Background: Systemic autoimmune rheumatic diseases-associated interstitial lung disease (SARD-ILD) presents with varied disease courses, emphasizing the need for reliable predictors of progression. The prognostic utility of bronchoalveolar lavage (BAL) in SARD-ILD remains underexplored. The objective of this study was to evaluate the role of BAL fluid lymphocyte count in predicting disease progression in patients with SARD-ILD. Methods: This observational study included patients with SARD-ILD undergoing BAL as part of their diagnostic workup. Disease progression was defined as either Forced vital capacity (FVC) decrease >10%, two out of the following three criteria within two years: FVC decrease of 5-10%, worsening symptoms, increased fibrosis on imaging, or any of the following: escalation of treatment, Interstitial lung disease (ILD) exacerbation, lung transplantation, or disease-specific mortality. Logistic regression identified predictors of progression. Time-to-progression was assessed using Kaplan-Meier survival curves. The optimal BAL lymphocyte threshold for predicting progression was identified using the Youden Index and the Wilcoxon method. Results: We identified 89 patients, of whom 30 (33.7%) had progressive disease. Progressors had a significantly higher BAL lymphocyte count compared to non-progressors (31.6 ± 24.8% vs. 14.3 ± 16.5%, p < 0.001). BAL lymphocyte proportion was significantly and independently associated with disease progression (odds ratio, 1.05; 95% confidence interval 1.02-1.07; p < 0.01). A lymphocyte count above 9 percent was associated with a markedly increased risk of disease progression (odds ratio, 13.14; 95% confidence interval, 4.20-51.98; p < 0.01). Conclusions: BAL lymphocyte count was associated with a higher likelihood of progression in SARD-ILD. BAL assessment may help identify patients at increased risk of disease progression. However, these findings should be considered exploratory and require validation in larger prospective studies and across individual SARD-ILD subtypes.

Background: Proton pump inhibitors (PPIs) have been associated with lung dysbiosis and increased respiratory risk. Micro-aspiration is a proposed mechanism, but reliable biomarkers remain elusive. This study evaluates the potential of fluorescein as a biomarker of micro-aspiration and PPI-associated pulmonary risk. Methods: We conducted a retrospective analysis of 137 bronchial washing fluid samples from patients with pulmonary conditions to assess microbial colonization in relation to PPI use. Bacterial burden was determined by culture and PCR and categorized as 0, 1 or ≥2 pathogens. Micro-aspiration was evaluated by quantifying fluorescein-laden macrophages in bronchoalveolar lavage following oral fluorescein administration. Associations between PPI use, fluorescein levels and pathogen burden were analyzed using adjusted ordinal regression models. Results: PPI use was associated with higher odds of increased pathogen burden, though not statistically significant (OR = 1.40, 95% CI: 0.71–2.75, p = 0.33). Fluorescein-laden macrophages were higher in PPI users (41.5 versus 31.2 ng/mL), but showed no meaningful correlation with pathogen load (p = 0.09). Corticosteroid therapy was significantly associated with Gram stain results (OR = 2.37, 95% CI: 1.12–5.15, p = 0.03). Conclusions: These findings suggest a potential link between PPI use and airway colonization. Fluorescein shows promise as a biomarker for micro-aspiration, but its clinical utility requires further validation.

The enrichment of immunosuppressive M2 macrophages, combined with diminished CD8+ T cell infiltration, represents a key mechanism driving tumor progression and limiting immunotherapy efficacy in non-small cell lung cancer (NSCLC). Here, we provide evidence that the purinergic P2Y2 receptor (P2RY2) is a key regulator of M2 macrophage enrichment and contributes to the exclusion of CD8+ T cells from the tumor microenvironment (TME). P2RY2 expression is significantly elevated in human NSCLC compared to non-malignant tissues and M2-like macrophages expressing P2RY2 are more prevalent in tumors with an advanced TNM (Tumor, Node, Metastasis) stage. Elevated P2RY2 mRNA levels are significantly associated with poorer overall survival in a NSCLC patients. Furthermore, we selectively inhibited P2RY2 in syngeneic or autochthonous mouse models of NSCLC driven by Kras or Egfr mutations. This resulted in a significant reduction of M2-like macrophages, enhanced CD8+ T cell migration and tumor infiltration and a marked decrease in tumor burden. Similar results were evident following the genetic deletion of P2ry2, validating the impact on the TME. Importantly, macrophages are the predominant P2RY2-expressing cells within the TME. Moreover, tumor-educated macrophages (TEMs) isolated from P2ry2-/- tumor-bearing mice exhibited reduced proliferation compared with wild-type macrophages when co-cultured with LLC1 cells, revealing a potential mechanism underlying P2RY2-mediated pro-tumorigenic activity. Our study underscores the clinical significance of P2RY2 in NSCLC and provides evidence of its pivotal role in the regulation of M2 macrophage enrichment and the exclusion of CD8+ T cells from the TME. Targeting P2RY2 may offer a novel immunotherapeutic intervention for NSCLC.

Die endoskopische Lungenvolumenreduktion stellt eine minimalinvasive Therapieoption bei Patient*innen mit fortgeschrittenem Emphysem dar, die trotz einer maximalen konservativen Therapie symptomatisch sind. Die endoskopische Ventiltherapie, deren Effektivität bei Emphysempatient*innen mit fehlender interlobärer Kollateralventilation in zahlreichen randomisiert kontrollierten Studien belegt werden konnte, ist mittlerweile im klinischen Alltag etabliert. Bei Patient*innen mit relevanter Kollateralventilation stehen ebenfalls endoskopische Therapien zur Verfügung, die jedoch aufgrund geringer Datenlage im Rahmen von Studien nach individueller Benefit-Risiko-Abwägung erfolgen sollten. Essenziell für den Erfolg jeder dieser Therapiemethoden sind die präzise Patientenselektion und die interdisziplinäre Indikationsstellung in einem Emphysemboard.

BACKGROUND:In lung cancer, adequate treatment selection relies on accurate diagnosis and staging. Tissue sampling is generally indicated. This guideline explores the role of endosonography via the major airways (endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)) and oesophagus (endoscopic transoesophageal ultrasound-guided fine-needle aspiration (EUS-FNA)). EUS-FNA can also be performed using an EBUS scope (EUS-B-FNA). METHODS:Task force members were selected from the European Respiratory Society, European Society of Gastrointestinal Endoscopy and European Society of Thoracic Surgeons. Members formulated 12 guideline questions. Systematic literature searches were performed in MEDLINE and Embase (final searches: April 2025). Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was applied for assessing the certainty of evidence and developing recommendations. RESULTS:In (suspected) non-small cell lung cancer, endosonography is recommended over mediastinoscopy for mediastinal nodal tissue staging. Systematic staging is suggested over targeted staging as the minimal standard. Ideally, combined EBUS-TBNA+EUS(-B)-FNA is performed instead of EBUS-TBNA alone. Add-on mediastinoscopy after a negative endosonography is not recommended. Endosonography is suggested over mediastinoscopy for restaging after induction therapy. EBUS-TBNA and EUS(-B)-FNA are recommended for centrally located tumours adjacent to the major airways/oesophagus. Both EUS-B-FNA and EUS-FNA are suggested for left adrenal gland analysis. It is suggested that competence is acquired in a simulation-based environment and ensured using valid assessment methods. 21G/22G TBNA needles are considered the standard; there is insufficient evidence to support the structural use of alternative needle sizes/types or cryobiopsy. EBUS-TBNA has a high suitability rate for programmed death-ligand 1 assessment. CONCLUSIONS:Endobronchial and oesophageal endosonography provide accurate and minimally invasive tests for the diagnosis and staging of lung cancer.

Endoscopic lung volume reduction represents a minimally invasive treatment option for patients with advanced emphysema who remain symptomatic despite receiving the maximum conservative treatment. Endoscopic valve treatment, the effectiveness of which has been demonstrated in numerous randomized controlled trials in emphysema patients without interlobar collateral ventilation, is now well-established in clinical practice. For patients with interlobar collateral ventilation, various treatment approaches are available; however, due to limited data from clinical trials, these should be performed following an individual benefit-risk assessment within clinical trials. Overall, successful implementation of each of these treatment methods requires precise patient selection and interdisciplinary decisions through a dedicated emphysema board.

Background/Objectives: In recent years, neoadjuvant chemoimmunotherapy followed by surgery has improved outcomes in patients with stage II/III non-small cell lung cancer (NSCLC). However, the prognostic impact of residual mediastinal nodal disease after chemoimmunotherapy remains insufficiently defined, particularly with the introduction of the Union for International Cancer Control/American Joint Committee on Cancer (UICC/AJCC) 9th edition nodal subclassification. Methods: In this retrospective study, 90 consecutive patients with clinically node-positive (cN1-2) resectable locally advanced NSCLC who underwent neoadjuvant chemoimmunotherapy followed by curative-intent resection were included. Disease-free survival (DFS) was analyzed according to postoperative pathologic nodal status. Nodal status was assessed using the UICC/AJCC 8th edition (ypN0, ypN1, ypN2) and reclassified according to the 9th edition (ypN0, ypN1, ypN2a, ypN2b). Residual postoperative nodal disease was defined as residual pathologic nodal involvement (ypN+) in patients with clinically node-positive (cN+) disease at baseline. Results: The cohort comprised 90 patients (60% male, median age 63 years [interquartile range (IQR) 58–69]). Following neoadjuvant therapy, surgery revealed pathologic nodal clearance in 53 (58.9%) and residual nodal disease in 37 (41.1%) patients (ypN1, n = 16 [17.8%]; ypN2a, n = 15 [16.7%]; and ypN2b, n = 6 [6.7%]). DFS differed significantly by postoperative nodal status (global log-rank p < 0.001), with progressively poorer outcomes with increasing residual nodal burden. Conclusions: Residual nodal disease after neoadjuvant chemoimmunotherapy and surgery is associated with progressively inferior DFS according to its anatomic extent. The UICC/AJCC 9th-edition staging system provides clinically relevant prognostic granularity, supporting further investigation of mediastinal restaging and postoperative treatment strategies.

Abstract:Attracting and retaining the next generation of physicians for a medical specialty is discussed in many fields of medicine as one of the key issues for the future. This question is particularly relevant for pulmonology, given the growing importance of respiratory diseases, which are often given only secondary importance in university curricula. For this reason, the event "PneumoNEXT - Continuing Education, Exchange, Future" was conceived as a one-week continuing education program for medical students starting in their 10th semester and physicians in training. The program combines case-based learning with practical workshops on key topics in pulmonology, as well as opportunities for networking and exchange with experienced pulmonologists.The pilot project included 16 participants (mean age 33 ± 5.9 years, 50% women). In the accompanying evaluation via an online survey, all participants reported a positive change in their confidence in practical decision-making. Additionally, 93% stated that their professional focus had shifted more toward pulmonology and that they would like to begin or continue pulmonology training. There is still potential for improvement, including the integration of patient-centered workshop formats. PneumoNEXT can therefore be understood as a practice-oriented, structured continuing education and networking format that creates suitable conditions to promote interest in pulmonology, introduce young professionals to the field at an early stage, and support the decision to pursue further training in pulmonology.

This article summarises the highlights in the field of interventional pneumology from the congresses of the German Society of Pneumology (DGP) in March 2025 and the Austrian Society of Pneumology (ÖGP) in October 2025. Numerous prospective and retrospective studies were presented in inspiring and varied congress programmes, providing valuable insights into the field of interventional pneumology and discussing new perspectives. Key topics included innovations in the diagnostic and therapeutic bronchoscopy for peripheral pulmonary nodules as well as new developments in the field of endoscopic lung volume reduction.

Lung cancer remains one of the most prognostically unfavourable malignancies and is the leading cause of cancer-related mortality worldwide. The most significant risk factor is active smoking, which accounts for over 85% of lung cancer deaths. Approximately 8 million people die annually from tobacco-related causes - the primary driver of lung cancer - exceeding the combined mortality from HIV, malaria, and tuberculosis. Although substantial advances have been made in recent years regarding treatment options for lung cancer, rapid diagnosis remains of paramount importance. The often late diagnosis, due to absent early symptoms and nonspecific clinical presentation, significantly worsens patient outcomes. This underscores the need for heightened diagnostic vigilance, particularly in high-risk populations, along with rapid and systematic diagnostic procedures. The patient's general clinical condition and ability to tolerate therapy form the basis of the initial diagnostic workup. Accurate staging is critical for treatment planning and prognostic assessment. The following overview summarizes the key diagnostic steps for early detection and effective therapy planning in lung cancer.

This article summarises the highlights in the field of interventional pneumology from the congresses of the German Society of Pneumology (DGP) in March 2024 and the Austrian Society of Pneumology (ÖGP) in September 2024. Developments and numerous studies in the field of endoscopy and interventional pneumology were presented in the diverse programmes of these two congresses. New bronchoscopic techniques for the diagnosis of mediastinal lymphadenopathy were discussed, innovative navigation techniques and the use of new imaging techniques for the diagnosis of peripheral pulmonary nodules were presented and knowledge in the field of endoscopic lung volume reduction in emphysema patients was expanded.

Following recovery from COVID-19, there is evidence for pulmonary sequelae and functional impairment. Data regarding the immunopathological mechanisms are limited. This study aimed to investigate the relationship between bronchoalveolar lavage fluid (BALF) cellularity, lung function impairment and high-resolution computed tomography (HRCT) changes in post-COVID syndrome patients. Patients with post-COVID syndrome were enrolled in this Austrian single-center prospective observational cohort study. All patients underwent a pulmonary function test (PFT) and chest HRCT. Those with pathological HRCT findings underwent bronchoscopy with BALF sampling for differential cell count and fluorescence-activated cell sorting analysis. In this study 26 patients with post-COVID syndrome underwent bronchoscopy with BAL. The HRCT showed ground-glass opacifications (69.2

Background/Objectives: Malignant pleural mesothelioma (MPM) remains challenging to treat, with a poor prognosis. As controversy about clinical management continues, predictive biomarkers for patient selection to indicate the benefit of treatment modalities are urgently needed. Methods: In a retrospective analysis of 195 patients between 1994 and 2020 at the Department of Thoracic Surgery, Medical University of Vienna, Austria, the Mesothelioma Systemic Inflammation Score (MSIS)—consisting of pretreatment neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), C-reactive protein (CRP), and fibrinogen—was tested for its prognostic and predictive significance. The prognostic impact of MSIS was subsequently validated in an independent cohort of 80 patients treated at the Department of Thoracic Surgery, Karl Landsteiner Institute for Clinical and Translational Thoracic Surgery Research, Clinic Floridsdorf, Vienna, Austria. Results: Median overall survival (OS) was 14 months for the entire cohort (95% CI: 11.4–16.6). Patients undergoing multimodality treatment including macroscopic complete resection had a longer OS (22.3 months, 95% CI: 18.6–26.0; p < 0.001). In multivariable analysis, MSIS (p < 0.001), disease stage (p = 0.001), and the type of treatment (p = 0.004) were confirmed as independent predictors for OS. Higher MSIS was associated with shorter OS (p < 0.001). Significant survival benefit of multimodality regimens including surgery was limited to patients with low MSIS. Among patients with low (≤ 2) MSIS, multimodality therapy was associated with significantly prolonged OS when compared with chemo- and/or radiotherapy alone (25.8 months [95% CI: 16.4–35.3] vs. 14.4 months [95% CI: 10.4–18.4], p < 0.001). In contrast, among patients with elevated MSIS, no survival benefit was achieved by surgery over conservative treatment (11.8 months [95% CI: 8.3–15.3] vs. 8.2 months [95% CI: 5.2–11.3], p = 0.233). The ability of MSIS to predict survival was equivalent between the baseline and the independent validation cohort (p < 0.001). Conclusions: The Mesothelioma Systemic Inflammation Score was found to be an independent prognostic score in pleural mesothelioma, predicting benefit from macroscopic complete resection as part of multimodality treatment in distinct patients.

Background and Objective: Due to the increasing use of imaging and lung cancer screening programs, the rate of detected pulmonary nodules has steadily increased over the past decade. Overall, the diagnosis and management of pulmonary nodules remain challenging. Moreover, no specific guidelines exist for the management of pulmonary nodules in patients with a history of previous malignancy. This study reflects the current management in a real-world setting in a specialized European center. Methods: In this retrospective single-center study, patients with a pulmonary nodule <3 cm referred to the Division of Pulmonology or the Department of Thoracic Surgery at the Medical University of Vienna, Austria, from November 2022 to July 2024, were analyzed. A subgroup analysis of patients with a history of previous malignancy was performed and compared to patients without previous malignancies. Results: In total, 356 patients (48.5% male, median age 67 years [IQR 61–74], 53.7% with a history of previous cancer) with a pulmonary nodule (mean size of 14.8 mm) were enrolled. Bronchoscopy, computed tomography (CT)-guided biopsy, or surgery was performed in 13.2%, 7.3%, and 65.2% of the cases, respectively. The overall malignancy rate was 70.5%. Pulmonary nodules in patients with a prior malignancy were significantly larger (p < 0.001), showed a progression in size (p < 0.001), and were found to be malignant more frequently when compared to patients without previous cancer (p = 0.032). Conclusions: As most patients referred to a specialized center represent a selected group of high-risk patients, the majority of pulmonary nodules were found to be malignant. In patients with a history of previous malignancy, tissue sampling is warranted as the rate of malignancy is high.

Introduction:Sex-based differences in histological subtypes, in frequencies of mutations, and differences in response to the various therapeutic approaches in lung cancer are well studied. In general, the literature is controversial, and the large majority of the investigations may not provide evidence from the last decade. Objective:The objective of the current study was to reveal timely sex-based differences in patients with lung cancer in the era of immunotherapy and molecularly targeted agents. Methods:We retrospectively analyzed a consecutive cohort of 286 patients (female:male ratio 134:152/47 %:53 %) who were diagnosed with lung cancer between 2020 and 2022 in the pulmonology department of the Medical University of Vienna, Austria. Demographic characteristics, histological subtypes, the PD-L1 expression on tumor cells, presence of mutations, treatment, and survival of male and female patients were compared. Results:The smoking rate in women with lung cancer was significantly lower than in men (p = 0.005). The rate of targetable mutations was significantly higher in female patients (52 % vs. 30 %, p = 0.011). There were no significant differences in age at diagnosis, body mass index, lung function parameters, histological subtypes, PD-L1 protein expression, disease stage, and survival between men and women (all p > 0.05). Conclusion:Female Caucasian patients seem to have a higher susceptibility to lung cancer. Although the rate of genetic alterations is similar in both sexes, actionable driver mutations are significantly more common in women.

BACKGROUND:The diagnosis of interstitial lung disease (ILD) can pose a challenge as the pulmonary function test (PFT) is only minimally affected at the onset. To improve early diagnosis, this study aims to explore the potential of artificial intelligence (AI) software in assisting pulmonologists with PFT interpretation for ILD diagnosis. The software provides an automated description of PFT and disease probabilities computed from an AI model. STUDY METHODS:In study phase 1, a cohort of 60 patients, 30 of whom had ILD, were retrospectively diagnosed by 25 pulmonologists (8 junior physicians and 17 experienced pneumologists) by evaluating a PFT (body plethysmography and diffusion capacity) and a short medical history. The experts screened the cohort twice, without and with the aid of AI (ArtiQ.PFT, V.1.4.0, ArtiQ, BE) software and provided a primary diagnosis and up to three differential diagnoses for each case. In study phase 2, 19 pulmonologists repeated the protocol after using ArtiQ.PFT for 4-6 months. RESULTS:Overall, AI increased the diagnostic accuracy for various lung diseases from 41.8% to 62.3% in study phase 1. Focusing on ILD, AI improved the detection of lung fibrosis as the primary diagnosis from 42.8% without AI to 72.1% with AI (p<0.0001). Phase 2 yielded a similar outcome: using AI increased ILD diagnosis based on primary diagnosis (53.2% to 75.1%; p<0.0001). ILD detections without AI support significantly increased between phase 1 and phase 2 (p=0.028) but not with AI (p=0.24). INTERPRETATION:This study shows that AI-based decision support on PFT interpretation improves accurate and early ILD diagnosis.