Left Lung Research Articles

A pictorial essay on the potential use of the transhepatic subcostal ultrasound view for the evaluation of lower lung lobe pathology.

Lung ultrasound has become indispensable in managing critically ill patients, offering bedside evaluation capabilities for intensive care unit physicians without ionizing radiation. This noninvasive technique demonstrates high sensitivity and specificity in diagnosing various lung pathologies, including pleural effusion and consolidation syndrome. A novel trans-hepatic subcostal approach enhances visualization of the lower right lung lobe, revealing the diaphragm dome and inferior lobe through oblique coronal sections. Challenges include inadequate liver visibility hindering right lung views and difficulties in left lung assessment due to gastric interference. Despite limitations, this method proves invaluable when conventional imaging is impractical, showcasing its utility in critical care settings.

Impact of deep inspiration breath hold, surface-guided radiotherapy, and daily CBCT on the organs at risk in breast cancer radiotherapy.

The goal of the study was to assess the impact of deep inspiration breath hold technique (DIBH), surface-guided radiotherapy (SGRT), and daily kilovoltage cone-beam computed tomography (kV-CBCT) on the dose to organs at risk (OAR) in left-sided breast cancer radiotherapy. Twenty-six consecutive left-sided breast cancer patients treated using Volumetric Intensity Modulated Arc Therapy (VMAT), DIBH, SGRT, and a hypofractionated regimen were retrospectively evaluated in this study. Dose parameters were extracted from dose-volume histograms (DVH). The Wilcoxon Matched Pairs test was used to test dose parameters obtained in free breathing (FB) and DIBH for statistical significance. Multivariable analysis of variance (ANOVA) and receiver operating characteristics (ROC) analysis were used to identify parameters and cut-off points associated with the reduction of the mean heart dose (MHD) by DIBH. Based on published models, the risk of cardiac and lung toxicity (pneumonitis) using SGRT or daily kV-CBCT was estimated and compared. DIBH substantially reduced the MHD (median, 43.6%; range, 4.2% to 75.1%; P < 0.00001). The risk of cardiac toxicity using SGRT increased by 1%, compared to 3.6% to 20.5% using daily kV-CBCT. No significant difference in the risk of radiation-induced pneumonitis using SGRT versus daily kV-CBCT was detected. The ANOVA revealed the relative increase of the left lung volume by DIBH as the only significant impact factor for the MHD. The ROC analysis of this parameter showed an area under the curve (AUC) of 0.89 (95%CI, 0.71 to 0.98; P < 0.0001). DIBH can substantially reduce the MHD in left-sided breast cancer patients treated with modern radiotherapy techniques and hypofractionation. Patient setup using SGRT compared to daily kV-CBCT may be the preferred option for many patients. In our patient cohort, the relative reduction of the left lung volume by DIBH can be used as a predictor to select patients who benefit from DIBH.

Lung lobe torsion following intrathoracic surgery in a dog

AbstractA 6‐year‐old, male, neutered Irish Setter was presented for subacute onset of coughing/gagging, fever and lethargy. Computed tomography showed paraoesophageal nodules. Exploratory thoracotomy was performed with excision of three tracheobronchial lymph nodes, and the dog was discharged 2 days postoperatively. Seven days after thoracotomy, the dog developed tachypnoea and haemoptysis. A thoracic computed tomography was performed 14 days after thoracotomy, which revealed left caudal lung lobe torsion. At surgery, the lung lobe torsion was confirmed, and the left caudal lung lobe was excised. The dog was discharged 3 days postoperatively. Lung lobe torsion following thoracic surgery is more commonly reported in humans, and rarely occurs in dogs without prior lung lobectomy. This case report shows that lung lobe torsion can be a complication of thoracic surgery, even without prior lung lobectomy.

Abstract 4135534: Total and Regional Lung Volumes And Pulmonary Blood Flow In Repaired Tetralogy Of Fallot - Smaller Lungs And A Maldistribution of Flow

Introduction: Many pts with repaired tetralogy of Fallot (rTOF) are left with residual pulmonary regurgitation (PR) and poor exercise performance. Small studies in young children suggest that the total lung volume of rTOF pts are smaller than normal and may contribute to these sequelae. As exercise and cardiac performance are intimately related to lung function, it’s surprising that few rTOF studies have investigated cardiopulmonary interactions. Aims: To determine if regional and total lung volumes in rTOF pts are the same size as normals and if the larger amount of forward blood flow courses to the bigger lung. We hypothesized that this may not be the case. Methods: rTOF patients undergoing clinically indicated cardiac magnetic resonance (CMR) were evaluated for lung volumes using dark blood imaging (figure) and blood flow to the branch pulmonary arteries (bPA) using velocity mapping. Significance &lt; P=0.05. Results: Eleven rTOF patients and 25 normal controls were studied. Total control lung volume was significantly larger than those of rTOF. Regional rTOF right and left lung volumes were smaller than their respective control lung volumes, barely missed statistical significance (table). In 6 rTOF pts with CMR prior to and after pulmonary valve replacement (PVR), lung volumes did not differ between the 2 timepoints (1034 vs 998 cc/m 2 respectively). Only 3/11 (27%) rTOF pts had the higher bPA flow coursing to the higher regional lung. The ratio of right bPA forward flow/right lung volume to left bPA forward flow/left lung volume ranged from 0.72-1.51 (ideal balanced flow to each lung would be 1), implying a maldistribution of flow. Conclusion: rTOF patients have smaller total lung volumes than controls with no change after PVR in our study. In addition, only a small proportion of rTOF patients have the larger amount of flow coursing to the larger lung. The ratio of individual bPA flow to individual lung volume implies a maldistribution of pulmonary flow relative to the respective lung volume. Our findings may have implications for timing of PVR, partially explaining PR and poor exercise performance. Flow limiters placed by cath or surgery may be able to redistribute the appropriate flow to regional lung fields.

Posterior mediastinal extralobar pulmonary sequestration in a neonate with pulmonary artery supply: a case report

This paper reports a rare case of extralobar pulmonary sequestration in the posterior mediastinum of a neonate with arterial supply from the pulmonary artery. A 3-day-old male neonate was diagnosed with type II congenital pulmonary airway malformation after prenatal color Doppler ultrasonography showed a lesion with blood supply from the pulmonary artery in the left lung. Post-birth chest computed tomography(CT) showed that the lesion was located in the posterior mediastinum with low density change, mild stripe enhancement after contrast, and no obvious blood supply vessels. A neurogenic tumor was considered for the preoperative diagnosis. The mass was removed by video-assisted thoracoscopic surgery. During the surgery, the mass was observed to be a dark red solid lump with a feeding vessel originating from the pulmonary artery. The postoperative histopathological diagnosis was extralobar pulmonary sequestration. Combined with the preoperative imaging results, it was considered that the nourishing vessels might have intermittent torsion. The patient recovered well after surgery, and no recurrence was observed after 6 months of follow-up. Therefore, the possibility of extralobar pulmonary sequestration cannot be ruled out for posterior mediastinal masses that are not supplied by the descending aorta or without identified feeding vessels.

The impact of the EVLP on the lung microbiome and its inflammatory reaction

The pulmonary microbiome has emerged as a significant factor in respiratory health and diseases. Despite the sterile conditions maintained during ex vivo lung perfusion (EVLP), the use of antibiotics in the perfuse liquid can lead to dynamic changes in the lung microbiome. Here, we present the design of a study that aims to investigate the hypothesis that EVLP alters the lung microbiome and induces tissue inflammation. This pilot, prospective, controlled study will be conducted in two Spanish donor centers and will include seven organ donors after brain death or after controlled cardiac death. After standardized retrieval, the left lung will be preserved in cold storage and the right lung will be perfused with EVLP. Samples from bronchoalveolar lavage, perfusion and preservation solutions, and lung biopsies will be collected from both lungs and changes in lung microbiome and inflammatory response will be compared.

Streptococcus salivarius pneumonia-associated pneumomediastinum: a case report and literature review

BackgroundStreptococcus salivarius is an opportunistic pathogen, and there have been no reported cases of Streptococcus salivarius pneumonia to date. Pneumomediastinum is usually secondary to tracheal or esophageal injury and is very rare as a complication of pneumonia. We report a case of Streptococcus salivarius pneumonia complicated by pneumomediastinum, aiming to enhance clinicians’ awareness of rare pathogens and uncommon complications in pneumonia.Case presentationThe patient, a 36-year-old male, presented with a persistent cough and sputum production for one week, accompanied by a sore throat that had developed just one day prior. Chest computed tomography (CT) disclosed pneumomediastinum alongside obstructive atelectasis in the left lower lobe. Streptococcus salivarius infection was conclusively identified through bronchoalveolar lavage metagenomic next-generation sequencing (mNGS), as well as smear and culture analyses. The patient was administered intravenous amoxicillin-clavulanate potassium for a duration of seven days as part of the anti-infection regimen. Given the stability of the patient’s respiratory and circulatory systems, a tube drainage procedure was deemed unnecessary. Post-treatment, the patient’s clinical symptoms notably improved. A subsequent chest CT scan revealed the re-expansion of the left lower lung and near-complete resolution of pneumomediastinum.ConclusionThere are numerous pathogens that can cause pneumonia. While focusing on common pathogens, it is important not to overlook rare ones. When considering infections from rare pathogens, it is recommended to promptly perform a bronchoscopy and submit bronchoalveolar lavage fluid for mNGS to improve pathogen detection rates. During the diagnosis and treatment of pneumonia, it is crucial to be vigilant for rare complications. When a patient presents with symptoms such as dyspnea or subcutaneous emphysema, it is advisable to immediately perform a chest CT scan to rule out pneumomediastinum.

Middle Lobe Syndrome: A Case Report and Literature Review

Background: Middle lobe syndrome (MLS) is a distinct clinical and radiographic entity characterized by recurrent or chronic collapse of the middle lobe of the right lung, but it can also involve the lingula of the left lung. Case Study: This study presents a rare case of MLS caused by a vascular ring never described in the literature until now and provides physicians with the clinical and instrumental tools in order to early recognize and promptly treat this condition. The case report was reported according to CARE guidelines. A literature research on PubMed/MEDLINE was also performed using the MeSH terms “Middle lobe syndrome OR MLS AND double aortic arch” “Middle lobe syndrome OR MLS AND vascular rings”. No case described in the literature was found. In most cases, MLS presents non-specific respiratory symptoms, which unfortunately is responsible for the diagnostic delay that patients with this pathology often suffer. The diagnostic delay is estimated to be 8 months (range 3 to 36 months). A history of dysphagia and regurgitation can be indirect signs of a vascular compression, such as vascular rings, which can cause MLS. Conclusion: To date, the reported case is the only case in the literature of MLS caused by double aortic arch. The key point for the diagnosis of MLS is diagnostic suspicion. Early recognition of MLS is essential to quickly start a targeted therapeutic program avoiding the persistence of vicious circle atelectasis-recurrent respiratory infections, and this could significantly improve the long-term outcome of these patients.

ASO Visual Abstract: Comparative Analyses of the Outcomes Between Lobectomies and Trisegmentectomies/Lingulectomies in the Surgical Management of Clinical Stage I Left Upper Lobe Non-small Cell Lung Cancer.

ASO Visual Abstract: Comparative Analyses of the Outcomes Between Lobectomies and Trisegmentectomies/Lingulectomies in the Surgical Management of Clinical Stage I Left Upper Lobe Non-small Cell Lung Cancer.

The relationship between lung MIBG uptake and clinical response to renal denervation

Abstract Background Renal denervation (RDN) reduces the sympathetic overdrive and can optimize blood pressure control in patients with difficult-to-treat hypertension (DTH). However, a substantial proportion of patients undergoing RDN do not show a clinical response to the procedure, making it critical to identify novel and more accurate predictors. The metaiodobenzylguanidine (MIBG) scintigraphy allows non-invasive assessment of sympathetic nerve activity. Yet, studies evaluating the heart and kidney MIBG uptake as predictors of clinical response to RDN provided conflicting results, and a comprehensive evaluation of the MIBG uptake in different organs of DTH patients undergoing RDN is lacking. Purpose To explore if a more comprehensive evaluation of MBG uptake in the kidneys, heart and lungs can predict the clinical response to RDN. Methods Eighteen patients with DTH underwent evaluation of their clinical and pharmacological history, office and ambulatory BP values and levels of cardiovascular risk factors. A rest echocardiography, carotid vascular ultrasound and MIBG scintigraphy were also performed before RDN. The patient’s pharmacological history and office and ambulatory BP values were re-evaluated after 3 months from RDN. We considered responders (R) those subjects with a significant reduction of the office BP values on stable BP-lowering treatment or a reduced burden of BP-lowering medications while maintaining optimal control of the office BP. Results Ten patients could be classified as R (1 woman, mean age 49±10 years), while 7 were non-responders (NR, 2 women, mean age 53±8 years). The reduction in office systolic and diastolic BP (baseline vs 3 months) was significantly larger in R vs NR (p=0.01 for both). The burden of BP-lowering medications after the procedure was reduced by 39% in R, compared to 2% in NR (p&amp;lt;0.01). Responders had a higher baseline HR and prevalence of carotid atherosclerosis than NR (p&amp;lt;0.05 for both). In early MIBG acquisitions, the lung/mediastinum ratio on both sides showed higher MIBG uptake in R vs NR (p&amp;lt;0.05). There was a higher MIBG uptake in the right vs. left lung in the whole population and in R vs NR. In late acquisitions, only the left side showed a significant difference between R and NR (p&amp;lt;0.05). The associations between the lung/mediastinum ratio MIBG uptake and response to RDN remained significant after adjusting for the baseline clinical predictors of the RDN response. All other MIBG scintigraphy parameters were similar between groups. Conclusions Our results suggest that RDN might be less effective in patients with an advanced burden of hypertension-mediated target organ damage and confirm a higher HR as a reliable predictor of the clinical response to the procedure. We also document a novel association between the lung/mediastinum ratio MIBG uptake and response to RDN that, if confirmed in future studies, might provide a novel marker to improve the selection of patients undergoing RDN.

Left inguinal dedifferentiated liposarcoma and primary unclassified sarcoma of the left lung as synchronous multiple sarcomas: a case report

BackgroundPulmonary nodules in patients with soft tissue sarcomas are likely pulmonary metastases, whereas synchronous primary pulmonary sarcomas are rare. Without surgery, determining whether a solitary pulmonary nodule is a primary or metastatic nodule is difficult. Herein, we report a rare case of a primary pulmonary sarcoma that presented synchronously with a primary dedifferentiated liposarcoma.Case presentationA 77-year-old man presented to another hospital with left inguinal swelling and a suspected recurrent inguinal hernia. Computed tomography revealed a left inguinal mass and pure-solid nodule in the left lung and the patient was referred to our hospital for detailed examination and treatment. The inguinal mass was pathologically diagnosed as a dedifferentiated liposarcoma using needle biopsy, whereas bronchoscopic biopsy revealed histological findings suggestive of a sarcoma; however, the primary site could not be determined. Positron emission tomography–computed tomography revealed no high-accumulation lesions except for the two sarcomas. We decided to perform surgery on both sarcomas for diagnostic and curative purposes. The surgical specimens showed that the two sarcomas were different. Based on the immunohistochemical staining findings of MDM2, a left inguinal dedifferentiated liposarcoma and primary pulmonary unclassified sarcoma were diagnosed. The patient displayed no evidence of recurrence 1 year after surgery.ConclusionsWe encountered a rare case of synchronous multiple primary sarcomas, one presenting in the lung and the other in the soft tissue. Surgery was required to achieve a definitive diagnosis for the patient, who achieved disease-free survival at 1 year. This case suggests that proactive resection of pulmonary nodules in patients with soft tissue sarcomas may be feasible as a diagnostic treatment if complete resection is achieved.

Intact DNA repair in differentiated cardiomyocytes is essential for maintaining cardiac function in response to pressure overload in mice

Abstract Introduction DNA in every cell is continuously damaged and DNA repair mechanisms are essential for protection against DNA damage-induced aging-related diseases. For example, deficient repair of endogenously generated DNA damage in mice with cardiomyocyte-restricted inactivation of Xpg, is associated with progressive heart failure. Purpose Here we tested the hypothesis that unrepaired DNA damage in differentiated cardiomyocytes increases cardiac vulnerability in response to hemodynamic overload. Methods To increase the burden of spontaneous DNA damage, we generated mice with cardiomyocyte-restricted inactivation of DNA repair endonuclease XPG. At 8 weeks of age, αMHC-Xpgc/- and control (Ctrl) mice were subjected to pressure overload by transverse aortic constriction (TAC). Eight weeks after TAC, left ventricular (LV) function was assessed using echocardiography and hemodynamic measurements, followed by molecular and histological analyses. Results Cardiomyocyte-restricted inactivation of Xpg resulted in systolic as well as diastolic LV dysfunction (Table). TAC-induced LV hypertrophy is similar in both groups (Ctrl 38%; αMHC-Xpgc/- 34%). In Ctrl mice, LV hypertrophy was accompanied by minimal LV dilation and modest changes in systolic and diastolic LV function. Conversely, TAC in αMHC-Xpgc/- produced severe LV dysfunction and resulted in overt congestive heart failure, demonstrated by aggravation of LV dilation, and marked increases in LV end-diastolic pressure, left atrial weight and lung fluid weight, which was accompanied by further increases in the expression levels of the hypertrophic marker genes atrial natriuretic peptide and beta-myosin heavy chain (Table). Moreover, lectin staining revealed a decrease in capillary density and TUNEL staining revealed further elevated levels of myocardial apoptosis. In addition, a significant increase of myocardial collagen content was observed. Conclusion Cardiomyocyte-restricted loss of DNA repair protein XPG increases cardiac vulnerability to develop heart failure in response to pressure overload. These findings underscore the importance of genomic stability for maintenance of cardiac function, not only during basal conditions, but also in response to a pathological stimulus.

Comparative Analyses of the Outcomes Between Lobectomies and Trisegmentectomies/Lingulectomies in the Surgical Management of Clinical Stage I Left Upper Lobe Non-small Cell Lung Cancer.

Lobectomies are the standard surgical intervention for lung cancer; however, recently, surgeons have considered segmentectomies for smaller tumors, with their potential for favorable survival outcomes while preserving lung function. The surgical outcomes of trisegmentectomies/lingulectomies and lobectomies for clinical stage I left upper lobe (LUL) non-small cell lung cancers (NSCLCs) remain undetermined. Thus, our study aimed to assess the differences between the short-term surgical and long-term survival outcomes in patients with clinical stage I LUL NSCLC who underwent trisegmentectomies/lingulectomies and those who underwent lobectomies. Between 2011 and 2021, we retrospectively reviewed the data of 377 patients with clinical stage I NSCLC who had undergone LUL lobectomies or trisegmentectomies/lingulectomies. Patients were categorized into two subcohorts according to tumor size, i.e. 0-2 and 2-4 cm. To ensure preoperative demographic comparability, 1:1 propensity-score matching (PSM) was performed. This study focused on the 2-4cm subcohort. Post-PSM, patients who underwent trisegmentectomies/lingulectomies had quicker operations and shorter postoperative hospital and intensive care unit lengths of stay than those who underwent lobectomies. Post-PSM, no statistically significant differences in progression-free survival (PFS) or overall survival (OS) were observed between the segmentectomy and lobectomy groups in both the0-2 and 2-4cm subcohorts. The multivariate analysis revealed that different surgical methods were not statistically significant factors for either PFS or OS. Trisegmentectomies/lingulectomies are a feasible option for clinical stage I NSCLC, with better perioperative outcomes and similar survival rates when compared with LUL lobectomies.

Synchronous primary gastric diffuse large B-cell lymphoma and multiple lung primary adenocarcinoma with pulmonary cryptococosis: a case report and literature review

BackgroundThe coexistence of non-Hodgkin’s lymphoma of the stomach and multiple primary lung adenocarcinomas with pulmonary cryptococcosis has rarely been reported.Case presentationWe herein present a 75-year-old man who was admitted to our hospital due to hematemesis. Gastroscopy and imaging revealed extensive stomach wall thickening and multiple lung lesions, including nodules and cavernous lesion. The patient was diagnosed with primary diffuse large B-cell lymphoma via gastroscopy and bilateral lung primary adenocarcinoma with cryptococcal infection via percutaneous CT-guided puncture biopsy. He subsequently underwent six cycles of R-CHOP regimen for gastric lymphoma, along with CT-guided radiofrequency ablation for the upper lobe of the right lung primary adenocarcinoma and radioactive particle implantation was performed on the lower lobe of the left lung primary adenocarcinoma, supplemented with antifungal therapy. After a definite diagnosis and systemic treatment, the patient was followed up for twenty-seven months with no tumor recurrence, progression or metastasis.ConclusionTo the best of our knowledge, the complex combination of multiple primary malignancies and pulmonary cryptococcal infection is extremely rare. The diagnosis is been confusing and challenging. CT-guided needle biopsy can help achieve pathological diagnosis, elucidate the type and stage of the tumor, and even change the clinical treatment strategy, which is necessary and beneficial.

Disseminated Cryptococcus over pancreas, lung, and brain: a case report

BackgroundCryptococcus is an opportunistic infection acquired through inhalation from the environment, primarily affecting individuals with compromised immune systems. It typically leads to pneumonia upon passing through lung tissue. The infection can disseminate to various organs via the bloodstream, resulting in meningitis or encephalitis in the central nervous system. Disseminated Cryptococcus has been reported to involve the skin, liver, eyes, lymph nodes, bone marrow, spleen, kidneys, and intestines, significantly increasing morbidity and mortality. However, pancreatic involvement in Cryptococcus is relatively rare, and a few case reports have highlighted severe organ damage and high mortality rates.Case presentationIn this case report, we present the case of a 36-year-old Asian man who presented with a 2-week history of headaches and blurred vision in his right eye. Brain magnetic resonance imaging revealed multiple brain masses, along with a mass in the lower left lung field and a tumor in the pancreatic tail, as detected by chest computed tomography. Endoscopic ultrasound-guided fine needle biopsy and computed tomography-guided lung biopsy confirmed the diagnosis of disseminated cryptococcal infection involving the pancreas, lung, and brain. The patient’s clinical condition improved following antifungal therapy. Additionally, we identified anti-granulocyte–macrophage colony-stimulating factor antibody as a risk factor for disseminated cryptococcal infection in this patient.ConclusionDisseminated cryptococcosis can be a potentially lethal condition, as highlighted by previous literature. However, early diagnosis using contrast-enhanced harmonic endoscopic ultrasound and endoscopic ultrasound-guided biopsies, as well as prompt treatment as demonstrated in our case, can improve outcomes and prevent mortality.

Lung Ultrasound Assessment of Regional Distribution of Pulmonary Edema and Atelectasis in Infants with Evolving Bronchopulmonary Dysplasia.

Background: Preterm infants are at risk for bronchopulmonary dysplasia (BPD) due to prolonged respiratory support. Studies have described differences in the regional distribution of lung ventilation (non-dependent (NDL) vs. dependent (DL)). The aim of this study was to use LUS to compare regional distribution of pulmonary edema and atelectasis in infants with evolving BPD. Methods: We prospectively performed LUS in premature infants with evolving BPD. On each side, three lung areas (NDL/anterior, lateral, and DL/posterior) were examined for the presence of pulmonary edema and atelectasis. Pulmonary edema scores were assigned based on the number of B-lines, and atelectasis scores were assigned based on the presence/absence of atelectasis. Results: 38 premature infants were enrolled. The NDL showed more pulmonary edema and atelectasis compared to the DL (p = 0.003, p = 0.049, respectively) and compared to the lateral lung (p =< 0.001, p = 0.004, respectively). There was no difference between the lateral and DL (p = 0.188, p = 0.156, respectively). There was no difference between the right and the left lung (p = 0.223, p = 0.656, respectively). Conclusions: In this cohort of preterm infants with evolving BPD, lung disease was unevenly distributed, with more pulmonary edema and atelectasis in the NDL regions compared to the DL or lateral regions.

A Case of CUP with Malignant Pleural Effusion: Overcoming Diagnostic and Therapeutic Hurdles with Chemotherapy

Introduction: Cancers of unknown primary (CUPs) present a diagnostic challenge as their origin is unidentified at diagnosis. Massive pleural effusion (MPE), indicative of lung metastasis in CUP, categorizes the condition into an unfavorable subset with a poor prognosis. Patients in this subset may exhibit a lower response to specific therapies. Case Presentation: A 62-year-old woman presented with cough, severe dyspnea, and MPE in the left lung. Thoracocentesis was performed, extracting 1,200 mL of hemorrhagic fluid, followed by the placement of an indwelling pleural catheter. The cytological examination of the pleural effusion indicated an adenocarcinoma, with immunohistochemistry revealing positive CK7 and negative CK20, Napsin A, and TTF-1. Additionally, elevated levels of Ca-125 (1,605 U/mL) and Ca 15-3 (242 U/mL) raised suspicion of gynecological malignancy. Thorax and abdominal CT scans, breast and thyroid ultrasounds showed no signs of malignancy, leading to the diagnosis of CUP. The patient’s performance status according to the Eastern Cooperative Oncology Group (ECOG) score was 4. Initial carboplatin 5 AUC and paclitaxel 175 mg/m2 administration resulted in improvement in performance status with ECOG score of 1, alleviation of dyspnea, reduction in pleural effusion 1 week after chemotherapy, with minimal effusion observed at 3 weeks, and Ca-125 levels decreased to 33.6 U/mL thereafter. Discussion: Empiric chemotherapy using carboplatin and paclitaxel is a feasible option for managing CUP with MPE mimicking gynecological malignancies with elevated Ca-125 and Ca 15-3 markers; initiating chemotherapy in poor performance status patients is beneficial with proper clinical judgment.

Dosimetric benefit and clinical feasibility of deep inspiration breath-hold and volumetric modulated arc therapy-based postmastectomy radiotherapy for left-sided breast cancer

To evaluate the dosimetric benefits and clinical feasibility of deep inspiratory breath-hold (DIBH) combined with volumetric modulated arc therapy (VMAT) in left-sided postmastectomy radiotherapy (PMRT). Eligible patients with left-sided breast cancer undergoing DIBH-based PMRT were prospectively included. Chest wall, supra/infraclavicular fossa, and/or internal mammary node irradiation (IMNI) were planned with a prescription dose of 43.5 Gy in 15 fractions. VMAT plans were designed on free breathing (FB)—and DIBH-CT to compare dosimetric parameters in heart, left anterior descending artery (LAD) and lung. Cone-beam computed tomography (CBCT) was performed before and after treatment to evaluate inter- and intra-fractional setup errors. Heart position and dose variations during treatment were estimated by fusing CBCT with DIBH-CT scans.Twenty patients were included with 10 receiving IMNI. In total, 193 pre-treatment and 39 pairs pre- and post-treatment CBCT scans were analyzed. The Dmean, Dmax, and V5−40 of the heart, LAD, and left lung were significantly lower in DIBH than FB (p < 0.05 for all), except for V5 of LAD (p = 0.167). The cardiopulmonary dosimetric benefits were maintained regardless of IMNI. The inter- and intra-fractional setup errors were < 0.3 cm; and the overall estimated PTV margins were < 1.0 cm. During treatment, the mean dice similarity coefficient of heart position and the mean ratio of heart Dmean between CBCT and DIBH-CT plans was 0.95 (0.88–1.00) and 100% (70.6–119.5%), respectively. DIBH-VMAT could effectively reduce the cardiopulmonary doses with acceptable reproducibility and stability in left-sided PMRT regardless of IMNI.

A Case of Intravascular Large B-cell Lymphoma That Was Overlooked due to Nonspecific Symptoms During Combination Immunotherapy for Left Upper Lobe Lung Adenocarcinoma

A Case of Intravascular Large B-cell Lymphoma That Was Overlooked due to Nonspecific Symptoms During Combination Immunotherapy for Left Upper Lobe Lung Adenocarcinoma

Regional ventilation dynamics of electrical impedance tomography validated with four-dimensional computed tomography: single-center, prospective, observational study

BackgroundThe dynamic regional accuracy of electrical impedance tomography has not yet been validated. We aimed to compare the regional accuracy of electrical impedance tomography with that of four-dimensional computed tomography during dynamic ventilation.MethodsThis single-center, prospective, observational study conducted in a general intensive care unit included adult patients receiving mechanical ventilation from July 2021 to February 2024. The patients were mechanically ventilated passively and underwent electrical impedance tomography and four-dimensional computed tomography on the same day.ResultsOverall, 45 patients were analyzed. The correlation coefficients in regional dynamic ventilation between four-dimensional computed tomography and electrical impedance tomography in each region were 0.963, 0.963, 0.835 (ventral, central, and dorsal, respectively) in the right lung and 0.947, 0.927, 0.823 (ventral, central, and dorsal, respectively) in the left lung. The correlation coefficient was low when the regional ventilation distribution detected by the electrical impedance tomography was < 2%. After excluding nine patients with a regional ventilation distribution of < 2%, the ventral, central, and dorsal correlation coefficients were 0.963, 0.963, and 0.946 in the right lung and 0.942, 0.924, and 0.951, respectively, in the left lung.ConclusionsRegional ventilation using electrical impedance tomography during dynamic ventilation was highly accurate and consistent with the time phase compared to four-dimensional computed tomography. Given the high correlation between these modalities, they can contribute significantly to further studies on regional ventilation dynamics.Trial registration number ClinicalTrials.gov (No. UMIN00044386).