Oke Dimas Asmara

Purpose: In many low- and middle-income countries, access to molecularly targeted therapies for lung cancer remains limited. This study assessed the gap between estimated epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) treatment need and observed uptake in Indonesia and evaluated the gap before and after implementation of the National Reimbursement System (NRS). We hypothesized that many potentially eligible patients in Indonesia would not receive EGFR-TKI therapy, as they ideally should. Methods: We retrospectively analyzed all patient cases of lung cancer registered between 2008 and 2020 at Indonesia's national referral hospital. Patients with a registered diagnosis verified by histopathology or supporting clinical evidence were included. Because patient-level molecular and clinical eligibility data were incomplete, EGFR-TKI eligibility was estimated using a stepwise epidemiologic model. A model-based sensitivity analysis was performed to assess robustness. Observed uptake was compared before and after NRS implementation. Results: A total of 1,426 patients with lung cancer were included; 67.8% were male; the median age was 55 years for men and 53 years for women. Of those with known stage and histology, 93.6% were stage IV; adenocarcinoma accounted for 57.2% of patients with non–small cell lung cancer. Under lower-bound, primary, and upper-bound models, estimated eligible populations were 128 (9.0%), 226 (15.8%), and 378 (26.5%) patients, respectively. Only 41 patients received EGFR-TKIs, corresponding to 32.0%, 18.1%, and 10.8% of the estimated eligible population, respectively. After NRS implementation, uptake increased from 0% to 25.0% of the primary estimate; however, a substantial gap persisted throughout the study period. Conclusion: Despite national reimbursement, EGFR-TKI uptake remained substantially below the estimated need even under the most conservative model. Persistent barriers that span diagnostics, infrastructure, and financing are likely to contribute. Coordinated strategies beyond formulary listings are required to improve access to EGFR-TKI therapy in middle-income settings.

Purpose To evaluate the pooled diagnostic accuracy of externally tested AI models for malignancy classification of lung nodules on chest CT. Materials and Methods A systematic search of PubMed, Embase, Web of Science, CINAHL, and the Cochrane Library was performed in January 2025 to identify studies evaluating AI models for malignancy classification of lung nodules on chest CT using pathology and/or at least 2-year follow-up as reference standards. Risk of bias was assessed using QUADAS-2, and pooled sensitivity and specificity were estimated using bivariate random-effects models. Results Twenty-one studies including 7,454 nodules were analyzed, with lung cancer prevalence ranging from 5.7% (17/297) to 91.5% (214/234). All models were based on deep learning; 17 studies (81%) involved Asian populations, 15 (71%) used non-screening populations, 14 (67%) reported 2D or 3D CNN architectures, and eight (38%) specified predefined malignancy thresholds. High risk of bias was identified in five studies for patient selection and two for index testing. Pooled sensitivity was 88%, specificity 75%, positive likelihood ratio 3.55, negative likelihood ratio 0.16, area under the receiver operating characteristic curve 0.89, and diagnostic odds ratio 22.4. Heterogeneity was high (I ² > 90%). Model architecture was associated with specificity, with higher values in studies reporting 2D or 3D CNNs compared with those without reported architecture (82–83% vs 58%, P = .03; meta-regression P = .02); other subgroup analyses showed no evidence of differences. Conclusion Externally tested AI models demonstrated high sensitivity but moderate specificity for malignancy classification of lung nodules on chest CT, supporting a potential role in rule-out strategies. However, substantial heterogeneity, inconsistent reporting, and risk of bias limit interpretation. ©RSNA, 2026

Introduction: Chronic pulmonary aspergillosis (CPA) is a progressive, potentially life-threatening fungal infection of the lungs. Its management is complicated by comorbidities, chronicity, and diagnostic uncertainty. While antifungal therapy remains the cornerstone of treatment, surgical intervention is indicated in selected cases, especially those presenting with hemoptysis or suspicion of malignancy. Multidisciplinary evaluation and perioperative optimization are crucial, particularly in elderly or complex patients. Case: We described two patients with CPA who exhibited divergent clinical courses. Both were refractory to medical therapy and ultimately underwent surgical intervention. Thoracotomy revealed extensive necrotic cavities with high fungal burden, and histopathology confirmed chronic cavitary pulmonary aspergillosis. Debridement and postoperative antifungal therapy led to significant clinical improvement in both cases. These experiences highlight critical decision points in CPA management, including patient selection for surgery, intraoperative flexibility, and postoperative monitoring. Conclusion: Surgery remains an essential component of comprehensive CPA management, particularly when medical therapy fails or diagnostic uncertainty persists. Integrating surgical and pharmacological strategies through multidisciplinary collaboration ensures optimal outcomes, even in elderly or immunocompetent patients. Carefully timed and individualized surgical intervention provides both diagnostic confirmation and symptomatic relief in cases of advanced or refractory CPA.

Stage III nonsmall cell lung cancer (NSCLC) represents a wide range of tumour (T1 to T4) and nodal (N0 to N3) components, requiring variable management and a multidisciplinary approach. Recent advancements in minimally invasive techniques, molecular biology and novel drug discoveries have accelerated the refinement of stage III NSCLC management. The latest developments in staging include the forthcoming update of the nodal component in the 9th TNM (tumour–node–metastasis) edition, which emphasises the critical role for endobronchial ultrasonography in mediastinal staging. Recent treatment developments include the use of immunotherapy and targeted molecular therapy in both the neoadjuvant and adjuvant setting, either in combination with other modalities or used alone as consolidation. Surgical and radiotherapy advancements have further enhanced patient outcomes. These developments have significantly improved the prognosis for patients with stage III NSCLC. Fast-changing recommendations have also brought about a challenge, with clinicians facing a number of options to choose from. Therefore, a multimodal approach by a multidisciplinary team has become even more crucial in managing stage III NSCLC.

Precision medicine is the current approach to managing chronic respiratory diseases, especially asthma and chronic obstructive pulmonary disease (COPD). It involves the evaluation of genetic, environmental, and lifestyle variations for each patient. It requires valid and specific biomarkers obtained through genetic studies, biomolecular technology, and omics-based technology to determine targeted therapies. Asthma and COPD have heterogeneous clinical phenotype variations, and giving one standard treatment for asthma and COPD may not necessarily provide the same effectiveness to other patients. The endotype, a specific molecular mechanism in disease pathogenesis, is essential in phenotype variation. The role of precision medicine in asthma and COPD is to determine endotypes through specific biomarkers and to provide specific targeted therapy for achieving personalized treatment in each patient. The application of precision medicine not only provides precise diagnosis and treatment but also enables early detection in individuals at risk and prevention of progression and exacerbation in asthma and COPD.