the course of COVID-19.Although a positive SARS CoV-2 polymerase chain reaction (PCR) test is helpful, this result does not definitively identify SARS CoV-2 as the primary cause of symptoms in patients with a history of vaping, as both processes may be coexistent. Coinfection with other infectious agents is commonly found in children with COVID-19 infection, and the majority of children with PCR positive SARS CoV-2 are asymptomatic or mildly symptomatic.MethodsIn hopes of better defining EVALI versus COVID-19 clinical syndromes, we reviewed charts of pediatric patients admitted to a freestanding children’s hospital in Texas diagnosed with EVALI over a year period from June 1, 2019 and June 1, 2020. Cases were identified through a local patient registry. We compared findings in these cases with literature regarding pediatric patients with acute COVID-19 and EVALI. Variables included presenting symptoms, timing of symptoms, vital signs, imaging, and laboratory results.ResultsTwelve patients with EVALI diagnosis were included. Clinical presentation, imaging, and laboratory findings were similar to those described with acute COVID-19 and are included in figures 1 and 2. Repeated interviewing regarding vaping revealed a history of vaping in all EVALI cases; frequency reported varied from multiple times daily to remote use. Some cases with EVALI also had a significant psychiatric history, positive urine drug screen, or significant weight loss prior to hospitalization. Cases with EVALI and steroid treatment improved within days of treatment. In a review of literature, BAL sampling often reveals lipoid pneumonia in EVALI cases, which would not be expected in COVID-19. Of note, the single case in our group tested did not have lipoid pneumonia on bronchoalveolar lavage (BAL) cytology. ConclusionPresence of prolonged preceding weight loss, or BAL cytology could help differentiate these clinical states.Disclosures All Authors: No reported disclosures

Peritoneal Lavage Cytology Following Neoadjuvant Chemotherapy for Gastric Adenocarcinoma: Low Yield in Detecting Peritoneal Metastases.

Peritoneal lavage cytology (PLC) can detect advanced disease in gastric adenocarcinoma (GC); however, routine practice remains controversial. Furthermore, the effect of neoadjuvant chemotherapy (NAC) on cytological detection of carcinomatosis is unknown. Using a 2012-2020 prospective database, we retrospectively reviewed patients with GC who underwent NAC followed by a staging laparoscopic peritoneal lavage with or without biopsy of suspicious peritoneal nodules. PLC results were considered discordant if they did not align with the peritoneal biopsy results. Patients with benign peritoneal cytology (Cyt-) or biopsy results who had postoperative time to carcinomatosis of <6months were considered to have diagnostic failure of peritoneal lavage. Fifty-five patients with GC who underwent NAC followed by staging diagnostic laparoscopy with peritoneal lavage were identified. The majority of the patients in the cohort had Cyt- lavage (89.1%). Of the patients who underwent resection, 76.1% had T3 or greater disease on final pathology and 66% had nodal metastases. In 23 patients (41.8%) who had both peritoneal lavage and biopsy, four cases (17.4%) had discordant results. Diagnostic failure rate was 20% at 6months and 42.2% at 12months. The median time to carcinomatosis in patients who were Cyt- or biopsy negative was 7.9months. PLC after NAC has a high diagnostic failure rate and inaccurately predicts carcinomatosis in 20% of patients with GC. Novel methods for identifying cytology positive GC after NAC should also be developed and evaluated, since the risk of peritoneal dissemination is high.

Multiresistent opportunistic talaromycosis in a patient with ovarian cancer

Background Talaromycosis (penicillinosis) is multiresistent opportunistic mycosis. The infection can be inapparent and it can simmulate malignant tumor dissemination in some patients. Case We present a case of 33-years-old patient with mucinous adenocarcinoma of left ovary, initially FIGO IIC. The patient had had hysterectomy, bilateral adnexectomy, omentectomy and port-site metastasis extirpation. Six cycles of 1st chemother-apy paclitaxel and carboplatin had been administered to patient follow-ing the surgery. Positron emission tomography / computed tomography (PET/CT) scan after the treatment, had shown metabolic activity infiltrat-ing both lung apexes, supposedly with no dis-ease correlation, and hypermetabolic foci in spleen, suspicious of be-ing metastases. Pa-cient showed no clinical symp-toms, nor markers of inflammation elevation. Initially elevated serum tumor markers CA125 and CA72-4 had decreased after the treatment. Bronchoalveolar lavage cytology described presence of inflammatory infiltration with fungiform-ing hyphae - most probably an aspergillosis. Mannan and galactomannan serology was negative. In regard to splenectomy plans, treatment with voriconazol was initiated empirically. Result of fungi cultivation out of bronchoalveolar lavage was finalized later, show-ing sporadic presence o Penicillium sp. with resistance to antimycotic treatment except for amphotericin B. Liposomal amphotericin B treatment was administered in two cures, 28 days in total. Immunomodulatory treatment of secondary cellular immunodeficiency and vaccination against encapsulated bacteria was given to the patient. Splenectomy was performed 6 months after the end of chemother-apy treatment. Histopathology showed chronic granulomatous inflammation without mycotic hyphae, with no evidence of tumor cells. After the splenectomy, patient was treated by surgical incision and drainage and by klindamycin for intraabdominal abscess in left hypogastric area. Conclusion Patient is under follow up by oncologist, immunologist and gynecologist 12 months after the splenectomy, she is surveilled by PET/CT and serum tumor markers. Talaromycosis can be clinically inapparent in spite of its dissemination. It can be present in diffuse, granulomatous and mixed form. Therapeutic agent is sometimes limited to amphotericin B due to its resistence. Liposomal form of amphotericin B is recommended regard-ing its pharmacokinetic properties. In case of dissemination, administration period of more than 14 days is recommended, even in inapparent form. Immunomodulatory treatment is recommended due to opportunistic infection.

Pleural invasion, epidermal growth factor receptor mutation and carcinoembryonic antigen level affect pleural lavage cytology-positive status in non-small-cell lung cancer.

Pleural invasion (pl) is strongly associated with the pleural lavage cytology (PLC) status. We analysed tumours with pl and evaluated the relationship between the PLC status and pl. We retrospectively reviewed 428 surgically treated patients who had been diagnosed with non-small-cell lung cancer with pl and had their PLC status examined between 2000 and 2016. We investigated the influence of a PLC-positive status on the prognosis and searched for the factors predictive of a PLC-positive status. Seventy-eight (18%) patients were PLC positive. The recurrence-free survival of PLC-positive patients was significantly worse than that of PLC-negative patients in pl1 and pl2, but not in pl3 (5-year recurrence-free survival rate, PLC positive versus PLC negative: pl1, 22.0% vs 60.0%, P = 0.002; pl2, 30.4% vs 59.7%, P = 0.015; pl3, 50.0% vs 59.6%, P = 0.427). A multivariable analysis showed that the degree of pl (pl2-3 versus pl1) [odds ratio (OR) 5.34, P < 0.001] was an independent predictive factor for PLC positivity. Epidermal growth factor receptor (EGFR) mutation positivity (OR 5.48, P = 0.042) and carcinoembryonic antigen (CEA) ≥5 ng/ml (OR 3.78, P = 0.042) were associated with a PLC-positive status in patients with pl2-3. We found that the PLC-positive rate in patients with pl2-3 was 35.6%; however, if the tumour was EGFR mutation positive and had CEA ≥5 ng/ml, the PLC-positive rate increased to 77%. If a tumour was suspected of being pl2-3 and had EGFR mutation positivity and CEA ≥5 ng/ml, the PLC-positive rate was extremely high. Hyogo Cancer Center, G-138.

Impact of preoperative chemotherapy as initial treatment for advanced gastric cancer with peritoneal metastasis limited to positive peritoneal lavage cytology (CY1) or localized peritoneal metastasis (P1a): a multi-institutional retrospective study.

Gastric cancer (GC) patients with peritoneal metastasis are defined as stage IV in the Japanese classification of GC. For patients with peritoneal metastasis limited to positive peritoneal lavage cytology (CY1) and/or localized peritoneal metastasis (P1a), gastrectomy followed by S1 monotherapy is one of the most widely accepted therapeutic strategy in Japan. This study investigated the efficacy of preoperative chemotherapy as initial treatment in GC patients with CY1 and/or P1a. We retrospectively reviewed GC patients diagnosed with CY1 and/or P1a at 34 institutions in Japan between 2008 and 2012. Selection criteria were: adenocarcinoma, no distant metastasis except CY1 or P1a, and no prior treatment. The subjects were divided into an Initial-Chemotherapy group and an Initial-Surgery group, according to the initial treatment. A total of 824 patients were collected and 713 eligible patients were identified for this study. As the initial treatment, 150 patients received chemotherapy (Initial-Cx), and 563 patients underwent surgery (Initial-Sx). Initial-Cx regimens were cisplatin plus S1/docetaxel plus cisplatin plus S1/others (n = 90/37/23). Both overall survival (OS) and progression-free survival (PFS) were similar between the Initial-Cx and Initial-Sx groups (median OS 24.8 and 24.0months, HR 1.07, 95% CI 0.87-1.3; median PFS 14.9 and 13.9months, HR 1.04, 95% CI 0.85-1.27). The 5-year OS rates were 22.3% in the Initial-Cx group and 21.5% in the Initial-Sx group. Although, the preoperative chemotherapy did not show a survival benefit for GC patients with CY1 and/or P1a, initial-Cx showed favorable survival in patients who converted to P0 and CY0.

Cysteinyl leukotriene D4 (LTD4) promotes airway epithelial cell inflammation and remodelling.

Cysteinyl leukotrienes (CysLTs), a group of inflammatory lipid mediators, are found elevated in obese-asthmatic patients. Leukotriene D4 (LTD4), a representative CysLT, is implicated in promoting lung inflammation and remodelling in allergic asthma, but its role in non-allergic asthma, especially in obese-asthmatic patients, is not known. Here, using primary human small airway epithelial cells (SAECs) we have investigated the mechanism of LTD4-induced inflammation and remodelling and assessed high proneness of obese mice to develop asthma upon challenge with allergen ovalbumin (OVA). Primary human small airway epithelial cells (SAECs) were stimulated with different concentrations of LTD4 for different time intervals and various inflammatory markers were measured through cytokine array, membrane-based ELISA and Western blotting. An air-liquid interface (ALI) model of SAECs was used to study the effects of LTD4-induced remodelling in SAECs using Western blotting, H&E staining and PAS staining.Further, OVA-based murine model was used to examine thepropensity of high-fat diet (HFD)-fed obese mice todevelop asthma symptoms by studying theinfiltration of inflammatory cells (assessed by bronchioalveolar lavage (BAL) cytology) and airway remodelling (assessed by histopathology) upon allergen exposure. The human primary small airway epithelial cells (SAECs) treated with LTD4 showed significant alterations in the levels of inflammatory markers such as GM-CSF, TNF-α, IL-1β, EGF and eotaxin in dose- and time-dependent manner. Further, LTD4 enhanced the activation of inflammasomes as evidenced by increased levels of NALP3, cleaved caspase-1 and IL-1β. LTD4 also enhanced inflammation by increasing the expression of COX-2 in SAECs. The airway remodelling markers Vimentin and Muc5AC were found elevated in ALI culture of SAECs when stimulated with LTD4, as it also increased TGF-β levels and activation of Smad2/3 phosphorylation in SAECs. Last, sensitization and challenge of HFD-fed obese mice with OVA showed increased infiltration of inflammatory cells in BAL and enhanced levels of remodeling phenotypes like loss of cilia, mucus cell metaplasia and collagen deposition in mice lung tissues. The results suggest that LTD4 could induce inflammatory response in human airway epithelial cell by activating NALP3 inflammasome. LTD4 could further promote airway epithelial cells' remodelling through TGF-β/smad2/3-mediated pathway. Our in vivo results suggested that obesity predisposed the OVA challenged mice to develop lung inflammation and remodelling akin to asthma-like phenotypes during obesity.

Status of pleural lavage cytology in cases of pulmonary metastasis: a single-institution retrospective study.

In primary lung cancer surgery, intraoperative pleural lavage cytology (PLC) has been identified as a prognostic marker. However, there have been no reports on PLC for pulmonary metastasectomies. Therefore, the impact of PLC status for patients undergoing pulmonary metastasectomy remains unknown. We aimed to know the incidence and prognostic impact of positive PLC findings in pulmonary metastasectomies. We retrospectively reviewed patients undergoing pulmonary metastasectomies between January 2013 and December 2018. One hundred and eighty-nine PLC procedures in 159 patients undergoing pulmonary metastasectomy were analyzed. Follow-up information was available in 107 patients who underwent 132 procedure, and they were investigated for pleural recurrence-free probability (PRFP) and overall survival (OS) after pulmonary metastasectomy. The type of primary lesion was colorectal cancer (101/189, 53%), urothelial/kidney cancer (17/189, 9%), skeletal/soft tissue tumor (18/189, 10%), hepatobiliary/pancreatic cancer (19/189, 10%), uterine/ovarian cancer (14/189, 7%), otorhinolaryngological cancer (11/189, 6%), and other minor lesions (9/189, 5%). Nine PLC-positive metastasectomies were revealed (9/189, 4.8%). They consisted of six metastasectomies from pancreatic cancer, two from osteosarcoma, and one from tongue cancer. Significant predictors for PLC status was type of primary tumor (P < 0.001). PRFP and OS rate of PLC-positive group were significantly lower than PLC-negative (P < 0.001, respectively). PLC-positive results were rarely seen in pulmonary metastasectomies. PLC status was associated with the incidence of ipsilateral pleural recurrence and survival after metastasectomy. Cytologic examination of PLC should be considered in patients undergoing pulmonary metastasectomy.

Utility of Bronchoalveolar Lavage Cytology for Aspiration in Pediatric Patients: An 11-year Retrospective Study

Utility of Bronchoalveolar Lavage Cytology for Aspiration in Pediatric Patients: An 11-year Retrospective Study

Complete Resection in Lung Cancer Surgery: From Definition to Validation and Beyond.

The International Association for the Study of Lung Cancer (IASLC) proposed definitions for complete, incomplete, and uncertain resections in lung cancer 15 years ago.1 The definitions were based on several previous definitions and on the consideration of different issues related to the surgical treatment of lung cancer, that is, the different ways of intraoperative nodal assessment, the requirements for pathologic absence of nodal disease (pN0), and the prognostic impact of pleural lavage cytology.

Clinicopathological and imaging features of pulmonary alveolar microlithiasis in a dog \u2013 a case report

BackgroundThe aetiology of pulmonary alveolar microlithiasis (PAM) in animals is still unknown. In humans, this pulmonary disorder is a rare autosomal recessive disorder triggered by a mutation in the gene SLC34A2, which causes deposition and aggregation of calcium and phosphate in the pulmonary parenchyma with formation of microliths. Although histopathological examination is required for a definite diagnosis, in humans, imaging modalities such as computed tomography can demonstrate typical patterns of the disease. This is the first description of the computed tomographic (CT) features of a histologically confirmed PAM in dogs.Case presentationThe following report describes a case of a 7-year-old female Boxer dog evaluated for paroxysmal loss of muscle tone and consciousness with excitement. The main differential diagnoses considered were syncope, seizures, and narcolepsy-cataplexy. The results of the complete blood count, serum biochemistry panel, urinalysis, arterial blood pressure, echocardiography, abdominal ultrasound, Holter monitoring, and ECG were all within normal limits. Additional exams included thoracic radiographs, head and thorax CT, bronchoalveolar lavage (BAL), and CT-guided cytology. Thoracic radiographs revealed micronodular calcifications in the lungs, with sandstorm appearance. Computed tomography of the thorax showed the presence of numerous mineralized high-density agglomerates of multiple sizes throughout the pulmonary parenchyma, a reticular pattern with ground glass opacity and intense mineralized fibrosis of the pleural lining. Head CT was unremarkable. BAL and CT-guided cytology were inconclusive, but imaging features strongly suggest the diagnosis of PAM, which was histologically confirmed after necropsy.ConclusionsThis case report contributes to the clinicopathological and imaging characterization of pulmonary alveolar microlithiasis in dogs. In this species, the diagnosis of PAM should be considered when CT features evidence a reticular pattern with ground glass opacity and the presence of an elevated number and size of calcifications.

MULTIPLE CHEST CT FINDINGS IN A POST-TRANSPLANT PATIENT

SESSION TITLE: Fellows Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary complications are common in hematopoietic stem cell transplantation recipients. Late complications occur more than 100 days after HSCT. During this time frame noninfectious causes are more common than infectious complications. CASE PRESENTATION: 57 y/o Panamanian female never-smoker with history of Common Variable Immune Deficiency, and recurrent non-Hodgkin lymphoma status post-chemotherapy and autologous stem cell transplant 2015 followed by allogeneic bone marrow transplant in 2017 presented with dyspnea and non-productive cough. She had presumed pneumonia two months prior but denied infectious or constitutional symptoms. Initial CT chest demonstrated diffuse bilateral GGOs and PFTs had a restrictive pattern with decreased DLCO. PET CT lacked findings suggesting recurrent lymphoma and connective tissue disease. Initial differential diagnosis included infection, organizing pneumonia, and eosinophilic lung disease. The patient underwent bronchoscopy with bronchoalveolar lavage (negative cultures and cytology). Prednisone therapy for presumed cryptogenic organizing pneumonia was initiated. Shortly after she developed worsening dyspnea, tachycardia and new exertional hypoxia and was found to have pneumomediastinum. Bronchoscopy was repeated and again cultures and cytology negative and TTE demonstrated only mild diastolic dysfunction. Without an alternative diagnosis treatment for PCP was provided for 21 days and 50 mg prednisone continued. At completion of treatment there was no improvement on her CT. A surgical lung biopsy was performed, and multidisciplinary radiologic-pathologic diagnosis of pleuroparenchymal fibroelastosis (PPFE) was rendered. DISCUSSION: Predominant findings such as the GGO and pneumomediastinum, can overshadow less conspicuous features such as PPFE which can be confounding. PPFE is a rare disorder usually occurring between age 40 to 70. Numerous potential risk factors for the development of PPFE have been described most common of which are bone marrow, hematopoietic stem cell and lung transplant along with CTD, familial, post infectious, and idiopathic. Clinical features include exertional dyspnea, insidious dry cough, and weight loss. Typically a restrictive ventilatory defect and reduced DLCO are noted. In 2012 Reddy and colleagues proposed diagnostic criteria integrating histopathologic and radiographic features included bilateral upper zone pleural thickening with associated subpleural fibrosis on CT and intraalveolar fibrosis and elastosis on histopathological exam. Pneumothorax and pneumomediastinum are frequent complications of PPFE. CONCLUSIONS: PPFE is a rare condition but should be considered in patients a history of transplant. Treatment remains a clinical challenge and lung transplant is an option. In our patient, possible contributing factors for the development of PPFE were recurrent pulmonary infection and late-onset complication following HSCT. Reference #1: Pena E, Souza CA, Escuissato DL, et al. Noninfectious pulmonary complications after hematopoietic stem cell transplantation: practical approach to imaging diagnosis. Radiographics 2014; 34: 663–683 Reference #2: Chua, F, Desai, SR, Nicholson, AG, et al. Pleuroparenchymal fibroelastosis: a review of clinical, radiological and pathological characteristics. Ann Am Thorac Soc 2019; 16: 1351–1359 Reference #3: Reddy TL, Tominaga M, Hansell DM, von der Thusen J Jr, Rassl D, Parfrey H, Guy S, Twentyman O, Rice A, Maher TM, et al. Pleuroparenchymal fibroelastosis: a spectrum of histopathological and imaging phenotypes. Eur Respir J 2012;40:377–385 DISCLOSURES: No relevant relationships by Sally Delvecchio, source=Web Response No relevant relationships by Teri Franks, source=Web Response No relevant relationships by Jeffrey Galvin, source=Web Response No relevant relationships by Michael Luca, source=Web Response

Preoperative or Perioperative Docetaxel, Oxaliplatin, and Capecitabine (GASTRODOC Regimen) in Patients with Locally-Advanced Resectable Gastric Cancer: A Randomized Phase-II Trial.

Docetaxel associated with oxaliplatin and 5-fluorouracil (FLOT) has been reported as the best perioperative treatment for gastric cancer. However, there is still some debate about the most appropriate number and timing of chemotherapy cycles. In this randomized multicenter phase II study, patients with resectable gastric cancer were staged through laparoscopy and peritoneal lavage cytology, and randomly assigned (1:1) to either four cycles of neoadjuvant chemotherapy (arm A) or two preoperative + two postoperative cycles of docetaxel, oxaliplatin, and capecitabine (DOC) chemotherapy (arm B). The primary endpoint was to assess the percentage of patients receiving all the planned preoperative or perioperative chemotherapeutic cycles. Ninety-one patients were enrolled between September 2010 and August 2016. The treatment was well tolerated in both arms. Thirty-three (71.7%) and 24 (53.3%) patients completed the planned cycles in arms A and B, respectively (p = 0.066), reporting an odds ratio for early interruption of treatment of 0.45 (95% confidence interval (CI): 0.18–1.07). Resection was curative in 39 (88.6%) arm A patients and 35 (83.3%) arm B patients. Five-year progression-free survival (PFS) was 51.2% (95% CI: 34.2–65.8) in arm A and 40.3% (95% CI: 28.9–55.2) in arm B (p = 0.300). Five-year survival was 58.5% (95% CI: 41.3–72.2) and 53.9% (95% CI: 35.5–69.3) (p = 0.883) in arms A and B, respectively. The planned treatment was more frequently completed and was more active, albeit not significantly, in the neoadjuvant arm than in the perioperative group.

Is it Necessary to Confirm Negative Margins in Gastrectomy for Peritoneal Lavage Cytology-positive Gastric Cancer?

The survival benefit of negative resection margins in patients who undergo gastrectomy with positive peritoneal lavage cytology (CY1) is unknown. We reviewed the medical records of 128 patients with CY1 but no other distant metastases who had undergone R1 gastrectomy, 21 of whom had positive margins. We compared overall survival (OS) according to margin status. The positive-margin group had poorer performance status scores (p=0.02), higher number of patients had undergone limited lymphadenectomy (p=0.01), had type 4 tumors (p=0.01), and undifferentiated type (p=0.02). Median OS was 19.0 and 16.9 months in the groups with negative and positive margins, respectively (HR=1.26, 95%CI=0.75-2.12, p=0.39). An inverse probability of treatment weighted analysis showed an OS of 13.1 and 11.9 months for the groups with negative and positive margins, respectively (HR=0.83, 95%CI=0.43-1.63, p=0.59). The prognoses of patients with CY1 and negative or positive margins may be equivalent.

Impact of Positive Pleural Lavage Cytology for Each Stage of Non-Small Cell Lung Cancer Patients

Positive preresection pleural lavage cytology (PLC+) is a poor prognostic factor in non-small cell lung cancer (NSCLC). This study evaluated the prognostic value of PLC+ for the different pathologic stages (p-stages) of NSCLC. A retrospective analysis was conducted of all 1293 staged patients who underwent curative resection in the Shizuoka Cancer Center Hospital, Shizuoka, Japan, for NSCLC to evaluate the impact of PLC+ on survival, specifically in patients with p-stage I NSCLC. The survival rate between patients with and without PLC+ was compared using the Kaplan-Meier method with the log-rank test for comparison. PLC+ was identified in 50 of the 1293 patients (3.9%) and was correlated with lymph node metastasis (P < .001), a pathologic tumor size larger than 3 cm (P= .033), the presence of pleural invasion (P < .001), and adenocarcinoma (P= .038). In patients with PLC+, the 5-year disease-free survival (DFS) was 31.1%, compared with 75.7% for patients with a negative PLC (PLC-) (P < .001). On multivariate analysis, the PLC+ status was an independent prognostic factor of DFS (hazard ratio 1.70; P= .013). Among the 818 patients with p-stage I NSCLC, PLC+ was identified in 22, with a 5-year DFS of 40.4%. The prognosis in patients with p-stage I NSCLC with PLC+ was equal to that in patients with p-stage IIIA NSCLC with PLC- (5-year DFS, 40.4% and 39.0%). PLC is an independent prognostic factor in early-stage NSCLC. Therefore, it may be appropriate to up-stage an NSCLC diagnosis in the presence of PLC+, especially for patients with p stage I.

Importance of The Medical History in The Diagnosis of Hypersensitivity Pneumonitis: A Case Report

Introduction: Hypersensitivity pneumonitis, most frequent types are those related to farming and bird breeding. In this paper, a patient with occupational exposure to metal dusts and welding fumes but diagnosed with HP thanks to the guidance of detailed anamnesis revealing inhalational exposure to pigeon antigens both at home and in workplace Case: 32-year-old male. He applied with shortness of breath, dry cough. He has been working production of kitchen equipment made from stainless steel. When environmental exposures questioned, he declared that he bred up to ten pigeons at the basement of his house and up to fifteen pigeons at a coop next to workplace building. Spirometry revealed restrictive pattern. In patient’s chest X-ray, bilateral increased reticular densities were observed. Computed tomography of thorax revealed radiological findings supporting subacute hypersensitivity pneumonitis such as bilateral diffuse millimetric centrilobular ground-glass nodules which are coalescing in some areas, mosaic perfusion and air trapping in basal areas. Bronchoalveolar lavage cytology revealed percentages of lymphocytes as 85%. Discussion: Detailed anamnesis revealing environmental and occupational inhalational exposures guides the physician in diagnosis of HP. After initial suspicion, supporting laboratory and radiologic findings confirm the diagnosis to provide appropriate management.

Staging laparoscopy is mandatory for the treatment of pancreatic cancer to avoid missing radiologically negative metastases.

Staging laparoscopy is considered useful for determining treatment plans for advanced pancreatic cancer. However, the indications for staging laparoscopy are not clear. This study aimed to evaluate the safety of staging laparoscopy and its usefulness for detecting distant metastases in patients with pancreatic cancer. A total of 146 patients with pancreatic cancer who underwent staging laparoscopy between 2013 and 2019 were analyzed. Staging laparoscopy was performed in all pancreatic cancer patients in whom surgery was considered possible. In this cohort, 42 patients (29%) were diagnosed with malignant cells on peritoneal lavage cytology, 9 (6%) had peritoneal dissemination, and 11 (8%) had liver metastases. A total of 48 (33%) had radiologically negative metastases. On a multivariate analysis, body and tail cancer [odds ratio (OR) 5.00, 95% confidence interval (CI) 2.15-11.6, p < 0.001], high CA19-9 level [OR 4.04, 95% CI 1.74-9.38, p = 0.001], and a resectability status of unresectable (OR 2.31, 95% CI 1.03-5.20, p = 0.04) were independent risk factors for radiologically negative metastases. Staging laparoscopy can be safely performed and is useful for the diagnosis of radiologically negative metastases. Staging laparoscopy should be routinely performed for the accurate diagnosis of pancreatic cancer patients before pancreatectomy and/or local treatment, such as radiotherapy.

Peritoneal Lavage Tumor DNA as a Novel Biomarker for Predicting Peritoneal Recurrence in Pancreatic Ductal Adenocarcinoma.

The clinical role of peritoneal lavage cytology (CY) in pancreatic ductal adenocarcinoma (PDAC) remains controversial, partly due to its low sensitivity. This study aimed to develop a new biomarker, defined as peritoneal lavage tumor DNA (ptDNA), using DNAs extracted from peritoneal lavage samples from patients with PDAC. Samples were collected intraoperatively from 89 PDAC patients who underwent pancreatectomy between 2012 and 2017. Droplet digital polymerase chain reaction (PCR) was used to measure ptDNA for detection of KRAS mutations. The ptDNA status and clinical characteristics were retrospectively evaluated. Positive ptDNA was found in 41 patients, including all 9 patients positive for CY (CY+) and 32 patients negative for CY (CY-). The mutant allele frequency was significantly higher in the CY+ patients than in the CY- patients. The disease-free survival (DFS) and overall survival (OS) were significantly poorer in the high-ptDNA group than in the low-ptDNA group (median DFS, 11.0 vs. 18.8months; p = 0.007; median OS, 28.7 vs not reached; p = 0.001). The survival curves of DFS and OS in the CY+ group were almost equal to those in the CY- and high-ptDNA group. In a multivariable analysis, ptDNA was an independent predictive factor for DFS (p = 0.025) and OS (p = 0.047). The estimated cumulative incidence of peritoneal recurrence was 45.5% in the high-ptDNA group. The ptDNA biomarker had a much higher sensitivity for peritoneal recurrence than CY, whereas CY had higher specificity. As a promising biomarker, ptDNA may predict poor prognosis and peritoneal recurrence in PDAC, resolving the controversy surrounding CY.