Juntima Euathrongchit

High-resolution computed tomographic findings in systemic sclerosis-associated interstitial lung disease: comparison between diffuse and limited systemic sclerosis.

ObjectiveThis study aimed to compare the high-resolution computed tomographic (HRCT) findings between patients with diffuse cutaneous systemic sclerosis (DcSSc) and limited cutaneous systemic sclerosis (LcSSc) as well as to correlate the HRCT scores and the other variables. MethodsThe medical records of all patients with SSc who presented at the Rheumatology Clinic, Chiang Mai University Hospital, from March 2005 to 2010 and underwent HRCT of the chest for the presence of interstitial lung disease were retrospectively reviewed. The extent of ground glass, lung fibrosis, and honeycombing was scored. All scores were aggregated to produce a total CT perfusion score. The widest coronal esophageal diameter (WED), the maximum diameter of the main pulmonary artery (MPAD), and ascending aortic diameter (AD) were measured. The ratio of MPAD to AD (MPAD/AD) was calculated. ResultsOf the 71 patients with SSc, mean (SD) age and disease duration were 54.8 (11.8) and 3.9 (4.2) years, respectively. Of them, 69.0% were female and 67.6% were classified as having DcSSc. There were no significant differences between patients with DcSSc and LcSSc with respect to age, disease duration, New York Heart Association Functional Classification, the calculated HRCT scores, WED, and MPAD. The lung fibrosis and total CT perfusion score correlated inversely with the SpO2 (r = −0.47, P < 0.01). The honeycombing correlated positively with the New York Heart Association Functional Classification and the WED (r = 0.29 and r = 0.32, respectively, P < 0.05). ConclusionsThe HRCT scores of these patients were comparable in both subtypes of SSc. Careful evaluation of lungs and esophageal involvement should be performed irrespective of SSc subtypes. The calculated HRCT scores may be useful to assess the severity of the interstitial lung disease in SSc.

Nodal involvement pattern in resectable lung cancer according to tumor location

The aim in this study was to define the pattern of lymph node metastasis according to the primary tumor location. In this retrospective cohort study, each of the operable patients diagnosed with lung cancer was grouped by tumor mass location. The International Association for the Study of Lung Cancer nodal chart with stations and zones, established in 2009, was used to define lymph node levels. From 2006 to 2010, 197 patients underwent a lobectomy with systematic nodal resection for primary lung cancer at Chiang Mai University Hospital. There were 123 male and 74 female patients, with ages ranging from 16– 85 years old and an average age of 61.31. Analyses of tumor location, histology type, and nodal metastasis were performed. The locations were the right upper lobe in 63 patients (31.98%), the right middle lobe in 18 patients (9.14%), the right lower lobe in 30 patients (15.23%), the left upper lobe in 55 patients (27.92%), the left lower lobe in 16 patients (8.12%), and mixed lobes (more than one lobe) in 15 patients (7.61%). The mean tumor size was 4.45 cm in diameter (range 1.2–16.5 cm). Adenocarcinoma was the most common histological type, which occurred in 132 cases (67.01%), followed by squamous cell carcinoma in 41 cases (20.81%), bronchiolo alveolar cell carcinoma in nine cases (4.57%), and large cell carcinoma in seven cases (3.55%). Eighteen cases (9.6%) had skip metastasis (mediastinal lymph node metastasis without hilar node metastasis). Adenocarcinoma and intratumoral lymphatic invasion were the predictors of mediastinal lymph node metastases. There were statistically significant differences between a tumor in the right upper lobe and the right lower lobe. However, there were no statistically significant differences between tumors in the other lobes. In conclusion, tumor location is not a precise predictor of the pattern of nodal metastasis. Systematic lymph node dissection is the only way to accurately determine lymph node status. Further studies are required for evaluation and conclusions.

Retrospective Study of ALK Rearrangement and Clinicopathological Implications in Completely Resected Non- small Cell Lung Cancer Patients in Northern Thailand: Role of Screening with D5F3 Antibodies

BACKGROUND Anaplastic lymphoma kinase (ALK) gene rearrangement in non-small cell lung cancer (NSCLC) has been intensively studied. The gold standard for ALK detection is FISH, but this is not routinely conducted in clinical practice, so that the IHC method has a role. The aim of this study was to identify the incidence of ALK rearrangement and risk or prognostic factors for ALK positivity using both of IHC and FISH methods. MATERIALS AND METHODS From January 2008 to December 2012, 267 completely resected NSCLC patients in Chiang Mai University Hospital were enrolled in this study. Clinical and pathological variables and outcomes of treatment were retrospectively reviewed. IHC and FISH were used to evaluate ALK rearrangement. Sensitivity and specificity of IHC were analyzed. Multivariable analysis was used to identify clinico-pathological correlations with positive results of IHC and clinical outcomes. RESULTS Twenty-two (8.2%) of 267 specimens were IHC-positive for ALK with intense cytoplasmic staining, whereas only 10 (3.8%) were FISH-positive. Sensitivity, specificity and the positive likelihood ratio with IHC were 80.0%, 94.9%, and 15.8 respectively. Age less than 55 years (RR 4.4, 95%CI 1.78-10.73, p value=0.001) and presence of visceral pleural invasion (VPI) (RR 2.9, 95%CI 1.21-6.78, p value =0.017) were identified as risk factors for ALK rearrangement with FISH. There were no statistically significant differences in other clinical and pathological variables. ALK rearrangement was not a prognostic factor for tumor recurrence or overall survival. CONCLUSIONS The incidences of ALK positivity in completely resected NSCLCs in northern Thailand were 8.2% by IHC and 3.8% by FISH. IHC with mouse monoclonal, Ventana D5F3 antibody can be used as a screening tool before FISH method because of high specificity and high positive likelihood ratio. Age less than 55 years and VPI are risk factors for ALK positivity.

Learning styles and academic achievement among undergraduate medical students in Thailand

Purpose: This study aimed to explore the associations between learning styles and high academic achievement and to ascertain whether the factors associated with high academic achievement differed between preclinical and clinical students. Methods: A survey was conducted among undergraduate medical students in Chiang Mai University, Thailand. The Index of Learning Styles questionnaire was used to assess each student’s learning style across four domains. High academic achievement was defined as a grade point average of at least 3.0. Results: Of the 1,248 eligible medical students, 1,014 (81.3%) participated. Learning styles differed between the preclinical and clinical students in the active/reflective domain. A sequential learning style was associated with high academic achievement in both preclinical and clinical students. A reflective learning style was only associated with high academic achievement among preclinical students. Conclusion: The association between learning styles and academic achievement may have differed between preclinical and clinical students due to different learning content and teaching methods. Students should be encouraged to be flexible in their own learning styles in order to engage successfully with various and changing teaching methods across the curriculum. Instructors should be also encouraged to provide a variety of teaching materials and resources to suit different learning styles.

Incidence and predictors of interstitial lung disease (ILD) in Thai patients with early systemic sclerosis: Inception cohort study.

Abstract Objectives: To determine and compare the prevalence of interstitial lung disease (ILD), the severity of high-resolution computed tomography (HRCT) score and incidence rate (IR) of ILD between the two subsets of early-SSc (systemic sclerosis) patients. We also determined the factors associated with ILD. Methods: We used an inception cohort of early-SSc patients seen between January 2010 and June 2014. All patients underwent HRCT at study entry and annually thereafter. Results: One hundred and thirteen patients (66 females and 89 diffuse cutaneous SSc [dcSSc]) with a mean ± SD age of 53.4 ± 8.4 years and mean disease duration of 12.9 ± 10.3 months at cohort entry were enrolled. At enrollment, patients with dcSSc had a higher prevalence of ILD (78.7% vs. 45.8%, p = 0.002), and a higher total HRCT score (10.3 ± 9.5 vs. 4.4 ± 5.6, p = 0.001) compared with limited cutaneous SSc (lcSSc). DcSSc patients had a higher IR of ILD than lcSSc patients (58.8 vs.17.3 per 100 person-years, p < 0.001). Univariable analysis revealed that male gender, presence of anti-Scl 70 and absent anti-centromere antibody was significant predictors of ILD. In Cox-regression analysis, a positive anti-centromere [hazard ratio (HR) 0.09 95% confidence interval (95% CI 0.01–0.73)] was a protective factor. Conclusions: DcSSc patients had more severe HRCT scores and higher IR of ILD compared with lcSSc patients. Male gender, presence of anti-Scl 70, and absent anti-centromere antibody predicted the future development of ILD in early-SSc patients.

Preoperative plasmapheresis for elective thymectomy in myasthenia patient: is it necessary?

Background. Role of plasmapheresis before thymectomy remains controversial. The aim of this study is to determine the peri-operative and post-operative outcome of a thymectomy between performing and not performing a pre-operative plasmaphreresis. Patients and Methods. A retrospective chart review study was conducted in Chiang Mai University Hospital between January 2006 and December 2011. There were 86 myasthenia patients divided into two groups; Preoperative plasmapheresis group (PPG) and no preoperative plasmapheresis group (NPPG). The primary outcome involved post-operative extubation and the secondary outcome included post-operative complications, 28 day mortality and length of hospital stay. Results. Eighty-six patients were enrolled in this study. The number of patients who had a history of myasthenic crisis at any time or within one month in the PPG was significantly more than those in the NPPG. Muscle power and forced expiratory vital capacity in the NPPG was higher than that in the PPG. The postoperative extubation rate was similar in both groups. After controlling for the propensity score, there were no statistically significant differences in both of primary and secondary outcomes. Conclusion. The results of this study shows no significant differences between both groups in all outcomes, therefore the pre-operative plasmaphresis is not necessary for elective thymectomy.

P2.15-28 Effect of Insurance Types on Tumor Recurrence and Overall Survival in Resectable Non-Small Lung Cancer Patients in Northern Thailand

Background: High-precision three-dimensional (3D) image analysis system has been used for preoperative planning in various fields including thoracic surgery. Such software has made us quite easy to measure lung volume. Change of pulmonary function after surgery has been surveyed in some reports, but there are few reports about lung volume change after surgery. Method: We conducted a retrospective review of 49 patients who underwent lobectomy between January 2014 and June 2016 at General Hospital of Japan Railway Company. We used 3D image analysis system (SYNAPSE VINCENT, Fujifilm Corp, Tokyo, Japan) to calculate lung volume of each patient from computed tomography (CT) images which were taken twice, before surgery and 6 months after surgery. We estimated lung volume change from the difference between those two values. Result: There were 19 right upper lobectomies (RUL), 7 right middle lobectomies (RML), 8 right lower lobectomies (RLL), 5 left upper lobectomies (LUL), and 10 left lower lobectomies (LLL). We performed lobectomies in three different surgical approaches; Thoracotomy (n1⁄45), Hybrid Video-assisted thoracic surgery (VATS) (n1⁄424), Complete VATS (n1⁄420). 7 patients needed pleurodesis after surgery to treat air leakage. The average of total lung volume change was -10.4%. Right lobectomies showed 11.45% decrease of lung volume in average, while left lobectomies showed 5.34% decrease (p1⁄40.18). Decrease ratio seemed to depend on the way of approaches; Thoracotomy was -19.98% and VATS (hybrid and complete) was -8.58% (p1⁄40.12). Volume change of patients who underwent pleurodesis after surgery was -20.37%, while the ratio of the others was -7.84% (p1⁄40.03). Conclusion: VATS seemed to be better in the point of lung volume after lobectomy than thoracotomy. Pleurodesis turned out to reduce lung volume significantly. For furthur study, we will compare lung volume with pulmonary function on a lager aomount of data.

FRI0300 Correlations of Δ High-Resolution Computed Tomography (HRCT) Score with Δ Clinical Variables in Early Systemic Sclerosis (SSC) Patients

Background The high-resolution computed tomography (HRCT) score showed correlation with % predicted Forced Vital Capacity (%pFVC) in our previous study1. However, the correlations of the delta (Δ) HRCT scores with Δ %pFVC and Δ clinical variables have not been reported. Objectives To evaluate the correlation of the Δ HRCT scores with Δ %pFVC, Δ Modified Rodnan Skin Score (MRSS) and Δ ESR in patients with early SSc. Methods We used an inception cohort of early SSc patients seen at the Rheumatology clinic, Chiang Mai University, between January 2010 and June 2014. All patients underwent HRCT at study entry and every 12 months thereafter. The extent of ground glass (GG), lung fibrosis (Fib), bronchiectasis (B) and honeycombing (HC) was scored and then were aggregated to produce a total (t) HRCT score1. Thirty-one SSc patients who underwent pulmonary function test within 12 weeks of their corresponding HRCT were identified. The Δ HRCT score (the difference between the last visit and the baseline HRCT score) along with their corresponding clinical variables were used for analysis. Data abstracted include the HRCT scores: total (t)-GG, t-Fib, t-B, t-HC and t-HRCT; %pFVC; MRSS; and ESR. Results Mean±SD age and disease duration (from non-Raynauds phenomenon to undergo first HRCT) were 52.2 ± 8.8 years and 11.7 ± 7.1 months, respectively. Seventeen (54.8%) patients were female and 20 (64.5%) were classified as diffuse cutaneous SSc. Mean±SD interval between the two HRCT tests was 16.0 ± 7.2 months. The mean±SD baseline t-GG, t-Fib, t-B, t-HC and t-HRCT scores were 3.2± 3.3, 4.0±3.5, 2.4±3.3, 0.7 ±2.2 and 10.3±10.3, respectively. The mean ±SD baseline %pFVC, MRSS and ESR were 69.0±15.9, 15.4±9.9 and 34.0±25.3, respectively. The mean ±SD absolute Δ HRCT scores were: t-GG, -0.5±2.1 (range -6.0 to 3.0); t-Fib, 0.3±1.9 (range -7.0 to 5.0); t-B, 0.5±1.2 (range -2.0 to 4.0); t-HC, 0.3±0.8 (range 0 to 3.0); t-HRCT, 0.7±3.8 (range-9.0 to 10.0). The mean ±SD absolute Δ clinical variables were: % of predicted FVC, 4.8 ±12.8 (range -33 to 26); MRSS, 4.9± 6.5 (range -17.0 to 8.0); ESR, -5.8 ±22.3 (range -60 to 58). Spearman rank correlations coefficient between the mean absolute ΔHRCT scores and the other variables were (N=31): Δt-GG Δt-Fib Δt-B Δt-HC Δt-HRCT Δ%pFVC −0.09 −0.16 0.05 −0.15 −0.05 ΔMRSS 0.05 −0.08 0.01 −0.02 −0.01 ΔESR −0.02 −0.09 −0.29 −0.44* −0.33 *p<0.05. Conclusions In this study, the HRCT scores were fairly stable over the first two years of patients with early SSc; while %pFVC, MRSS and ESR showed relatively more change over the times. We found significantly negative correlation between Δ t-HC and Δ ESR. However, no significant correlations of Δ HRCT scores with Δ %pFVC and Δ MRSS were observed. Further longer study duration with larger study population is needed to confirm our findings. References Wangkaew S, et al. Mod Rheumatol. 2015 Dec 23:1–6. Disclosure of Interest None declared

Chest Including Lungs and Mediastinum

The common pitfalls encountered in the chest radiography and chest computed tomography (CT) are reviewed. Chest radiograph interpretation pitfalls include technical and observer errors. Anatomic structures and their variations are sometimes confusing. To be able to recognize these variations or know the limitations of natural disease will help improve and enable a more confident diagnosis. Pitfalls in chest CT may be due to technical issues, artifacts, error of perception, and error of interpretation. The common misinterpretations, misses, and mimics encountered in chest CT are described. As they may have decisive impact on patient care, radiologists should be aware of these variety of pitfalls.

Lung Cancer: Diagnosis and Treatment Approach

Lung cancer is one of the most common causes of cancer death in the world. There are many risk factors for lung cancer including tobacco smoking, chronic lung disease, race and ethnicity, occupational carcinogen exposure, diet and genetic factors. Until now there have been no effective modalities for the early detection of lung cancer. The National Cancer Institute recently released results from its National Lung Screening Trial (NLST) which showed that low dose CT scans compared to chest x-rays can reduce lung cancer mortality by 20 %. For accurate lung cancer staging, multi-modality approaches are used such as positron emission tomography (PET) scan, computed tomography (CT) scan, endobronchial ultrasound (EBUS) biopsy or mediastinoscope biopsy of mediastinal lymph node, pleural tapping procedure, or video-assisted thoracoscopic surgery (VATS). Multi-modality methods have a vital role in lung cancer treatment including surgery, chemotherapy, radiotherapy, targeted therapy and immunotherapy. Anatomical resection and systematic lymphadenectomy is the treatment of choice for early stage lung cancer. Neo-adjuvant chemotherapy is utilized for resectable N2 disease or adjuvant chemotherapy for pathological N2 disease and unresectable advanced disease. Targeted therapies have already been proven as highly effective and less toxic therapies for positive molecular testing in advanced disease.