Choonhee Son

Role of the Neutrophil-Lymphocyte Count Ratio in the Differential Diagnosis between Pulmonary Tuberculosis and Bacterial Community-Acquired Pneumonia

Background Differential diagnosis between pulmonary tuberculosis (TB) and bacterial community-acquired pneumonia (CAP) is often challenging. The neutrophil-lymphocyte count ratio (NLR), a convenient marker of inflammation, has been demonstrated to be a useful biomarker for predicting bacteremia. We investigated the usefulness of the NLR for discriminating pulmonary TB from bacterial CAP in an intermediate TB-burden country. Methods We retrospectively analyzed the clinical and laboratory characteristics of 206 patients suspected of having pulmonary TB or bacterial CAP from January 2009 to February 2011. The diagnostic ability of the NLR for differential diagnosis was evaluated and compared with that of C-reactive protein. Results Serum NLR levels were significantly lower in patients with pulmonary TB than in patients with bacterial CAP (3.67±2.12 vs. 14.64±9.72, P<0.001). A NLR <7 was an optimal cut-off value to discriminate patients with pulmonary TB from patients with bacterial CAP (sensitivity 91.1%, specificity 81.9%, positive predictive value 85.7%, negative predictive value 88.5%). The area under the curve for the NLR (0.95, 95% confidence interval [CI], 0.91-0.98) was significantly greater than that of C-reactive protein (0.83, 95% CI, 0.76-0.88; P=0.0015). Conclusions The NLR obtained at the initial diagnostic stage is a useful laboratory marker to discriminate patients with pulmonary TB from patients with bacterial CAP in an intermediate TB-burden country.

Four Cases of a Cerebral Air Embolism Complicating a Percutaneous Transthoracic Needle Biopsy

A percutaneous transthoracic needle biopsy is a common procedure in the practice of pulmonology. An air embolism is a rare but potentially fatal complication of a percutaneous transthoracic needle biopsy. We report four cases of a cerebral air embolism that developed after a percutaneous transthoracic needle biopsy. Early diagnosis and the rapid application of hyperbaric oxygen therapy is the mainstay of therapy for an embolism. Prevention is the best course and it is essential that possible risk factors be avoided.

Phase I study of autologous dendritic cell tumor vaccine in patients with non-small cell lung cancer

BACKGROUND A dendritic cell vaccine has been developed as a novel strategy for generating antitumor immunity in the treatment of cancer. The purpose of this study was to assess the maximal tolerated dose, safety, and immunologic response of a new dendritic cell vaccine (DC-Vac) into which tumor lysate was loaded by electroporation and pulse in patients with advanced non-small cell lung cancer (NSCLC). PATIENTS AND METHODS Fifteen patients with inoperable stage III or IV NSCLC were assigned to cohorts that received 3, 6, or 12 × 10(6) DC-Vac intradermally 3 times at 2 week intervals. We also evaluated immunologic and tumor responses. RESULTS The maximum dose of DC-Vac (12 × 10(6)) was shown to be safe. In 5 of 9 patients, the vaccine resulted in increased interferon (IFN)-γ production by CD8+ cells after exposure to tumor lysate. Additionally, there were mixed responses which do fulfill progressive disease definition but demonstrate some clinical benefit in two patients. CONCLUSION The administration of tumor lysate-loaded autologous dendritic cells by electroporation and pulse was non-toxic and induced immunologic responses to tumor antigens. The two mixed tumor responses which were achieved may represent a potential benefit of this new DC-Vac.

Catamenial hemoptysis: a nationwide analysis in Korea.

Background: Hemoptysis is a potentially serious clinical problem. However, there is no consensus on the clinical characteristics, treatment and patient outcome of catamenial hemoptysis. Objective: Clinical characteristics, treatments and outcome in patients of catamenial hemoptysis were evaluated. Methods: We conducted a retrospective nationwide observational analysis of Korean patients with catamenial hemoptysis. Results: Nineteen patients with catamenial hemoptysis were evaluated from 13 tertiary-care hospitals in Korea. The median age of the patients was 25 years; 8 (42%) were ever-smokers. Eight patients were pathologically diagnosed; 11 were diagnosed by clinical criteria. Sixteen (84%) patients had a history of obstetric or gynecological procedures before developing hemoptysis. The mean amount of hemoptysis (mean ± SD) was 58.3 ± 71.3 for surgery, 46.4 ± 33.2 for hormonal and 29.1 ± 26.3 for conservative treatment groups. Hemoptysis did not recur in 8 (89%) of 9 patients after surgery. None of the patients in the hormonal or conservative treatment groups had persistent hemoptysis. There was an excellent outcome (complete remission and partial responses) in all patients with conservative treatment, suggesting that endometrial cells implanted into the lung may have a benign course. Conclusion: Patients without massive hemoptysis can be treated conservatively or with hormonal agents.

An Aortoesophageal Fistula in Patient with Lung Cancer after Chemo-Irradiation and Subsequent Esophageal Stent Implantation

An aortoesophageal fistula (AEF) is uncommon but is frequently fatal. Most cases are attributable to a thoracic aortic aneurysm. Other common causes include malignant intrathoracic neoplasm, foreign body ingestion, endovascular stent graft repair for thoracic aortic disease, and esophageal surgery. We report a case of an AEF that developed after chemo-irradiation and subsequent esophageal stent implantation in patient with non-small cell lung cancer. The patient underwent self expanding metallic esophageal stent implantation for an esophageal stricture after chemotherapy and radiotherapy. However, 1 month later, he presented with hematemesis. Chest computed tomography and aortography revealed a fistula from the descending thoracic aorta to the stented esophagus. The patient expired 36 hours after initial hematemesis. To our knowledge, this is the first confirmed report of an AEF in patient with a nonesophageal malignancy that had undergone chemo-irradiation and subsequent esophageal stent implantation. We recommend that special caution be exercised when performing esophageal stent implantation in patients who have received prior radiotherapy to the thorax including the esophagus.

Primary Extraskeletal Mesenchymal Chondrosarcoma of the Anterior Mediastinum

Primary extraskeletal mesenchymal chondrosarcoma (EMC) of the mediastinum is an extremely rare disease. To date, only seven cases have been reported in the literature 1-4 since it was first reported by Chetty in 1990.1 We experienced a case of primary mediastinal EMC presenting as an anterior mediastinal mass, a previously unreported site. Here, we describe the characteristic features of the lesion with a review of the literature to emphasize that EMC should be considered in the differential diagnosis of mediastinal tumors.

Characteristics of additional primary malignancies in Korean patients with non-small cell lung cancer.

BACKGROUND Long-term cancer survival results in increasing numbers of multiple primary malignancies in one person, which represents growing clinical challenge in patients with lung cancer. This study was intended to assess the incidence rate, temporal relationship, and characteristics of additional primary malignancies (APM) in Korean patients with non-small cell lung cancer (NSCLC). MATERIALS AND METHODS We reviewed all 632 NSCLCs (313 adenocarcinomas, 276 squamous cell carcinomas, and 43 other NSCLCs) patients who underwent curative resection of NSCLC at the Dong-A University Medical Center from January 1991 to December 2009. We used the hospital information system and medical record to collect data about these patients and their tumors. In the data base, the following parameters were recorded: patients demographics (age, gender and smoking habit), time interval between the diagnosis of the NSCLC and APM, NSCLC characteristics (date of diagnosis, histology, TNM staging, operative details, and survival) and characteristics of APM (site of tumor, date of diagnosis, histology, TNM staging, operative details, and survival). RESULTS Eighty-one (12.8%) of the 632 patients with NSCLC had APMs. Thirty-three patients (40.8%) had APM in their history [occurring earlier than six months or more before NSCLC diagnosis; prior (P) group], 18 patients (22.2%) were diagnosed with an APM synchronously [diagnosed within six months before or after NSCLC; synchronous (S) group], and the remaining 30 patients (37.0%) were diagnosed with an APM during the follow-up period [occurring six months or more after NSCLC diagnosis; metachronous (M) group]. The second primary malignancy occurred most often two to five years in both P group (39.4%) and M group (36.7%). The most frequent APM was stomach cancer (25.0%), followed by colorectal cancer (19.0%), and thyroid cancer (10.7%). Interestingly, we found difference in the incidence of APM between different NSCLC histotypes. In the adenocarcinoma group, colorectal cancer was the most frequently discovered [12 of 46 events (26.1%)], followed by thyroid cancer [9 of 46 events (19.6%)]. In the squamous cell carcinoma group, stomach cancer occurred most frequently [12 of 36 events (33.3%)]. CONCLUSIONS APMs are commonly seen in patients with NSCLC, either preceding or following its occurrence. Therefore, it is important to recognize the characteristic of NSCLC patients with APM in order to detect the second primary malignancy as early as possible and to achieve a possible cure of disease.

Absence of Hyper-Responsiveness to Methacholine after Specific Bronchial Provocation Tests in a Worker With Hydroxyapatite-Induced Occupational Asthma

Hydroxyapatite is commonly used as a filler to replace amputated bone or as a coating to promote bone ingrowth into prosthetic implants. Many modern implants, such as hip replacements and dental implants, are coated with hydroxyapatite. We report a patient with occupational asthma due to hydroxyapatite, proven by a specific inhalation challenge, who experienced an early asthmatic reaction after exposure to hydroxyapatite, without increased airway responsiveness to methacholine despite an increased eosinophil count in the peripheral blood. A 38-year-old male dental implant worker visited our allergy department for the evaluation of occupational asthma. He had treated dental implant titanium surfaces with hydroxyapatite for 1.5 years. One year after starting his employment, he noticed symptoms of rhinorrhea, paroxysmal cough, and chest tightness. His symptoms were aggravated during and shortly after work and subsided several hours after work. When he stopped working for 2 months because of his chest symptoms, he became asymptomatic. After restarting his work, his symptoms reappeared and were aggravated. A methacholine bronchial challenge test had a negative response. The following day, a specific bronchial provocation test with wheat powder was negative. On the third day, a specific bronchial provocation test with hydroxyapatite powder produced an early asthmatic response. On the fourth day, a methacholine bronchial challenge test was negative. Further studies are needed to evaluate the exact pathogenetic mechanism of hydroxyapatite-induced occupational asthma.

Fatal interstitial lung disease after erlotinib administration in a patient with radiation fibrosis

Introduction:  Although gefitinib used for the treatment of non‐small‐cell lung cancer is a well‐known cause of interstitial lung disease (ILD), few case reports on erlotinib‐induced ILD have been issued. The common risk factor of both of these two drug‐induced ILDs is idiopathic interstitial pneumonia, but ILD in a patient with radiation fibrosis has not been previously reported.

Strategic management of transthoracic needle aspirates for histological subtyping and EGFR testing in patients with peripheral lung cancer: An institutional experience.

Lung cancer therapy is personalized based on the histological subtype and molecular status. Totally, 70% of lung cancer patients present in advanced stages and are diagnosed on small biopsy or cytology specimens, hence an accurate but tissue‐sparing approach is necessary. This study aimed to demonstrate efficient utilization of cell block (CB) on transthoracic needle aspiration (TTNA) for lung cancer subtyping, and to investigate the usefulness of needle washing after TTNA for assessing EGFR molecular status.