An 81-year-old man with lower extremity arteriosclerosis obliterans presented with massive hemoptysis. Computed tomography revealed an enlarged ectopic right bronchial artery originating from the concavity of aortic arch, prompting the decision to perform bronchial artery embolization (BAE). Due to occlusion of bilateral femoral and left subclavian arteries, transfemoral or left transbrachial access was not feasible; therefore, right transbrachial access was chosen. BAE was successfully completed, and antiplatelet and anticoagulant therapy was subsequently initiated. No recurrence of bleeding was observed at the time of this report, with a follow-up of at least 20 months. This is the first reported case of transbrachial BAE targeting an ectopic bronchial artery arising from the concavity of the aortic arch, achieved by modifying coronary catheterization techniques with the use of the Ishikawa catheter.

Background:When performing bronchial artery embolization (BAE), identifying the side of bleeding and thereby deciding the side of embolization is crucial for an effective and safe procedure. However, there is little evidence regarding the utility of bronchoscopy for determining the side of embolization prior to BAE in nonintubated patients with hemoptysis admitted to general wards. Research Question:Is bronchoscopy necessary prior to BAE in nonintubated patients with hemoptysis following bronchiectasis and chronic pulmonary infection? Study Design and Methods:Data from 93 consecutive nonintubated general ward patients with bronchiectasis and chronic pulmonary infection (nontuberculous mycobacteriosis, aspergillosis, and TB) who underwent de novo BAE from September 2017 to August 2023 were retrospectively reviewed. The contribution of bronchoscopy in deciding the side of embolization was evaluated. Results:All patients underwent CT imaging and 27 also underwent bronchoscopy. Bronchoscopy identified the sides of bleeding in 9 patients, but these sides could be correctly estimated in 8 of them from the CT information alone. Bronchoscopy did not reveal the side of bleeding in 18 patients, whose sides of embolization were decided using CT imaging and angiographic information. Of 66 patients without bronchoscopy, the sides of embolization were decided in 63 patients using CT imaging and angiographic information, but the priority of the embolization side could not be decided in the remaining 3 patients. Overall, 96% (89 of 93) of patients did not require bronchoscopy as part of their embolization plan. The 90-day overall survival and hemoptysis-free survival rates were 98.9% (95% CI, 92.5-99.8) and 92.3% (95% CI, 84.6-96.3), respectively. Interpretation:This study showed that bronchoscopy contributed little to the planning of BAE in nonintubated patients with hemoptysis following bronchiectasis and chronic pulmonary infection. Our findings do not support the routine use of bronchoscopy prior to BAE in this population.

Hemoptysis is a symptom with a high mortality rate. The in-hospital mortality rate of hospitalized patients with hemoptysis is 5%-9%. Bronchial artery embolization was formerly positioned as an emergency treatment for massive hemoptysis. Nowadays, it has become a standard treatment for elective treatment for chronic recurrent hemoptysis. Despite the high mortality rate, only 2%-8% of hospitalized patients with hemoptysis underwent Bronchial Artery Embolization (BAE). One possible reason is the concern about spinal cord infarction, followed by the shortage of operators specializing in BAE.

Purpose: To investigate the prevalence, clinical characteristics, and long-term prognosis of bronchial artery aneurysm (BAA) following bronchial artery embolization (BAE). Materials and Methods: The medical records of consecutive patients who underwent bronchial artery angiography between August 2013 and December 2019 were retrospectively reviewed. Patients who were diagnosed with BAA during this period were included in this study. The prevalence, patients' characteristics, symptoms, comorbidities, angiographic findings, and long-term prognosis following BAE were investigated. Results: BAA was observed in 20 of 508 patients who underwent bronchial artery angiography (3.9%). The patients' median age was 69 (interquartile range [IQR], 63.5-76.7) years. The main causes of BAA were cryptogenic, bronchiectasis or cystic fibrosis, and pulmonary aspergillosis. The median diameter of ruptured BAAs was significantly smaller than that of unruptured BAAs (5.4 mm [IQR, 4.8-7.3 mm] vs 9.0 mm [IQR, 7.2-13.9 mm], P = .009). All the patients were successfully treated with BAE, without major adverse events. The median follow-up period after BAE was 970 (IQR, 561-1,796) days. The BAA-related survival rate was 100% at 2 and 3 years after BAE, and the overall survival rate after BAE was 89.2% (95% confidence interval [CI] 89.0-89.3) at 2 years and 74.3% (95% CI 74.0-74.5) at 3 years. BAA-related adverse events and mortality did not occur during the follow-up period. Conclusions: BAA was observed in 3.9 % (20/508) of the patients who underwent bronchial artery angiography. All the patients with BAA were successfully treated with BAE. BAA rupture and consequent mortality did not occur during the follow-up period.

OBJECTIVES:To identify the prevalence of non-bronchial systemic culprit arteries and their relationship to bleeding lobes in patients with hemoptysis with bronchiectasis and chronic pulmonary infection who underwent de novo bronchial artery embolization (BAE).METHODS:Data of 83 consecutive patients with bronchiectasis and chronic pulmonary infection (non-tuberculous mycobacteriosis, aspergillosis, and tuberculosis) who underwent de novo BAE between January 2019 and December 2020 were retrospectively reviewed. The prevalence of culprit arteries was investigated.RESULTS:Fifty-five patients (66%) had 172 non-bronchial systemic culprit arteries. The bleeding lobes were the right upper, right middle, right lower, left upper, and left lower lobes in 14 (17%), 20 (24%), 7 (8%), 31 (37%), and 11 (13%) patients, respectively. The internal thoracic (49%; n = 41), intercostal (28%; n = 23), and inferior phrenic (28%; n = 23) arteries were the top three non-bronchial systemic culprit arteries, which were involved in all five types of bleeding lobes. The costocervical trunk and thoracoacromial and lateral thoracic arteries were predominant in patients with upper lobe bleeding. Ligament arteries were predominant in patients with left lower lobe bleeding.CONCLUSIONS:These findings will better ensure the identification of non-bronchial systemic culprit arteries in patients with hemoptysis with bronchiectasis and chronic pulmonary infection. All systemic arteries, especially those which are adjacent to the lung lesions, should be evaluated carefully using MDCT; the internal thoracic, intercostal, and inferior phrenic arteries should be proactively assessed using angiography.KEY POINTS:• Non-bronchial systemic culprit arteries were identified in 66% of patients with hemoptysis with bronchiectasis and chronic pulmonary infection who underwent de novo bronchial artery embolization. • The internal thoracic (49%), intercostal (28%), and inferior phrenic (28%) arteries were the top three arteries, which were involved in all five types of bleeding lobes. • The costocervical trunk and thoracoacromial and lateral thoracic arteries were prominent in patients with upper lobe bleeding, and the ligament artery was prominent in patients with left lower lobe bleeding.

A 58-year-old woman with bronchiectasis presented with massive hemoptysis and severe respiratory failure, which required long-term extracorporeal membrane oxygenation with continuous heparin infusion. Bronchial artery embolization using hydrogel coils, which provide a greater volume occlusion than bare platinum coils, was performed; hemoptysis stopped and she fully recovered. No recanalization was observed on follow-up computed tomography angiography 2 months postbronchial artery embolization, and there had been no recurrence of bleeding at the time of this report (at least 6 months). Although continuous anticoagulation during extracorporeal membrane oxygenation might hinder complete vessel occlusion by metallic coils or induce early recanalization (because the homeostatic mechanism of coils depends on the patient's coagulability), our experience showed that bronchial artery embolization using hydrogel coils was effective and safe. Additionally, this case presents a successful example of anticoagulation management for patients with hemoptysis on extracorporeal membrane oxygenation who undergo bronchial artery embolization using coils.

Objectives Patients with haemoptysis often experience daily physical and mental impairment. Bronchial artery embolisation is among the first-line treatment options used worldwide; however, no evidence exists regarding the health-related quality of life (HRQoL) after bronchial artery embolisation. Therefore, this study aimed to evaluate the effects of bronchial artery embolisation on the HRQoL of patients with haemoptysis. Methods We prospectively enrolled 61 consecutive patients who visited our hospital from July 2017 to August 2018 and received bronchial artery embolisation for haemoptysis. The primary outcome was the HRQoL evaluated using the Short Form Health Survey, which contains physical and mental components, before and after bronchial artery embolisation. The secondary outcomes were procedural success, complications, and recurrence-free survival rate at 6 months. Results The mean age of the patients was 69 years (range, 31–87 years). The procedural success rate was 98%. No major complications occurred. The recurrence-free survival rate estimated using the Kaplan-Meier analysis at 6 months after bronchial artery embolisation was 91.8% (95% confidence interval, 91.1–92.5%). Compared with the pre-treatment scores, the physical and mental scores were significantly improved at 6 months after bronchial artery embolisation ( p < 0.05). Conclusion Bronchial artery embolisation improved the HRQoL of patients with haemoptysis. Key Points • Bronchial artery embolisation improved the HRQoL of patients with haemoptysis . • Vessel dilation on computed tomography and systemic artery-pulmonary artery direct shunting on angiography were the most common abnormalities . • The recurrence-free survival rate estimated using the Kaplan-Meier analysis at 6 months after bronchial artery embolisation was 91.8% .

Introduction: Three-dimensional (3D) printing is increasingly being used for medical applications.We described a case of 3D-airway model prototype reconstructed from a patient with complex post tuberculous tracheobronchial stenosis.Methods: Thin slice (1mm) CT thorax images in DICOM format (Digital Imaging and Communications in Medicine) were imported into a 3D image computing platform (3D Slicer, https://www.slicer.org)for airway modelling and reconstruction.The airway model was then exported to STL file (Standard Tessellation Language) into a 3D printer (Tiertime UP Mini, Milpitas, USA) and subsequently printed with 1.75mm high impact polystyrene fiber.Result: 32 years old lady with pulmonary tuberculosis presented with progressive exertional dyspnea and new onset stridor during maintenance phase of her anti-tuberculous therapy.CT scan noted complex multilevel airway stenosis in the trachea and right main bronchus.The airway model was reconstructed and 3D printed for better understanding of the anatomy prior intervention.Patient then underwent rigid bronchoscopy and balloon tracheoplasty successfully.Bronchoscopic examination correlate well with the 3D reconstructed airway model prototype.Topical mitomycin C was applied over stenotic region post dilatation.She remains symptoms free at three-months surveillance.Conclusion: 3D printed airway model offers a better understanding of post tuberculous tracheobronchial stenosis which is often complex in nature.This technique potentially allows us to simulate complex airway intervention, create an educational material or even development of individualized tracheal endoprosthesis in the future.

Afatinib (AFA) is an effective treatment in advanced non-small-cell lung cancer (NSCLC) patients harboring epidermal growth factor receptor (EGFR) mutation. However, there were few reports about the cerebrospinal fluid (CSF) penetration rate and the efficacy for central nervous system (CNS) metastasis. Therefore, we conducted the study to evaluate the CSF penetration rate and efficacy of AFA in NSCLC patients harboring EGFR mutation with leptomeningeal carcinomatosis (LC). Eligibility criteria included performance status (PS) 0-3, aged 20 years or older, pathologically proven NSCLC, harboring EGFR mutation, with LC, adequate organ function, and written informed consent. Patients received AFA (40mg/body every day). We analyzed the blood and CSF level of AFA before administrating AFA on the eighth day. The primary endpoint was the CSF penetration rate. Secondary endpoints included objective response rate (ORR), progression free survival (PFS), overall survival (OS), and safety profile. A total of 11 patients were enrolled. And we could analyze the blood level in 10 patients and the CSF level in 8 patients. Median patients-age was 66 years old. All patients were adenocarcinoma. In EGFR mutation status, 5 patients had exon 19 deletion, 3 had L858R and 3 had minor (exon18) mutation. The patients with PS 2 were 3 patients and PS 3 were 4 patients. Almost all patients received AFA after third-line or more line chemotherapy. The blood level was the Median 88.2 ng/ml (range: 30.4-373), the CSF level was Median 1.4 ng/ml (range: 0.39-2.85) and the CSF penetration rate was Median 1.65% (range: 0.1-9.25). The ORR is 27.3%, and two of three patients with exon 18 mutation showed the partial response. Median OS was 3.8 months (95%CI: 1.1-13.1) and median PFS was 2.0 months (95%CI: 0.6-5.8). Hematological toxicity was mild, however we have to take care of severe diarrhea and skin toxicities, especially in patients with poor PS. The median CSF penetration rate (1.65%) of AFA were higher than the penetration rate in previous case report. Although the efficacy for EGFR mutation positive patients with LC was moderate, the promising efficacy for the patient with LC harboring EGFR exon 18 mutation was demonstrated. And we have to take care of diarrhea and skin toxicities, especially in the patients with poor PS.

BACKGROUND:Afatinib is an effective first-line treatment for epidermal growth factor receptor (EGFR) mutation-positive advanced non-small cell lung cancer (NSCLC). However, few reports have addressed the influence of cerebrospinal fluid (CSF) penetration rate on the efficacy of afatinib in patients with central nervous system metastases. Therefore, we conducted a prospective multicenter trial to evaluate the CSF penetration rate and efficacy of afatinib in patients with EGFR mutation-positive NSCLC with leptomeningeal carcinomatosis.PATIENTS AND METHODS:Eleven patients with histologically-proven EGFR mutation-positive NSCLC with leptomeningeal carcinomatosis were enrolled in the study between April 2014 and November 2015. They were treated with afatinib (40 mg/day), and blood and CSF levels of afatinib were analyzed on day 8. The primary endpoint was CSF penetration rate. Secondary endpoints included the objective response rate (ORR), progression-free survival (PFS), and overall survival (OS).RESULTS:The median age of patients was 66 years. Five patients harbored an exon 19 deletion, three harbored a p.L858R point mutation, and three harbored an uncommon exon 18 mutation. The levels of afatinib in blood and CSF (mean±SD) were 233.26±195.40 nM and 3.16±1.95 nM, respectively. The CSF penetration rate was 2.45±2.91%. The ORR was 27.3% (three out of 11 patients), and two out of these three responders had uncommon EGFR mutations. The median PFS and OS were 2.0 and 3.8 months, respectively.CONCLUSION:The median CSF penetration rate of afatinib was higher than previously reported. Afatinib was effective against leptomeningeal carcinomatosis particularly in patients with NSCLC harboring uncommon EGFR mutations. The criteria for selecting a specific EGFR tyrosine kinase inhibitor for therapy of NSCLC should include its ability to penetrate CSF and its efficacy against specific mutation types.

BACKGROUND Long-term oxygen therapy (LTOT) is sometimes prescribed for patients with advanced lung cancer who are potential candidates for chemotherapy. The aim of this study was to assess the usefulness of chemotherapy for patients with this disease who require LTOT. METHODS The medical records of 40 patients with advanced lung cancer who received LTOT while undergoing systemic chemotherapy at our institution between January 2009 and December 2014 were retrospectively reviewed. Chemotherapy consisted of cytotoxic or molecular-targeted agents. RESULTS Twenty-four patients had adenocarcinoma, 6 had squamous cell carcinoma, and 10 had small cell lung cancer (SCLC). The median survival time from the date of the first chemotherapy cycle performed in conjunction with LTOT was 194 days. In a multivariate analysis, the only factor significantly associated with better prognosis was the line (first or second) of the first chemotherapy with LTOT (hazard ratio =0.42; 95% confidence interval, 0.18 to 0.94). Among the 40 patients, 10 (25%) received chemotherapy during the last 30 days of their lives, 2 of whom died of chemotherapy-related adverse events. CONCLUSIONS Chemotherapy for patients with advanced lung cancer who receive LTOT may be acceptable if it is the first- or second-line treatment. However, we should be mindful of the potential overuse of chemotherapy and its negative impact on quality of life.

Background: Radial endobronchial ultrasound with a guide sheath (EBUS-GS) has improved the diagnostic outcomes of peripheral lung lesions. However, to our knowledge, reports on the use of EBUS-GS for diagnosis of cavitary lesions are unavailable. Therefore, this study aimed to assess the effectiveness and safety of EBUS-GS for diagnosis of peripheral cavitary lung lesions (PCLLs).Methods: This study was a single-institution retrospective review of PCLLs examined by using EBUS-GS between July 2013 and October 2015. The diagnostic results of different EBUS-GS samples, including cytologic, histopathologic, and microbiologic samples, were analysed separately.Results: Of 696 radial EBUS procedures performed during the study period, 50 were performed for examination of PCLLs. The overall diagnostic yield for EBUS-GS was 80 % (40/50). Regarding 27 malignant lesions, the diagnostic yields for cytologic and histopathologic samples were 63.0 % (17/27) and 74.1 % (20/27), respectively. Regarding 23 benign lesions, the diagnostic yields for histopathologic and microbiologic samples were 69.6 % (16/23) and 47.8 % (11/23), respectively. Uni- and multivariate analyses indicated that the EBUS probe being within the lesion was the only factor significantly associated with increased diagnostic yield (odds ratio, 7.04; P = 0.03). Although pulmonary infection occurred after the procedure in 1 patient (2.0 %), no other complications, including pneumothorax or significant haemorrhage, were reported.Conclusion: EBUS-GS was found to be an effective and safe procedure for diagnosis of PCLLs.

A 68-year-old woman with interstitial lung disease related to dermatomyositis and systemic scleroderma was admitted to our hospital with fever and dyspnoea. Although the fever was reduced after antibiotic therapy, a left pneumothorax suddenly occurred on day 27 after admission. A continuous air leak persisted despite chest drainage with three tubes and repeated pleurodesis. Chest computed tomography (CT) images showed a cavitary lesion with a pinhole in the left upper division, which was suspected to be the affected lesion with the air leak. Virtual bronchoscopic navigation images were constructed from CT data. Bronchial occlusion with Endobronchial Watanabe Spigots (EWSs) was performed on day 52. Two medium-sized EWSs were inserted into the left B1 + 2a and B1 + 2b, and the air leak stopped immediately. No procedure-related adverse events occurred. All three chest tubes were successfully removed by day 60. This case demonstrates that virtual bronchoscopic navigation can improve bronchial occlusion procedures using EWSs.

An 87-year-old man with postoperative recurrent lung adenocarcinoma was treated with gefitinib. At the beginning of treatment, surgically resected archived tumor tissue revealed a deletion in exon 19 of the EGFR gene, but no ALK gene rearrangement. After gefitinib treatment for 9 months, the disease progressed. Bronchoscopic rebiopsy was used to evaluate resistance mechanisms, and revealed lung adenocarcinoma with wild-type EGFR genes and a newly emerged ALK gene rearrangement. Treatment was switched to alectinib and a partial response was achieved within 4 weeks. This is a rare case of heterochronic genetic change to an ALK gene rearrangement in EGFR mutant lung adenocarcinoma.

Exon18 mutations are detected in 3.6% of epidermal growth factor receptor mutations. Exon 18 mutations as driver mutations have higher sensitivities in vitro to second-generation (G)-tyrosine kinase inhibitors (TKIs) than to first G- and third G-TKIs at clinically relevant doses. In clinical trial, first G-TKIs have moderate but insufficient efficacy, and afatinib was more active in uncommon epidermal growth factor receptor mutations. Here, we present a case of a woman who was initially prescribed erlotinib for lung adenocarcinoma with an exon18 mutation. She developed a leptomeningeal metastasis during treatment and was switched to afatinib. Subsequently, her symptoms improved and she is currently treated with maintenance afatinib therapy. This report suggests improved efficacy of afatinib compared to erlotinib for refractory leptomeningeal metastasis in exon18 mutation.