堀口 智也

BACKGROUND: Patients with thoracic malignancy and interstitial pneumonia (IP) are often excluded from clinical trials, consequently lacking quantitative evidence of poorer prognosis and lower programmed death-ligand 1 (PD-L1) testing rates. METHODS: We evaluated the real-world impact of comorbid IP on biomarker adoption and survival in thoracic malignancy patients receiving first-line systemic therapy at a tertiary teaching hospital between 2016 and 2023. RESULTS: Among 1247 patients, 98 (7.5%) had comorbid IP. Multigene testing rates in IP patients were similar to those in non-IP patients. Only three actionable genomic alterations were found in the IP group, highlighting PD-L1 testing as the key element. PD-L1 testing was underutilized in the IP group (63.3%) compared with the non-IP group (75.1%). Immune checkpoint inhibitor (ICI) therapy was utilized in 12.2% of IP versus 29.3% in non-IP, despite comparable clinical situations. Comorbid IP predicted worse survival (hazard ratio: 1.789; 95% confidence interval: 1.373-2.331; p < 0.001). Although survival significantly improved in non-IP after 2020, no benefit was observed in IP. A multivariable model incorporating an IP × Period interaction confirmed comorbid IP remained a negative prognostic factor, highlighting recent advances have not bridged the survival disparity for this high-risk group. CONCLUSIONS: Despite recent progress, patients with comorbid IP experience limited clinical benefit, characterized by lower rates of PD-L1 testing, restricted use of immune checkpoint inhibitors, and absence of post-2020 survival gains. This large-scale and quantitative evidence demonstrates persistent disparities and their prognostic significance, reflecting the limited applicability of current immunotherapy-based strategies in this high-risk population.

BACKGROUND: We compared the capabilities of quantitatively assessed paired inspiratory-expiratory area-detector computed tomography (ADCT) for pulmonary functional loss and disease severity evaluations between upright and supine ADCT in matched progressive pulmonary fibrosis (PPF) patients. MATERIALS AND METHODS: This retrospective cohort consisted of age-, sex-, and underlying disease-matched patients with PPF who underwent paired inspiratory-expiratory CT on upright ADCT (n = 40) and supine ADCT (n = 40), pulmonary function tests, and disease severity assessment. Based on CT data, the absolute values of the logarithm of the Jacobian determinant and warp-field magnitude of the whole lung and all lobes were calculated. Stepwise regression analyses were performed. RESULTS: On supine ADCT, both indices of the left lower lobe (LLL) were the first and only steps for pulmonary function test results and CT-assessed disease severity (absolute value of the logarithm of the Jacobian determinant: 0.139 ≤ r2 ≤ 0.175, 0.007 ≤ p ≤ 0.018; absolute value of the warp-field magnitude: 0.371 ≤ r2 ≤ 0.447, p < 0.001). However, on upright ADCT, both indices indicated that LLL was the first step and the right lower lobe was the second step for pulmonary function test results and CT-assessed disease severity (0.503 ≤ r2 ≤ 0.674, p < 0.001 or 0.000 < p ≤ 0.006 and 0.474 ≤ r2 ≤ 0.652, 0.002 ≤ p ≤ 0.045, respectively). CONCLUSION: Upright ADCT has equal to or better potential than supine ADCT for detecting pulmonary functional loss and evaluating disease severity when paired inspiratory-expiratory ADCT is applied in PPF patients. RELEVANCE STATEMENT: Upright ADCT has superior potential to supine ADCT for pulmonary functional loss and disease severity evaluations when paired inspiratory-expiratory ADCT is performed in patients with progressive pulmonary fibrosis (PPF). KEY POINTS: Matched progressive pulmonary fibrosis patients compared functional loss and disease severity evaluations between inspiratory-expiratory upright and supine area-detector CT. Clinical parameters demonstrated better correlations with upright than with supine inspiratory-expiratory area-detector CT. Warp-field magnitude showed better correlations with disease severities than the logarithm of the Jacobian determinant on each area-detector CT.

INTRODUCTION: Accurate diagnosis of peripheral pulmonary lesions is crucial in respiratory medicine. Radial endobronchial ultrasound (R-EBUS), navigation technologies, and ultrathin bronchoscopes have progressively enhanced distal airway access. Mixed reality (MR) offers a hands-free method for visualizing and manipulating CT-derived three-dimensional (3D) anatomy within the operator's field of view. This retrospective study aimed to describe the technical feasibility and safety of intraprocedural MR-based holographic virtual bronchoscopy (VB) use. METHODS: This study included patients who underwent bronchoscopy for peripheral pulmonary lesions using an MR-based 3D holographic VB system. CT datasets were converted into 3D polygon models and displayed on a HoloLens 2 headset. Operators/assistants intraprocedurally referenced and manipulated the hologram while advancing the bronchoscope. Procedural variables, R-EBUS findings, biopsy techniques, diagnostic yield, and complications were evaluated. RESULTS: Eighteen patients were included. A direct bronchus sign was present in 12 lesions. The median bronchial generation that could be visualized on CT and 3D-VB was six, whereas bronchoscopy enabled advancement to a median of five generations. Radial EBUS demonstrated a within-lesion position in 13 cases. Biopsy techniques included forceps biopsy, cryobiopsy, and TBNA. The overall diagnostic yield was 72.2% (13/18), with malignant disease accounting for the majority of diagnoses. One patient developed mild pneumothorax, which resolved without drainage. CONCLUSION: MR-based holographic VB enabled real-time, hands-free 3D anatomical referencing without interrupting the procedure. Further prospective studies are warranted to assess procedural benefits and potential integration with other bronchoscopic modalities and devices.

BACKGROUND: Although bronchoscopic biopsy serves as a cornerstone for diagnosing lung cancer in elderly patients, whether this procedure leads to clinically relevant outcomes is still unclear. This study aimed to clarify the clinical significance of diagnostic bronchoscopy in lung cancer patients aged ≥80 years. METHODS: We retrospectively analyzed 803 patients diagnosed with lung cancer who underwent bronchoscopy at our hospital from April 2015 to March 2019. Those aged ≥80 years and <80 years were classified as the elderly group (n = 154) and young group (n = 649), respectively. RESULTS: The diagnostic yield of bronchoscopy in the elderly and young groups was 92.9 % and 83.5 %, respectively; complication rates were 9.6 % and 7.2 %. Approximately 89 % of the patients in the elderly group received specific lung cancer treatment. The 5-year survival rates for elderly and young patients who underwent surgery were 74.5 % and 78.2 %, respectively. In the elderly group, 11 % of the patients chose best supportive care (BSC) only, compared with 2 % in the young group. Notably, patients with non-diagnostic bronchoscopic results selected BSC more frequently in the elderly versus young groups (30.4 % versus 0 %, respectively). CONCLUSIONS: Bronchoscopy in elderly patients with lung cancer demonstrated a high diagnostic yield and an acceptable safety profile, enabling specific treatments in the majority of cases. These findings support the clinical usefulness of bronchoscopy in guiding treatment decisions for elderly patients. However, non-diagnostic results were associated with a higher likelihood of BCS, highlighting the importance of achieving a definitive diagnosis in this population.

Bronchoscopic lung volume reduction (BLVR) with endobronchial valves is an established treatment for selected patients with advanced emphysema. A 74-year-old male patient with chronic obstructive pulmonary disease and severe dyspnea was scheduled to undergo BLVR targeting the right middle lobe bronchus based on high-resolution CT findings, which showed severe emphysematous changes with hyperinflation and fissure completeness of 98% in the right middle lobe. The physician conducted preoperative virtual reality (VR)-assisted planning using the patient's imaging data, enabling comprehensive visualisation of the bronchial tree, airway measurements, and procedural simulation. The Chartis system confirmed a 'no flow' pattern, supporting the absence of collateral ventilation. During the procedure, a size 5.5 valve was placed in the right B4/5 bronchus following VR and intraoperative assessments. The patient remained stable postoperatively without complications. VR enhanced procedural planning by improving airway assessment, optimising valve sizing, and reducing cognitive load, leading to increased efficiency and operator confidence. Further research is warranted to validate the utility of VR in bronchoscopic interventions.

Epithelioid hemangioendothelioma (EHE) with pleural involvement presents significant diagnostic challenges, particularly in terms of differentiating it from malignant pleural effusion caused by other types of cancer, such as lung carcinoma. While most cases of EHE follow an indolent course, some can deteriorate rapidly, particularly those with serosal involvement such as pleural metastasis. In this report, we describe a case in which semi-rigid thoracoscopic cryobiopsy under local anesthesia yielded adequate specimens safely for diagnosis of pleural dissemination of EHE. The patient was a 46-year-old woman who had been diagnosed with multifocal EHE affecting the liver and both lungs a decade earlier. After radiofrequency ablation for the hepatic lesions and 2 years of chemotherapy, she was monitored without specific treatment for approximately 8 years with no significant tumor progression. She presented to our department following a rapid increase in left-sided pleural effusion over the previous month. Based on the clinical course and imaging findings, the diagnosis was initially difficult. However, thoracoscopic cryobiopsy provided definitive confirmation of pleural EHE.

The purpose of this study was to evaluate how the first oral administration of suvorexant affects PSG results in patients with severe obstructive sleep apnea (OSA). Single-center, prospective study conducted in a nonrandomized, uncontrolled, unblinded fashion. Undiagnosed 64 patients with suspected OSA underwent first-night PSG, and 30 patients with severe OSA (Apnea Hypopnea Index [AHI] ≥ 30 events/h) underwent second-night PSG testing after administration of 15 mg suvorexant. The change in AHI between the first and second nights was not significant, although the upper limit of the 95% confidence interval for the mean difference in AHI was high at 5.987.The mean duration of apnea on the second night was significantly prolonged compared to that on the first night, but there were no significant differences n 3% oxygen desaturation index, saturation of percutaneous oxygen<90% time. On the second night, total sleep time was significantly prolonged, mid-night awakenings decreased, REM sleep percentage increased, and REM latency was shorter. Because the environment for PSG testing is very different from the patient's home and many patients have difficulty sleeping, there are clinical cases in which PSG is performed with sleep medication. In this study, PSG after oral administration of 15 mg of suvorexant on the second night showed no significant difference or clear trend in AHI. However, the upper limit of the 95% confidence interval for the mean difference in AHI was greater than 5, suggesting that suvorexant may exacerbate AHI, even with the first administration.

BACKGROUND: The increasing prevalence of lung cancer in the elderly population necessitates a closer evaluation of diagnostic and therapeutic approaches. This study aimed to compare the safety and diagnostic efficacy of transbronchial lung cryobiopsy (TBLC) between patients ≥ 80 years and younger patients. METHODS: A retrospective review was conducted of 96 patients diagnosed with peripheral lung cancer who underwent TBLC between April 2021 and October 2023. The patients were categorized into two groups: the elderly group (age ≥ 80 years, n = 20) and younger group (age < 80 years; n = 76). Data regarding the biopsy yield, complications, and feasibility of molecular analyses were collected and analyzed. RESULTS: The diagnostic yield of TBLC was comparable between the elderly and younger groups (95% vs. 89.5%, p = 0.679). Biomarker testing, including programmed death-ligand 1 expression and genetic mutations, were feasible in all cases diagnosed with cancer using TBLC samples. No significant differences were observed in major complications such as pneumothorax or bleeding. CONCLUSIONS: TBLC was found to be a safe and effective diagnostic tool for peripheral lung cancer in elderly patients and provided adequate samples for molecular testing. Since the complication rates did not significantly differ between the two age groups, age alone should not be considered a contraindication for the procedure.