Management of the irradiated bronchus after lobectomy for lung cancer

Postoperative bronchopleural fistula repair: Surgical outcomes and adverse factors for its success

BACKGROUND

The purpose of this study was to investigate the results of postoperative bronchopleural fistula repair and to identify adverse factors for its success.

METHODS

We retrospectively reviewed the surgical results of 39 patients who underwent surgical repair for postoperative bronchopleural fistula between January 2010 and June 2020. Success of bronchopleural fistula repair was defined as the visual closure of the bronchopleural fistula with the absence of an air leak, a recurrence of bronchopleural fistula and infection in the thoracic cavity.

RESULTS

Twenty-five (64.1%) bronchopleural fistulas occurred after pulmonary resection and 14 (35.9%) after lung transplantation. Bronchopleural fistula was diagnosed 19 days (median) and repaired 28 days (median) after the initial operation by primary closure in 27 (69.2%) patients, and by additional resection in 12 (30.8%) patients. The overall success rate was 59% (23/39) and the overall mortality was 56.4% (22/39). Multivariable analysis revealed that the patients who were supported by mechanical ventilation at the time of repair had significantly lower success rates than those without (15.4%, 2/13 vs. 80.8%, 21/26, respectively, p < 0.001). The omental flap group tended to have a better success rate than the muscle flap group (p = 0.07).

CONCLUSIONS

There was a high overall mortality rate after bronchopleural fistula repair and a low success rate. Mechanical ventilation at the time of bronchopleural fistula repair was significantly related to the failure of bronchopleural fistula repair.

Late Central Airway Toxicity after High-Dose Radiotherapy: Clinical Outcomes and a Proposed Bronchoscopic Classification

Simple Summary

High-dose radiotherapy is frequently used to treat lung cancer, however, it can cause serious central airway toxicity. Although radiation toxicity of the lung parenchyma has been studied extensively, relatively little has been published on bronchoscopic findings in the central airways and no standard classification/reporting system exists. With the growing use of high-dose (chemo)radiotherapy and high-dose hypo-fractionated radiotherapy in close proximity to central airways, as well as potential interactions with new systemic therapies, the risks and incidence of central airway toxicity may increase. In this retrospective study, we analyzed patient characteristics and clinical outcomes of 70 patients with central airway toxicity after high-dose radiotherapy. Furthermore, we analyzed the post-radiotherapy bronchoscopic images to identify main patterns of airway toxicity. We identified luminal stenosis and vascular changes as the two main patterns and have proposed a classification system. Preliminary analysis suggests that the pattern and severity of radiation toxicity may be of prognostic value.

Abstract

The study’s purpose was to identify the bronchoscopic patterns of central airway toxicity following high-dose radiotherapy or chemoradiotherapy, and to look at the consequences of these findings. Our institutional bronchoscopy database was accessed to identify main patterns of airway toxicity observed in a seven-year period. A total of 70 patients were identified with central airway toxicity, and the findings of bronchoscopy were used to derive a classification system. Patient characteristics, time from radiotherapy to toxicity, follow-up and survival were retrospectively analyzed. Results: The main bronchoscopic patterns of airway toxicity were vascular changes (telangiectasia, loss of vascularity, necrosis) and stenosis of the lumen (moderate, severe). Indications for bronchoscopy were airway symptoms (n = 28), assessment post-CRT/surgery (n = 12), (suspected) recurrence (n = 21) or assessment of radiological findings (n = 9). Stenosis was revealed by bronchoscopy at a median time of 10.0 months (IQR: 4–23.5) after radiotherapy and subsequent follow-up after identification was 23 months (IQR: 1.5–55). The corresponding findings for vascular changes were 29 months (IQR: 10.5–48.5), and follow-up after identification was nine months (IQR: 2.5–19.5). There was a statistically significant difference in survival rates between patients with necrosis and telangiectasia (p = 0.002) and loss of vascularity (p = 0.001). Eight out of 10 deceased patients with telangiectasia died of other causes and 4/8 patients with necrosis died of other causes. We identified two main patterns of central airway toxicity visualized with bronchoscopy after high-dose radiotherapy or chemoradiotherapy, and propose a bronchoscopic classification system based on these findings. Preliminary analysis suggests that the pattern and severity of radiation damage might be of prognostic value. Prospective data are required to confirm our findings.

Pedicle Muscle Flaps in Intrathoracic Cancer Resection: Imaging Appearance and Evolution

Pedicle muscle flaps that are used to enhance surgical site integrity after thoracic cancer resections may simulate a recurrent mass at postoperative imaging. However, such flaps have a characteristic appearance and location that should allow their differentiation from a solid mass or fluid collection. The location and appearance of a flap depend on the type of muscle used (whether intercostal, serratus anterior, or latissimus dorsi) and the extent of resection. The appearance also varies according to the presence and amount of fat and calcification in the flap. Most flaps have fat strands along the flap axis that increase in size over time. Linear areas of calcification also may occur because of the inclusion of periosteum in a flap, or more extensive calcification may lead to ossification over time. Uncomplicated flaps do not show substantial radionuclide uptake at positron emission tomography (PET), but areas of extensive calcification may show increased uptake similar to that in bone. Vessels also may be seen within a flap, particularly if the flap has a high fat content; and enhancing vessels frequently are evident at contrast material-enhanced computed tomography (CT). The magnetic resonance (MR) imaging characteristics of flaps are similar to those of normal fat and muscle. Although CT is the modality most often used for follow-up imaging, PET or MR imaging may be helpful in cases in which the CT findings are questionable.

The effects of granulocyte colony-stimulating factor on the healing of tracheal anastomosis following radiation therapy in rats

OBJECTIVE

This study evaluates the effects of granulocyte colony-stimulating factor on the healing of tracheal anastomosis following radiation therapy in rats.

METHODS

Fifty-six male Wistar rats were divided into four groups. Group 1 underwent tracheal anastomosis. Group 2 underwent radiation therapy followed by tracheal anastomosis. Group 3 underwent radiation therapy followed by tracheal anastomosis and received granulocyte colony-stimulating factor. Group 4 underwent sham radiation therapy followed by sham tracheal anastomosis. At 10 days following radiation therapy, the trachea was dissected for histopathological, mechanical and biochemical evaluation.

RESULTS

Median scores for inflammation were three points for Group 1, two points for Group 2, two points for Group 3 and one point for Group 4. Median scores for angiogenesis were four points for Group 1, two points for Group 2, three points for Group 3 and one point for Group 4. Median scores for connective tissue regeneration were four points for Group 1, two points for Group 2, three points for Group 3 and one point for Group 4. Median scores for epithelial regeneration were two points for Group 1, one point for Group 2, one point for Group 3 and one point for Group 4. Mean anastomotic bursting pressures were 853 mmHg for Group 1, 293 mmHg for Group 2, 417 mmHg for Group 3 and 966 mmHg for Group 4. Mean hydroxyproline concentrations were 159 microg/mg for Group 1, 177 microg/mg for Group 2, 120 microg/mg for Group 3 and 117 microg/mg for Group 4.

CONCLUSIONS

This study suggests that granulocyte colony-stimulating factor contributes to the healing of tracheal anastomosis following radiation therapy through improved connective tissue regeneration.