We report two cases of severe SARS-CoV-2 infection successfully treated with venovenous extracorporeal membrane oxygenation (VV-ECMO) and continuous hemodiafiltration (CHDF). ECMO was indicated despite immediate anti-viral and anticoagulation therapy with maximal ventilatory support. Meticulous bronchoscopic drainage was necessary during treatment by ECMO due to copious fluid secretion. Renal replacement therapy with continuous hemodiafiltration was also required for both cases due to ongoing renal dysfunction. However, both patients recovered fully without any disability or neurological sequelae. VV-ECMO is a vital tool to maintain appropriate gas exchange for severe SARS-CoV-2 infection to facilitate functional recovery. Because subsequent renal impairment is common in such severe cases, hemodiafiltration undertaken in a timely manner may be necessary. Controlling secondary bacterial infection is also key for lung recovery, as it may otherwise compromise the chance to wean patients off ECMO.

Purpose Recent progress in the treatment of pulmonary arterial hypertension (PAH) such as high-dose epoprostenol and upfront combination therapy brought a marked improvement in prognosis of PAH. However, severely ill cases with PAH still need lung transplantation. Considering the first-come-first-served system and resulting long waiting period Japan, the timing of referral for lung transplantation is critical. Methods Consecutive 31 patients with PAH (including pulmonary veno-occlusive disease) referred to our hospital to be considered eligibility for lung transplantation were enrolled in this study. We retrospectively analyzed patients' characteristics at referral for lung transplantation and their clinical outcomes. Results Seventeen of 31 patients (55%) were female and average age at referral was 30.6±11.8 year-old. Twenty-six patients were idiopathic/heritable PAH, 4 were connective tissue disease associated PAH and 1 was pulmonary veno-occlusive disease. They were referred to our hospital 2127±1691 days after diagnosis. All but one patients were introduced parenteral prostanoid. Mean received dose of parenteral prostanoid was 98±56 ng/kg/min at referral. Although their mean pulmonary artery pressure was severely elevated (51.1±11.6 mmHg), cardiac index and six-minute walk distance were relatively maintained (3.63±0.98 L/min/m2 and 394±174m, respectively). Two patients were not registered as candidates for lung transplantation for medical or social reason. Three patients underwent successful lung transplantation, while eight patients died on the waiting list. Three-year survival after referral was 67% in total. Multivariate analysis revealed that heart rate (HR) and pulmonary vascular resistance (PVR) were independent predictors of all-cause mortality after referral (p=0.016 and p=0.016, respectively). Conclusion High HR and PVR are independent predictors of mortality in patients with PAH receiving parenteral prostanoid and awaiting lung transplantation. Although high-dose parenteral prostanoid improved hemodynamics in patients with PAH, the high output status and relatively maintained exercise capacity might have delayed referral for lung transplantation.

PURPOSE: Severely ill cases with pulmonary arterial hypertension (PAH) still need lung transplantation. Considering the first-come-first-served system and resulting long waiting period in Japan, it is necessary to clarify the timing of referral for lung transplantation. METHODS: Consecutive 31 patients with PAH (including pulmonary veno-occlusive disease) referred to our hospital to be considered eligibility for lung transplantation were enrolled in this study. We retrospectively analyzed patients’ characteristics at referral for lung transplantation and their clinical outcomes. RESULTS: Seventeen of 31 patients (55%) were female and average age at referral was 30.6±11.8 year-old. 26 patients were idiopathic/heritable PAH, 4 patients were connective tissue disease associated PAH and 1 patient was pulmonary veno-occlusive disease. They were referred to our hospital 2144±1701 days after diagnosis. All but one patients were introduced parenteral prostanoid at referral(mean received dose was 92±59 ng/kg/min), and 955±881 days had passed. Although their mean pulmonary artery pressure was severely elevated (51.1±11.6 mmHg), cardiac index (CI) and six-minute-walk-distance were relatively maintained (3.63±0.98 L/min/m2 and 394±174m, respectively). 3 patients underwent successful lung transplantation, while 8 patients died on the waiting list. Three-year survival after referral was 68% in total. Multivariate analysis revealed that heart rate (HR) and pulmonary vascular resistance (PVR) were independent predictors of all-cause mortality after referral (p=0.013 and p=0.049, respectively). CONCLUSIONS: Although high-dose parenteral prostanoid improved hemodynamics in patients with PAH, didn’t lead to a good outcome. It might delayed referral for lung transplantation. CLINICAL IMPLICATIONS: It may be necessary to expedite the timing of referral for lung transplantation.

Purpose In ISHLT 2018, we reported a rat lung transplant model of primary graft dysfunction (PGD) by histone administration. Recombinant thrombomodulin is clinically used antiinflammation and anticoagulation agent and previously reported that it reduces histone-induced endothelial damage and coagulation. We hypothesized that recombinant thrombomodulin administration reduced histone-induced PGD after lung transplantation. Methods Donor rats were randomly assigned to receive calf thymus histone (40 mg/kg) (Histone group), calf thymus histone (40 mg/kg) and recombinant thrombomodulin (3mg/kg) (Histone+rhTM group) or phosphate buffered saline (PBS) (control group). They were administered intravenously to the donor rats, then left lungs were explanted 3 hours after the administration. Immediately after the procurements of the donor lungs, orthotropic lung transplantations were performed. Donor and recipient rats were evaluated for lung functions and tissue damages by means of blood gas analysis, X-ray, real-time RT-PCR, plasma protein analysis and histopathological assessment. Results In the donor assessment, there were no significant differences in the blood gas analysis, chest X-ray nor histology between the groups. Gene expressions of inflammatory cytokines in lung tissue and plasma level of inflammation protein significantly increase in Histone group and Histone+rhTM group (figure A). However, there was marked worsening of gas exchanges in the Histone group after lung transplantation and recovery in Histone+rhTM group (figure B). Histopathologic evaluation revealed lung injury in Histone group and recovery in Histone+rhTM group (figure C). Radiograph taken after autopsy showed reduced radiolucency in Histone group and recovery in Histone+rhTM group (figure D). Conclusion Recombinant thrombomodulin administration reduced PGD like reaction in lung transplantation. It may indicate a possibility of novel treatment for PGD in lung transplantation.

Body composition measures may predict outcomes of cancer surgery. In this study we evaluated the prognostic significance of pectoralis muscle quantity and density in patients with surgical non-small cell lung cancer. Preoperative pectoralis muscle quantity and density were retrospectively assessed in 181 patients undergoing lobectomy and lymph node dissection for non-small cell lung cancer from 2009 to 2013. The pectoralis muscle index (cross-sectional area/height2) and density (average Hounsfield unit, HU) at the fourth thoracic vertebra level were measured and calculated on preoperative plain computed tomography. Overall survival was analyzed between the lowest gender-specific quartile of the pectoralis muscle index and density and the other quartiles. Positive correlations between pectoralis muscle index and density and body mass index (BMI) were identified in the cohort (Pearson's r=0.349, p＜0.001; r=0.206, p=0.005, respectively). The gender-specific lowest quartile cut-off values of the pectoralis muscle index and density was 10.14cm2/m2 and 28.97HU for males, 7.86cm2/m2 and 21.23HU for females, respectively. The cumulative five-year overall survival rates were significantly shorter in patients with low pectoralis muscle index (51.7% vs. 76.0%, p=0.009), while for low pectoralis density (66.0% vs. 70.7%, p=0.391). The multivariate analysis including age, smoke index, BMI, c-reactive protein, carcinoembryonic antigen and pathologic stage revealed that the pectoralis muscle index, not the pectoralis density or BMI, was an adverse independent risk factor for overall survival (p=0.002, hazard ratio: 2.815, 95% confidence interval: 1.473–5.377). A low preoperative pectoralis muscle index was associated with a poor postoperative outcome in surgical patients with non-small cell lung cancer. Pectoralis muscle quantity which is more predictive than density and BMI as a convenient measure, may be included in the preoperative assessment when surgical intervention is considered for non-small cell lung cancer.

Anatomical segmentectomies play an important role for the patients with small ground-glass lung cancer and metastatic lung tumors. Virtual assisted lung mapping (VAL-MAP) assists to localize hardly palpable lung tumors and to define the resection lines. VAL-MAPhas been found to be useful in thoracoscopic segmentectomies, particularly complex segmentectomies. VAL-MAP is a novel preoperative bronchoscopic multi-spot dye-marking technique to provide "geometric information" to the lung surface, using three-dimensional virtual images.The multiple spots (tattooing) of VAL-MAP assists not only to localize hardly palpable lung tumors but to define appropriate resection lines in sublobar lung resections including wedge resections and segmentectomies. The purpose of the study is to evaluate the role of VAL-MAP in simple and complex thoracoscopic segmentectomy. VAL-MAP was conducted before surgery as follows: the target bronchi were identified using radiology workstation; 1 ml of indigo carmine was injected through a catheter by bronchoscopy under fluoroscopy; another CT scan was taken to confirm marking locations. Segmentectomies were conducted thoracoscopically and intersegmental planes were made using staplers (Figure). Anatomical segmentectomies using VAL-MAP conducted were retrospectively analyzed (2014-2017). Simple segmentectomy was defined as a resection of anatomical single segment or combined segments. Other anatomical segmentectomies were defined as complex segmentectomy (Table). Successful resection rates, surgical margins, and post-operative course were compared between simple segmentectomy and complex segmentectomy. Atotal of 43 patients were included in the study (42% women; median age 68 yr (48-83 yrs.). The median tumor size was 12 mm. The average number of markings via VAL-MAP was 4.2 (1-8) points. Post-VAL-MAP complications identified in CT included 5 pneumothorax, 3 airway bleeding, and 2 mediastinal emphysema, although none needed additional treatment.Simple segmentectomy was conducted in 18 patients, while complex segmentectomy was conducted in 25 patients. There was no significant difference in operation time (simple vs. complex; 233±100 vs. 266±8 min), length of chest tube drainage (2.3±0.33 vs. 2.5±0.25 days), or margin/tumor diameter ratio (2.10±0.28 vs. 1.89±0.23). Minor postoperative complicationswere found in 4 patients (2 collapse lung after removed chest tube; 2 pneumonia and inflammatory reaction). No pleurodesis was needed postoperatively.Final pathology included 24 lung cancer, 15 metastatic tumors, and 3 others. VAL-MAP-assisted stapler-based thoracoscopic segmentectomies were safely and effectively conducted even in complex ones. The bronchoscopic approach of VAL-MAP made the anatomical liberty available to surgeons. The "map" drawn with VAL-MAP not only helps to identify the tumor, but also helps to determine oncologically appropriate resection lines.

Development of chronic lung allograft dysfunction involves various alloimmune-independent insults including those mediated by toll-like receptor (TLR) signaling. We hypothesized that TLR signaling promotes allograft airway fibrosis.

It has been known that intranuclear histones are released into systemic circulation in various medical conditions caused by massive tissue damage, such as stroke or trauma. We hypothesized that a histone-associated lung injury caused in the process of brain deaths of donors is one of risk factors of primary graft dysfunction (PGD) after lung transplantation.

Development of chronic lung allograft dysfunction involves various alloimmune-independent insults including those mediated by Toll-like receptor (TLR) signaling, which is known to activate alloimmune responses. We hypothesized that TLR signaling may also contribute to the activation of fibroblasts and promoting allograft airway fibrosis. Mouse orthotopic tracheal transplants were conducted between major histocompatibility complex (MHC)-mismatched Balb/c donor and wild-type C3H or C3H-derived TLR4 mutant recipients (nonfunctional TLR4). Immunohistochemistry on day 21 showed significantly smaller alpha-smooth muscle actin (α-SMA)-positive areas in TLR4 mutant recipients than wild-type recipients (P = .01). No difference was found for CD3+ T-cell infiltration. Proliferation of alloreactive T cells derived from the recipient spleen showed no difference between TLR4 mutant and wild-type recipients in a mixed lymphocyte reaction. The effect of TLR4 signaling was examined in primary pulmonary fibroblast cultures both with lipopolysaccharide (LPS) and transforming growth factor (TGF)-β1. Stimulation with LPS significantly increased expression of α-SMA mRNA in wild-type fibroblasts cultured with TGF-β1 compared with the control without LPS (P = .001). Taken together, these findings suggest disruption of TLR signaling leads to reduced activation of fibroblasts without affecting T-cell infiltration and proliferation in this model. TLR4-mediated activation of fibroblasts may be a potentially important mechanism of allograft remodeling.

Recent studies have reported that sublobar resection is not inferior to lobectomy for small-sized non-invasive adenocarcinoma (ADC); however, the adequacy for small-sized invasive ADC (IAD) remains unclear. The objective of this study was to identify prognostic factors and validate sublobar resection for small-sized IAD. We retrospectively reviewed patients with therapy-naïve, pathological stage I (≤2-cm) IAD, who had undergone complete resection from 1998-2015. Each tumor was evaluated by comprehensive histologic subtyping according to the 2015 World Health Organization classification. Overall survival (OS) and recurrence-free survival (RFS) was estimated using the Kaplan-Meier method. 179 patients met inclusion criteria. 104 (58%) were male and 75 (42%) were female, with a median age of 68 years; sublobar resection was performed in 35 (20%), and lobectomy or pneumonectomy in 144 (80%). Median pathological tumor size was 1.5 cm, with a median invasive component size of 0.9 cm, and pleural, lymphatic, or vascular invasion in 27 (15%), 25 (14%), and 49 (23%) patients, respectively. In IAD, the elderly patients and ever smokers were likely to undergo sublobar resection (p=0.015, 0.011, respectively). Patients undergoing sublobar resection for IAD had significantly worse prognosis (5-year OS: 59.9%, 90.2%, p<0.0001) and increased risk of local recurrence (5-year RFS: 60.0%, 87.6%, p<0.0001). Multivariable analysis revealed that sublobar resection, age, and sex was an independent risk factor of overall survival and sublobar resection and vascular invasion was an independent risk factor of recurrence for IAD ≤2-cm. Sublobar resection in patients with IAD ≤2-cm was significantly associated with increased risk of recurrence and worse prognosis.

PD-L1 expression on tumor cells, tumor infiltrating lymphocytes (TILs), and tumor mutational burden (TMB) have been reported as predictive biomarkers for checkpoint inhibitor immunotherapies. However, little is known about the relationship between each biomarkers. The aim of this study was to assess the relationship between these biomarkers, especially TIL and TMB. RNA-seq data of 533 primary lung adenocarcinoma were downloaded from The Cancer Genome Atlas (TCGA). Gene expression and gene set enrichment were analyzed. Clinical information and somatic missense mutation data were also integrated. Weak correlation between PD-L1 and CD8A expression (Spearman’s R=0.32, P<0.001), and PD-L1 expression and TMB (R=0.10, P=0.019) were seen, but not between CD8A expression and TMB (R=0.03, P=0.45). Next, we performed gene signature analysis related to cancer-immunity cycle (ref. Karasaki et al. J Thorac Oncol 2017). Hierarchical clustering resulted in 3 clusters: T cell non-inflamed phenotype with high antigenicity (Cluster 1), inflamed phenotype with low antigenicity (Cluster 2), and inflamed phenotype with high antigenicity (Cluster 3).(Fig.1) Compared with Cluster 3, Cluster 2 was featured by lower gene expression signature of cytolytic activity (P<0.0001, U-test), as well as lower expression of PD-L1 (P<0.0001, U-test). To further investigate the relationship between TMB and TILs, T-cell inflamed phenotype tumors were divided into four groups according to the quartiles of TMB. We estimated immune cell phenotypes of TMB-high (upper quartile) and TMB-low (lower quartile) groups using ssGSEA and CIBERSORT. Either analysis showed significant enrichment of activated CD4 T cells in TMB-high group (P<0.0001, T-test). Existence of Cluster 1 and 2 suggested that tumor antigenicity (TMB) does not necessarily correlate with TIL enrichment. TMB-low tumors may form T cell-inflamed tumors (Cluster 2), although the immune status may differ from TMB-high inflamed tumors (Cluster 3). Integrating multiple biomarkers for the assessment of tumor immune microenvironment is important for optimal immunotherapy.

The prognostic significance of pathological necrosis in small lung adenocarcinoma has not been investigated. The purpose of this study is to investigate the prognostic role of pathological necrosis in patients with completely resected small lung adenocarcinoma ≤2cm. All available tumor slides from patients with surgically resected lung adenocarcinoma ≤2cm in size (1998-2015) were retrospectively reviewed. Exclusion criteria: patients who received induction therapy and lung cancer surgery within preceding 2 years. Recurrence free probability and overall survival were assessed using the Kaplan-Meier method. 351 patients met inclusion criteria (48% women, median age 67yr (34-86 yrs), 50% never-smokers; 324 Stage IA, 27 Stage IB; 111 and 240 patients underwent sublobar resection and lobectomy, respectively). Presence of pathological necrosis was identified in 32 patients (9%). Presence of pathological necrosis was significantly associated with sex, smoking, clinical T classification in the 8th edition and pathological tumor size (p<0.01, p<0.001, p<0.01, p<0.001, respectively). Presence of pathological necrosis correlated with an increased risk of recurrence, compared with those without pathological necrosis (5-year RFP, 70.5%vs 93.8%; p<0.001). Presence of pathological necrosis did not affect OS (5-year OS, 80.8%vs 92.3%; p=0.21). In patients with small lung adenocarcinoma ≤2cm, presence of pathological necrosis was significantly associated with increased risk of recurrence.

For successful cancer immunotherapy, comprehensive profiling of cancer-immune system interaction is required for each individual patient. To this end, we developed an immunogram reflecting the cancer immunity cycle and applied it to real patients with lung cancer. Whole-exome sequencing and RNA-Seq were performed in 25 non-small cell lung cancer patients (13 adenocarcinoma, 11 squamous cell carcinoma, and 1 large cell neuroendocrine carcinoma). The number of somatic mutations and the expression of genes related to cancer-immunity were assessed and normalized using TCGA-LUAD and LUSC data (n=1035). Immunogram of each patient was drawn in a radar chart composed of 9 axes reflecting 7 steps of cancer-immunity cycle. Various patterns of immunogram were observed in all 25 lung cancer patients, suggesting that each patient has their own pattern of immunosuppressive microenvironment (Fig1). The hierarchical clustering using each scores of immunogram showed four clusters of patients characterized by T cell phenotype (inflamed vs non-inflamed) and tumor antigenicity (high vs low) (Fig2). T cell-inflamed tumors (Clusters 3&4) had gene signatures of abundant T cells and interferon gamma (IFNG) response, as well as inhibitory cells and checkpoint molecules, suggesting the presence of counter regulatory immunosuppressive microenvironment. Unleashing of counter regulations by checkpoint inhibitors, for example, may be indicated for these patients. Each scores of immunogram had no correlation with histology. This result was consistent with previous studies of checkpoint blockade that clinical responses were not easily predicted solely by the histology. Patient age, gender and TNM stage also did not correlate with each immunogram scores. The landscape of the tumor microenvironment in each patient can be appreciated by utilizing immunogram. Immunogram for the cancer-immunity cycle can be used for the assessment and visualization of cancer immunity status in each patient, and thus may become a helpful resource toward optimal personalized immunotherapy.

Recent studies have reported that sublobar resection is not inferior to lobectomy for small-sized non-invasive adenocarcinoma; however, the adequacy for small-sized invasive adenocarcinoma (IAD) remains unclear. We have reported that, in patients with pathological stage I IAD, the presence of ≥5% solid (SOL) histologic subtype is a significant predictor of recurrence, especially for the patients undergoing sublobar resection (Figure A). The objective of this study was to identify the clinical factors associated with the presence of SOL in patients with IAD. We retrospectively reviewed patients with therapy-naïve, pathological stage I (≤2-cm) lung adenocarcinoma, who had undergone complete resection from 1998-2015. Each tumor was evaluated by comprehensive histologic subtyping according to the 2015 WHO classification and re-evaluated preoperative thin-sliced computed tomography to determine solid size and reclassified them according to the new TNM classification. We defined carcinoembryonic antigen (CEA) cut-off value as 2.2 ng/mL. Recurrence-free probability was estimated using the Kaplan-Meier method. AD patients with available image was 160 cases (94 male and 66 female, 96 smokers, and median age: 69 years). Clinical T classification in the 7th edition was T1a:142, T1b:17, T2a:1, and in the 8th edition Tis:17, T1mi:3, T1a:37, T1b:100, T1c:3. The presence of ≥5% solid component (SOL) was identified in 70 patients (44%). In patients with IAD, the presence of ≥5% SOL was associated with increased risk of recurrence compared to those with SOL <5% (P=0.001, Figure B). The presence of ≥5% SOL was significantly associated with sex, smoking, clinical T classification in the 8th edition, and high CEA level (P = 0.001, P <0.001, P <0.001, P = 0.013, respectively). In patients with pathological stage I IAD, clinical T classification in the 8th edition, and high CEA level significantly correlated with the presence of ≥5% SOL, which was associated with recurrence after surgery.

Background:Chronic lung allograft dysfunction(CLAD)after lung transplantation is classified into at least パネルディスカッション1 肺移植 PD1