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8045 Background: Surgical resection is the primary therapy for stage I-II NSCLC but not performed in a subset of patients due to comorbidities or self-election, who instead undergo radiation with or without systemic therapy (RT±ST). Little is known about the demographic, tumoral, therapeutic, and quality-of-life (QOL) characteristics of this non-surgical group. Understanding their differences from the surgical group is essential for developing precision treatment strategies and tailored survivorship guidelines. Methods: In a prospectively enrolled (1997-2016) and followed (through 2025) cohort of 20,951 primary lung cancer patients, 6,486 (31%) had stage I-II NSCLC, including 5,359 (83%) treated surgically (Surgical) and 1,113 (17%) otherwise (Non-surgical). Preexisting diseases were grouped into cancer, lung, and other comorbidities. QOL data were available for 40% of all patients. Descriptive analysis of demographics, tumor features, treatment patterns, and QOL metrics, as well as survival analysis (median years and overall survival [OS] rates) were conducted. QOL measures, on overall and 15 symptom and functional domains, were scored 0 (worst) to 10 (best), with 1-unit difference considered clinically and statistically meaningful. Results: At time of diagnosis, compared to the Surgical, the Non-surgical patients were older (median 73 v 68 years), more likely to have smoked cigarettes (91% v 83%), squamous cell and unspecified NSCLC (53% v 28%), stage IIB (19% v 12%), and preexisting lung comorbidities (71% v 58%). Non-surgical patients more frequently received RT±ST than the Surgical (70% v 21%) and had shorter median survival (2.5 v 7.8) years. Within the Non-surgical, 28% had no cancer treatment (No-Tx), 44% RT-only, 7% ST-only, and 19% both (RT+ST); their respective median diagnosis ages were 74, 76, 68, 70 years; median survival were 1.7, 2.7, 2.2, 3.2 years; 5-year OS (95%CI) at 25% (21-31), 25% (21-29), 26% (17-38), 30% (25-37); and 10-year OS at 9% (7-14), 7% (5-10), 10% (5-21), 9% (6-14), respectively. RT-only group had highest rates of comorbidities (37-84%) and the No-Tx the lowest (31-66%). Although the overall QOL scored the same for all groups, RT-only patients reported the worst scores on multiple symptoms burden, and the No-Tx reported the least pain and lung cancer symptoms but the worst on mental well-being and social activities. Conclusions: Non-surgically managed stage I-II NSCLC cases present clinically distinct patients with the shortest median survival in No-Tx group and highest 5-year survival in RT+ST. RT-only patients were oldest, had the most comorbidities, and reported the worst symptom burdens. These differences highlight the need for more in-depth analyses and studies (considering age, histology, comorbidity, QOL, etc.) to support tailored therapeutic strategies and survivorship care for patients who decline or are not suitable for surgery.

OBJECTIVES: Pneumocystis jirovecii pneumonia (PCP) can cause severe hypoxemic respiratory failure in immunocompromised patients. Contemporary outcomes of venovenous extracorporeal membrane oxygenation (VV ECMO) support for PCP are poorly characterized, and existing reports are limited to small case series. DESIGN: Retrospective cohort study. SETTING: International registry study using the Extracorporeal Life Support Organization (ELSO) registry. PATIENTS/SUBJECTS: Adults with PCP-associated hypoxemic respiratory failure supported with VV ECMO between 2011 and 2024. INTERVENTIONS: VV ECMO. MEASUREMENTS AND MAIN RESULTS: A total of 209 patients with PCP-associated respiratory failure supported with VV ECMO were identified. The overall in-hospital mortality was 60.8%. Survivors were younger than nonsurvivors (median age 41.9 vs. 46.8 yr; p = 0.047). Duration of mechanical ventilation before VV ECMO was longer among nonsurvivors (median 4.7 vs. 1.6 d; p = 0.019). The proportion of patients with HIV infection was similar among survivors and nonsurvivors (19.5% vs. 22.1%; p = 0.73). Pre-ECMO vasopressor use, prone positioning, and renal replacement therapy were common and did not differ between groups. Clinical course was characterized by prolonged VV ECMO support (median 18.6 d) and frequent complications, including pneumothorax (21.1%), renal replacement therapy during VV ECMO (31.6%), intracranial hemorrhage or stroke (7.7%), and major pulmonary or gastrointestinal hemorrhage (16.8%). PCP accounted for a small proportion of VV ECMO runs reported to the ELSO registry throughout the study period at 0.36% of reported cases. No significant temporal trend in mortality was observed. CONCLUSIONS: PCP-associated respiratory failure supported with VV ECMO is associated with substantial mortality and prolonged VV ECMO support. These findings provide contemporary benchmarks that may inform VV ECMO candidacy discussions and expectations in this challenging patient population.

Summary Caustic esophageal injury can cause severe morbidity and mortality. Despite the need for emergent treatment, individual experience in diagnosis and management can be limited. Computed tomography (CT) has emerged as a promising non-invasive modality for assessing injury severity, but the clinical utility of both CT and endoscopy should be investigated. A systematic review was conducted following PRISMA guidelines. A comprehensive search of the PubMed database identified relevant articles published from January 1, 2000 to December 31, 2023. Inclusion criteria encompassed studies investigating the use of CT and/or endoscopy in diagnosing and managing caustic esophageal injury. Twelve articles were selected from a pool of 931 studies. Findings suggested that CT was superior in diagnostic capability to endoscopy in high-grade injury and stricture formation, but less so for low grade injuries. Diagnostic algorithms incorporating imaging with laboratory studies have emerged in the literature, which are promising pending additional validation. CT can serve as a valuable, non-invasive tool in the initial evaluation of caustic esophageal injury and is postulated to accurately predict both the need for emergent surgery and the risk of stricture formation. However, CT should not replace but rather complement the use of endoscopy to comprehensively evaluate these potentially highly morbid situations.

Abstract Introduction Rheumatoid arthritis (RA) is a systemic autoimmune rheumatic disease (SARD) primarily associated with articular involvement, but is often associated with lung involvement, sometimes preceding articular symptoms. Common pulmonary manifestations include interstitial lung disease (ILD), airway, and serosal involvement. RA-related pleural disease can mimic empyema due to the pleural fluid's green, pus-like appearance, exudative nature, low pH, markedly low glucose, and elevated lactate dehydrogenase (LDH) levels. Empyema sometimes yields negative cultures which can accentuate the diagnostic challenge in such cases. This report presents a patient with RA-related pleural lung disease who was referred to our hospital with trapped lung presumed to be secondary to empyema in the setting of pleural-based pulmonary abscess. Case Report A 66-year-old female with a 22-year history of RA presented with recurrent right-sided pleural effusions and progressive dyspnea over three years. Her initial presentation in 2022 involved a large right-sided pleural effusion, suspected to result from a ruptured pleural-based pulmonary abscess that led to empyema and subsequently a trapped lung. Pleural fluid analysis showed elevated LDH (1364 U/L), low glucose (45 mg/dL), high cholesterol (121 mg/dL), and low triglycerides (79 mg/dL). Due to refractory exudative effusion and a comprehensive negative infectious evaluation (bacterial, mycobacterial, and fungal cultures), RA-related pleural disease was suspected. The patient underwent video-assisted thoracoscopic surgery (VATS), which revealed pleural-based rheumatoid nodules and pleural thickening. (figure1) Lung and pleural biopsies confirmed RA-associated fibrinous pleuritis, RA-associated follicular bronchiolitis, and usual interstitial pneumonitis. Given the complexity of the infection, a thoracotomy with decortication and pleurectomy was planned and conducted in stages. Immunosuppressive regimen was switched from leflunomide to rituximab. Discussion This case underscores the diagnostic complexity in distinguishing RA-associated pleural effusion from empyema. Features such as pleural nodularity resembling a pulmonary abscess, unilateral exudative effusion, grossly purulent pleural fluid, low pH and glucose, and elevated LDH levels led to an initial misdiagnosis of empyema. Characteristic pleural fluid, along with persistent negative cultures and absence of sepsis pointed towards RA-related pleural disease. VATS and biopsy were instrumental in establishing the final diagnosis through characteristic histopathological findings of RA-associated pleural, parenchymal and airway involvement. Conclusion For RA patients with pleural effusion suggestive of empyema, especially in the context of negative cultures and no signs of sepsis, RA-related pleural disease should be a consideration. Early recognition and timely immunosuppressive therapy escalation can prevent complications such as trapped lungs and reduce the necessity for extensive surgical interventions. Figure1:

Abstract Introduction Unilateral pulmonary vein atresia (UPVA) is a rare congenital anomaly involving absent or obstructed pulmonary veins (PV), often leading to chronic pulmonary venous stasis, recurrent infections, and hemoptysis. Although typically diagnosed in infancy, UPVA can present in adulthood. This report presents a 63-year-old male referred as a case of chronic thromboembolic pulmonary disease (CTEPD) who was diagnosed with UPVA. We describe the diagnostic complexities and potential explanation for loss of pulmonary artery (PA) perfusion in such cases. Case Presentation A 63-year-old man was referred to rule out CTEPD. His past medical history included coronary artery disease and sleep apnea. He presented with chronic cough, repeated hemoptysis, recurrent pneumonias requiring prolonged antibiotics use, and progressive exertional dyspnea. Physical examination was unremarkable. Pulmonary function tests showed moderate restriction and moderately-reduced diffusion capacity. A ventilation-perfusion (V/Q) scan revealed complete absence of perfusion in the left lung. [figure1] High-resolution CT revealed a straight left atrial border sign with absent left superior and inferior PVs, left pulmonary arterial tree hypoplasia, hypoplastic left lung with fibrotic changes due to chronic venous-lymphatic engorgement and pulmonary hypoperfusion. CT also showed compensatory right lung hyperinflation and bronchial artery collaterals. Echocardiography indicated an atrial septal defect (ASD) with no pulmonary vascular disease. Based on CT angiography, UPVA was considered the leading diagnosis. Discussion UPVA is a congenital disease rarely presenting in adulthood with recurrent infections, hemoptysis, and fibrosis. It often accompanies congenital cardiac conditions, like ASD in our case. Pulmonary angiography may reveal ipsilateral PA hypoplasia and atrophied peripheral vessels. The absence of perfusion in the V/Q scan could be explained by reversed blood flow in the PA from congestion caused by the atretic PVs and ipsilateral backflow from the bronchial arteries collaterals. Differential diagnosis like CTEPD was excluded due to atypical complete loss of perfusion of the left lung, and lack of the other radiological stigmata. Swyer-James-MacLeod syndrome was excluded due to a mismatched perfusion defect. Proximal Interruption of the PA was also excluded due to normally developed proximal left and right PAs. Imaging is crucial in showing absent PVs and hypoplastic ipsilateral lung. Conservative management for UPVA is recommended. Given recurrent infections and hemoptysis, pneumonectomy can be considered. Conclusion This case illustrates the atypical presentation of UPVA as a CTEPD mimicker, presenting with absent pulmonary perfusion unilaterally, which can be explained by reversed pulmonary flow secondary to venous engorgement and backflow from bronchial artery collaterals. Figure1:

Mitral regurgitation (MR) in lung transplant (LTx) recipients is a rare but complex cardiopulmonary phenomenon. The overlap between symptoms of MR and post-LTx complications, such as primary graft dysfunction, complicates its diagnosis and management. This systematic review aims to characterize the incidence, pathophysiology, presentation, and management of MR in LTx patients. We conducted a literature search in PubMed, Web of Science, Scopus, and Embase. The search yielded 133 studies, of which 11 were included. Data regarding MR development, clinical presentation, echocardiographic findings, and management strategies were extracted and analyzed. Perioperative MR, occurring during or immediately post-LTx, was frequently attributed to the systolic anterior motion of the mitral valve (MV) occurring in the setting of hypovolemia and/or inotrope usage. Later postoperative MR, on the other hand, was associated with reverse ventricular remodeling and mitral annular dilation, although some variability in the literature was present. Preexisting MR or ventricular dysfunction, elongated MV leaflets, and bilateral LTx procedure appeared to be risk factors for MR development. Management was dependent on the timing of MR and its pathophysiology, where systolic anterior motion–related MR was treated with medical therapy, whereas postoperative MR often required MV interventions. In conclusion, the diagnosis of MR in LTx patients is complicated by its symptomatic overlap with other post-LTx complications. Echocardiographic monitoring in patients with preexisting MR, regardless of severity, is essential for early identification and management. Further research is needed to better understand the underlying mechanisms and refine management strategies for MR in this population.

SUMMARY Advancements in neoadjuvant regimens for esophageal adenocarcinoma have enabled some patients to achieve complete pathologic response at time of esophagectomy. There are currently limited data detailing this trend or the implications of complete pathologic response on survival. The National Cancer Database was used to identify 16,169 patients with esophageal adenocarcinoma that received trimodal therapy including esophagectomy between 2006 and 2020. Of these, 11.4% had complete pathologic response at esophagectomy. Patient factors, staging characteristics, and survival trends were evaluated. In patients diagnosed between 2016 and 2020, the rate of complete pathologic response was 17.5%. Female sex (OR 1.295, 95% CI 1.134–1.481, p = 0.0001), Black race (OR 1.729, 95% CI 1.362–2.196, p = 0.0002), Hispanic ethnicity (OR 1.418, 95% CI 1.073–1.875, p = 0.0141), and later era of diagnosis (2016–2020 OR 2.898, 95% CI 2.508–3.349, p < 0.0001) were independent predictors of complete pathologic response. Clinical stage II disease was associated with an increased probability of complete pathologic response (OR 1.492, 95% CI 1.19–1.871) while clinical stage III disease had a decreased probability of complete pathologic response (OR 0.762, 95% CI 0.621–0.936, p < 0.0001). Complete pathologic response conveyed a strong survival benefit, with a median survival of 86.4 months (95% CI 73.9–102.1) versus 30.7 months (95% CI 29.8–31.7, p < 0.0001) in those without complete pathologic response. Four-year median survival was also higher in those with complete pathologic response (63.3%, 95% CI 60.8–66.0% vs. 39.2%, 95% CI 38.4–40.1%, p < 0.0001). In summary, complete pathologic response is associated with a profound survival advantage in patients with esophageal adenocarcinoma. Such knowledge carries implications for patient counseling, prognostication, and surveillance and demonstrates a need for improved identification of complete clinical response prior to esophagectomy.