A case report of subconjunctival emphysema as a rare complication of pulmonary resections

Lung volume reduction surgery (LVRS) is performed to the selected patients with lung emphysema who have higher residual volume, restricted pulmonary functions and limited diaphragmatic movement. Post-operative prolonged air leak is not uncommon following LVRS due to pulmonary emphysema. In some patients with prolonged air leak, pneumoderma may develop. Subconjunctival emphysema is a bizarre and very rarely seen complication. We report a patient suffering from subconjunctival emphysema after an LVRS along with a diagnostic wedge resection for a suspected pulmonary nodule which was revealed to be a large cell neuroendocrine carcinoma. The condition was resolved with conservative management with no visual impairment. He has been doing well and tumour free for 38 months.

Mediastinal lymph node removal modulates natural killer cell exhaustion in patients with non-small cell lung cancer

Non-small cell lung cancer (NSCLC) is the leading cause of cancer-related death globally. In this study, the effect of complete removal of mediastinal lymph nodes by video-assisted mediastinoscopic lymphadenectomy (VAMLA) on natural killer (NK) cell phenotype and functions in patients with NSCLC was evaluated. The study included 21 NSCLC patients (cIA-IVA) undergoing VAMLA staging and 33 healthy controls. Mononuclear cells were isolated from peripheral blood of all participants and mediastinal lymph nodes of the patients. NK cells were analyzed by flow cytometry to define NK subsets, expressions of PD-1, CTLA-4, activating/inhibitory receptors, granzyme A, and CD107a. The plasma levels of soluble PD-1, PDL-1, and CTLA-4 were measured by ELISA. Mediastinal lymph nodes of NSCLC patients had increased ratios of exhausted NK cells, increased expression of PD-1 and IL-10, and impaired cytotoxicity. Mediastinal lymph nodes removal increased CD56dimCD16bright cytotoxic effector phenotype and reduced exhausted NK cells. PD-1+ NK cells were significantly more abundant in patients' blood, and VAMLA significantly reduced their ratio as well. The ratio of IL-10 secreting regulatory NK cells was also reduced after VAMLA. Blood NK cells had increased cytotoxic functions and spontaneous IFN-γ secretion, and these NK cell functions were also recovered by VAMLA. Mediastinal lymph node removal reversed NK cell exhaustion, reduced regulatory NK cells, and improved antitumoral functions of NK cells. Tumor-draining lymph nodes may contribute to tumor evasion from antitumoral immune responses. The role of their removal needs to be further studied both to better understand this mechanism and as a potential immunotherapeutic approach.

The IL-25/ILC2 axis promotes lung cancer with a concomitant accumulation of immune-suppressive cells in tumors in humans and mice

Background

Group 2 innate lymphoid cells (ILC2) can be activated by interleukin (IL)-33 or IL-25. IL-25-activated ILC2 cells help protect the host against helminth infection while exacerbating allergic-like inflammation and tissue damage in the lung. In the context of cancer, IL-33-activated ILC2 cells were found to bear anti-tumoral functions in lung cancer while IL-25-activated ILC2 cells promoted tumorigenesis in colorectal cancer. The role of IL-25-activated ILC2 cells in lung cancer remains to be addressed.

Methods

We examined the overall survival of human non-small cell lung cancer (NSCLC) patients according to IL25 expression as well as the distribution of ILC2 cells and regulatory T cells (Tregs) in various NSCLC patient tissues and peripheral blood (PB) of healthy donors (HDs). We analyzed the effect of adoptive transfer of IL-25-activated ILC2 cells on tumor growth, metastasis and survival in a heterotopic murine model of lung cancer.

Results

We report that human NSCLC patients with high IL-25 expression have reduced overall survival. Moreover, NSCLC patients bear increased frequencies of ILC2s compared to HDs. Frequencies of Tregs were also increased in NSCLC patients, concomitantly with ILC2s. In mice bearing heterotopic lung cancer, adoptive transfer of IL-25-activated ILC2s led to increased tumor growth, increased metastasis and reduced survival. The frequencies of monocytic myeloid-derived suppressor cells (M-MDSCs) were found to be increased in the tumors of mice that received ILC2s as compared to controls.

Conclusion

Overall, our results indicate that the IL-25/ILC2 axis promotes lung cancer potentially by recruiting immune-suppressive cells to the tumors both in humans and in mice, and that it may therefore represent a suitable novel target for NSCLC immunotherapeutic development.

Uniportal pure robotic-assisted thoracic surgery-technical aspects, tips and tricks

The uniportal access for robotic thoracic surgery presents itself as a natural evolution of minimally invasive thoracic surgery (MITS). It was developed by surgeons who pioneered the uniportal video-assisted thoracic surgery (U-VATS) in all its aspects following the same principles of a single incision by using robotic technology. The robotic surgery was initially started as a hybrid procedure with the use of thoracoscopic staplers by the assistant. However, due to the evolution of robotic modern platforms, the staplers can be nowadays controlled by the main surgeon from the console. The pure uniportal robotic-assisted thoracic surgery (U-RATS) is defined as the robotic thoracic surgery performed through a single intercostal (ic) incision, without rib spreading, using the robotic camera, robotic dissecting instruments and robotic staplers. There are presented the advantages, difficulties, the general aspects and specific considerations for U-RATS. For safety reasons, the authors recommend the transition from multiportal-RATS through biportal-RATS to U-RATS. The use of robotic dissection and staplers through a single incision and the rapid undocking with easy emergent conversion when needed (either to U-VATS or to thoracotomy) are safety advantages over multi-port RATS that cannot be overlooked, offering great comfort to the surgeon and quick and smooth recovery to the patient.

Minimally invasive approaches for en-bloc anatomical lung and chest wall resection

Background

The aim of this study was to evaluate the feasibility of en-bloc anatomical lung and chest wall resection via minimally invasive surgery.

Methods

Between January 2013 and December 2021, a total of 22 patients (18 males, 4 females; mean age: 63±6.9 years; range, 48 to 78 years) who underwent anatomical lung and chest wall resection using minimally invasive surgery for non-small cell lung cancer were retrospectively analyzed. Demographic, clinical, intra- and postoperative data of the patients, recurrence, metastasis, mortality, and overall survival rates were recorded.

Results

The surgical technique was robot-assisted thoracic surgery in two, multiport video-assisted thoracoscopic surgery in 18, and uniport video-assisted thoracoscopic surgery in two patients. Upper lobectomy was performed in 17 (77.3%) patients, lower lobectomy in three (13.6%) patients, and upper lobe segmentectomy in two (9.1%) patients. Five different techniques were used for chest wall resection. Nine (40.9%) patients had one, eight (36.4%) patients had two, four (18.2%) patients had three, and one (4.5%) patient had four rib resections. Chest wall reconstruction was necessary for only one of the patients. The mean operation time was 114±36.8 min. Complete resection was achieved in all patients. Complications were observed in seven (31.8%) patients without mortality. The mean follow-up was 24.4±17.9 months. The five-year overall survival rate was 55.3%.

Conclusion

Segmentectomy/lobectomy and chest wall resection with minimally invasive surgery are safe and feasible in patients with nonsmall cell lung cancer. In addition, the localization of the area where chest wall resection would be performed should be considered the most crucial criterion in selecting the ideal technique.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Post bar removal results of pectus deformity patients who underwent minimally invasive correction

Introduction

The most common chest wall deformities are pectus excavatum and pectus carinatum. Surgical repair of these deformities via minimally invasive technique using pectus bars is commonly preferred by numerous thoracic surgeons. Despite this common choice for treatment, the duration of the bar stay, the bar removal process, the possible complications and ways to prevent them have been debated over the years and still there is no single decision.

Aim

To determine the decision making, surgical outcomes and negative factors in the bar removal process.

Material and methods

There were 1032 patients underwent bar removal between 2006-2020 and their data was recorded prospectively. We analyzed patients' demographics, family history, Haller index, bar count, body mass index, stabilizer and wire usage, length of hospital stay, time until bar removal, incision side and complications retrospectively.

Results

There was no significant correlation between BMI and surgery time (p = 0.748). There was no statistically significant correlation between the age groups and the number of pectus bars removed. The other factors showed no significant difference. The surgery time was found to be significantly longer in those with callus tissue (p = 0.002).

Conclusions

These findings suggest that pectus bars can be left in place for a shorter time than the standard 3-year interval without any additional recurrence risk and without compromising quality of life. As a result, patients with persistent pain after pectus repair should be well evaluated for the possibility of life-threatening complications during bar removal.

Can postoperative complications be reduced by the application of ERAS protocols in operated non-small cell lung cancer patients?

Background

In our study, we aimed to evaluate the length of hospital stay and complication rate of patients before and after application o f t he E nhanced R ecovery A fter S urgery ( ERAS) protocols.

Methods

Between January 2001 and January 2021, a total of 845 patients (687 males, 158 females; mean age: 55±11 years; range, 19 to 89 years) who were operated with the diagnosis of non-small cell lung carcinoma were retrospectively analyzed. The patients were divided into three groups as follows: patients between 2001 and 2010 were evaluated as pre-ERAS (Group 1, n=285), patients between 2011 and 2015 as preparation for ERAS period (Group 2, n=269), and patients who had resection between 2016 and 2021 as the ERAS period (Group 3, n=291).

Results

All three groups were similar in terms of clinical, surgical and demographic characteristics. Smoking history was statistically significantly less in Group 3 (p=0.005). The forced expiratory volume in 1 sec/forced vital capacity and albumin levels were statistically significantly higher in Group 3 (p<0.001 and p=0.019, respectively). The leukocyte count and tumor maximum standardized uptake value were statistically significantly higher in Group 1 (p=0.018 and p=0.014, respectively). Postoperative hospitalization day, complication rate, and intensive care hospitalization rates were statistically significantly lower in Group 3 (p<0.001). The rate of additional disease was statistically significantly higher in Group 1 (p=0.030). Albumin level (<2.8 g/dL), lymphocyte/monocyte ratio (<1.35), and hemoglobin level (<8.3 g/dL) were found to be significant predictors of complication development.

Conclusion

With the application of ERAS protocols, length of postoperative hospital stay, complication rate, and the need for intensive care hospitalization decrease. Preoperative hemoglobin level, albumin level, and lymphocyte/monocyte ratio are the predictors of complication development. Increasing hemoglobin and albumin levels before operation may reduce postoperative complications.

Comparison of uniportal robotic-assisted thoracic surgery pulmonary anatomic resections with multiport robotic-assisted thoracic surgery: a multicenter study of the European experience

Background

Robotic-assisted thoracic surgery (RATS) has seen increasing interest in the last few years, with most procedures primarily being performed in the conventional multiport manner. Our team has developed a new approach that has the potential to convert surgeons from uniportal video-assisted thoracic surgery (VATS) or open surgery to robotic-assisted surgery, uniportal-RATS (U-RATS). We aimed to evaluate the outcomes of one single incision, uniportal robotic-assisted thoracic surgery (U-RATS) against standard multiport RATS (M-RATS) with regards to safety, feasibility, surgical technique, immediate oncological result, postoperative recovery, and 30-day follow-up morbidity and mortality.

Methods

We performed a large retrospective multi-institutional review of our prospectively curated database, including 101 consecutive U-RATS procedures performed from September 2021 to October 2022, in the European centers that our main surgeon operates in. We compared these cases to 101 consecutive M-RATS cases done by our colleagues in Barcelona between 2019 to 2022.

Results

Both patient groups were similar with respect to demographics, smoking status and tumor size, but were significantly younger in the U-RATS group [M-RATS =69 (range, 39-81) years; U-RATS =63 years (range, 19-82) years; P<0.0001]. Most patients in both operative groups underwent resection of a primary non-small cell lung cancer (NSCLC) [M-RATS 96/101 (95%); U-RATS =60/101 (59%); P<0.0001]. The main type of anatomic resection was lobectomy for the multiport group, and segmentectomy for the U-RATS group. In the M-RATS group, only one anatomical segmentectomy was performed, while the U-RATS group had twenty-four (24%) segmentectomies (P=0.0006). All M-RATS and U-RATS surgical specimens had negative resection margins (R0) and contained an equivalent median number of lymph nodes available for pathologic analysis [M-RATS =11 (range, 5-54); U-RATS =15 (range, 0-41); P=0.87]. Conversion rate to thoracotomy was zero in the U-RATS group and low in M-RATS [M-RATS =2/101 (2%); U-RATS =0/101; P=0.19]. Median operative time was also statistically different [M-RATS =150 (range, 60-300) minutes; U-RATS =136 (range, 30-308) minutes; P=0.0001]. Median length of stay was significantly lower in U-RATS group at four days [M-RATS =5 (range, 2-31) days; U-RATS =4 (range, 1-18) days; P<0.0001]. Rate of complications and 30-day mortality was low in both groups.

Conclusions

U-RATS is feasible and safe for anatomic lung resections and comparable to the multiport conventional approach regarding surgical outcomes. Given the similarity of the technique to uniportal VATS, it presents the potential to convert minimally invasive thoracic surgeons to a robotic-assisted approach.

Mediastinal lymph node removal ameliorates cytotoxic T-lymphocyte functions in patients with non-small cell lung cancer

INTRODUCTION

Mediastinal lymph node (MLN) removal by video-assisted mediastinoscopic lymphadenectomy (VAMLA) for preoperative cancer staging was reported to be associated with increased survival. The aim of this study was to evaluate the immunologic effects of complete MLN removal by VAMLA on cytotoxic T lymphocyte (CTL) phenotype and function.

METHODS

Seventeen patients with non-small cell lung cancer (NSCLC) (stage cT1-4N0-3M0-1A) and 20 healthy participants were included in this study. Blood samples were collected before and 4 weeks after the procedure. Lymphocytes were isolated from the removed MLNs. CTL phenotypes and functions were evaluated by flow cytometry. Plasma levels of soluble programmed cell death protein 1 (sPD-1), soluble programmed cell death protein 1 ligand, and soluble CTL antigen 4 (sCTLA-4) were measured with enzyme-linked immunosorbent assay.

RESULTS

The ratio of the immunosenescent CTLs (CD3⁺CD8⁺CD28^-) was increased in peripheral blood and MLNs of the patients with NSCLC compared to controls (p = 0.037), and MLN removal did not change this ratio. PD-1 and CTL antigen 4 expressions were significantly reduced in peripheral blood CTLs after MLN removal by VAMLA (p = 0.01 and p = 0.01, respectively). Granzyme A expression was significantly reduced in the peripheral blood CTLs of the patients compared to controls (p = 0.006) and MLN removal by VAMLA significantly improved Granzyme A expression in CTLs (p = 0.003). Plasma concentrations of sPD-1 and sCTLA-4 remained unchanged after VAMLA.

CONCLUSION

CTLs in the MLNs and peripheral blood of the patients with NSCLC had an immunosenescent phenotype, increased immune checkpoint receptor expression, and impaired cytotoxicity. MLN removal by VAMLA improved these phenotypic and functional characteristics of CTLs. These changes may explain the potential contribution of VAMLA to improved survival.

A thoracic surgery consensus statement for performing thoracic surgery in sars-cov-2 pandemic

Collapse

Evaluation of Exudative Pleural Effusions: A Multicenter, Prospective, Observational Study

PURPOSE

The aim of this study is to determine the diagnostic performances of pleural procedures in undiagnosed exudative pleural effusions and to evaluate factors suggestive of benign or malignant pleural effusions in tertiary care centers.

METHODS

This was a multicenter prospective observational study conducted between January 1 and December 31, 2018. A total of 777 patients with undiagnosed exudative pleural effusion after the initial work-up were evaluated. The results of diagnostic procedures and the patients' diagnoses were prospectively recorded. Sensitivity, specificity, and accuracy estimates with 95% confidence intervals were used to examine the performance of pleural procedures to detect malignancy.

RESULTS

The mean age ± SD of the 777 patients was 62.0 ± 16.0 years, and 68.3% of them were male. The most common cause was malignancy (38.3%). Lung cancer was the leading cause of malignant pleural effusions (20.2%). The diagnostic sensitivity and accuracy of cytology were 59.5% and 84.3%, respectively. The diagnostic sensitivity of image-guided pleural biopsy was 86.4%. The addition of image-guided pleural biopsy to cytology increased diagnostic sensitivity to more than 90%. Thoracoscopic biopsy provided the highest diagnostic sensitivity (94.3%). The highest diagnostic sensitivity of cytology was determined in metastatic pleural effusion from breast cancer (86.7%).

CONCLUSION

The diagnostic performance increases considerably when cytology is combined with image-guided pleural biopsy in malignant pleural effusions. However, to avoid unnecessary interventions and complications, the development of criteria to distinguish patients with benign pleural effusions is as important as the identification of patients with malignant pleural effusions.

Nonintubated versus intubated thoracoscopic bullectomy for primary spontaneous pneumothorax: A multicenter propensity-matched analysis

BACKGROUND

We aimed at comparing in a multicenter propensity-matched analysis, results of nonintubated versus intubated video-assisted thoracic surgery (VATS) bullectomy/blebectomy for primary spontaneous pneumothorax (PSP).

METHODS

Eleven Institutions participated in the study. A total of 208 patients underwent VATS bullectomy by intubated (IVATS) (N = 138) or nonintubated (NIVATS) (N = 70) anesthesia during 60 months. After propensity matching, 70 pairs of patients were compared. Anesthesia in NIVATS included intercostal (N = 61), paravertebral (N = 5) or thoracic epidural (N = 4) block and sedation with (N = 24) or without (N = 46) laryngeal mask under spontaneous ventilation. In the IVATS group, all patients underwent double-lumen-intubation and mechanical ventilation. Primary outcomes were morbidity and recurrence rates.

RESULTS

There was no difference in age (26.7 ± 8 vs 27.4 ± 9 years), body mass index (19.7 ± 2.6 vs 20.6 ± 2.5), and American Society of Anesthesiology score (2 vs 2). Main results show no difference both in morbidity (11.4% vs 12.8%; p = 0.79) and recurrence free rates (92.3% vs 91.4%; p = 0.49) between NIVATS and IVATS, respectively, whereas a difference favoring the NIVATS group was found in anesthesia time (p < 0.0001) and operative time (p < 0.0001), drainage time (p = 0.001), and hospital stay (p < 0.0001). There was no conversion to thoracotomy and no hospital mortality. One patient in the NIVATS group needed reoperation due to chest wall bleeding.

CONCLUSION

Results of this multicenter propensity-matched study have shown no intergroup difference in morbidity and recurrence rates whereas shorter operation room time and hospital stay favored the NIVATS group, suggesting a potential increase in the role of NIVATS in surgical management of PSP. Further prospective studies are warranted.

Two smoking-related lesions in the same pulmonary lobe of squamous cell carcinoma and pulmonary Langerhans cell histiocytosis: A case report

BACKGROUND

Pulmonary Langerhans cell histiocytosis (PLCH) is a rare cystic lung disease usually affecting young adults. It is predicted that PLCH is a lung tumor precursor associated with dysfunction of the myeloid dendritic cells in the lung.

CASE SUMMARY

A 70-year-old male patient presented with chronic cough and sputum. He had symptoms for 5 years and described shortness of breath on exertion for the previous 3 years. He had a 60 packs/year smoking history. Computerized tomography of the thorax revealed an 11-mm nodule in the right lung lower lobe superior segment and a 7-mm nodule in the right lung lower lobe poster basal segment. Those two nodules were resected by means of right thoracoscopic surgery. Pathological evaluation revealed a squamous cell carcinoma and PLCH.

CONCLUSION

Coexistent squamous cell carcinoma and PLCH suggest possible association between PLCH and lung cancer.

An intrapericardial thymoma resected by uniportal video-assisted thoracoscopic surgery

Thymomas are usually located in the normal location of the thymus in the anterior mediastinum. It is very rare for thymomas to arise primarily intrapericardially. A 76-year-old male patient with a known human immunodeficiency virus positivity and has been under close follow-up for five years was admitted to our clinic. Thoracic computed tomography revealed an intrapericardial mass. Uniportal video-assisted thoracoscopic surgery was performed for the resection of the intrapericardial mass. Pathological examination revealed a type AB thymoma with a 3x3x2.5-cm dimensions (Stage 1). He underwent adjuvant irradiation. He has been doing well without any recurrence for 41 months. In conclusion, resection of intrapericardial masses is feasible and safe. This is the first case with a purely intrapericardial thymoma that was resected via uniportal videoassisted thoracoscopic surgery in the literature.

Thoracic splenosis mimicking pleural tumor after firearm injury: A case report with long-term follow-up

Splenosis describe a clinical entity of autotransplantation after removal of the spleen secon-dary to a traumatic rupture or surgery. A 39-year-old female was referred to thoracic surgery department with complaints of severe chest pain. She had left thoracic and abdominal gun-shot injury that occurred 19 years earlier. Thorax computed tomograhy and thorax magnetic resonance imaging revealed pleural lesions. A video thoracoscopic biopsy disclosed splenosis in the patient. Splenic implants did not change in 6 years. The patient has mild thoracic pain. Thoracic splenosis can occur in patients who underwent abdominothoracic gunshot injury. The implants did not seem to change in long-term follow-up. Thoracic splenosis may occur, persist for years and it mimics pleural tumor after abdominal gun-shot injury and does not seem to necessitate any surgical intervention including diaphragmatic repair.

Multimodality approach in treatment of thymic tumors

Thymic tumors are rare neoplasms showing important clinical and pathologic polymorphisms ranging from low-mitotic encapsulated tumors to a highly aggressive and disseminating one. Complete resection of the tumor with surrounding fatty and mediastinal tissue is of paramount importance and provides good prognosis. Diagnosis of the tumor, radiologic evaluation and implementation of multimodal treatment including preoperative chemotherapy, radiotherapy, postoperative radiotherapy, adjuvant chemotherapy or radiotherapy are important components of the treatment strategy. Some of the stage III tumors can be resected without additional treatment, however, there is a good evidence to support administering preoperative and postoperative chemotherapy and postoperative radiotherapy in these patients providing higher complete resection rate and better survival. For stage IVA thymomas, surgery alone should not be considered as an effective approach and these tumors are considered as unresectable. Chemo/radiotherapy can be administered to those patients. Of those, postoperative chemotherapy and radiotherapy should be considered if these patients who were deemed to be previously unresectable become resectable. The combined modality treatment should provide prevention of locoregional and intrathoracic recurrence and eventually long-term survival with cure. New targeted therapies including agents against PI3K, CDK, and immune checkpoint PD-1/PD-L1 may lead to higher response rates with less toxicity.

The effect of minimally invasive pectus excavatum repair on thoracic scoliosis

OBJECTIVES

The Nuss technique comprises the placement of an intrathoracic bar behind the sternum. However, besides improving the body posture through the correction of the pectus excavatum (PE), this procedure may cause or worsen thoracic scoliosis as a result of the considerable stress loaded on the chest wall and the thorax. Our goal was to investigate the impact of the Nuss procedure on the thoracic spinal curvature in patients with PE.

METHODS

A total of 100 patients with PE who underwent the Nuss procedure were included in the study and evaluated retrospectively. The Haller index (HI), asymmetry index and sternal torsion angle were calculated from thoracic computed tomography images before the operation. To evaluate the scoliosis in the T2-T8 thoracic vertebrae, Cobb angles were calculated on a plain chest X-ray before the Nuss operation and after the removal of the bar. Cobb angles were classified as normal (5°), scoliotic posture (5°-10°) and scoliosis (>10°). All angles before and after the Nuss operation were compared. The patients were followed up for a mean of 41 months. Substernal bars were removed after a mean of 33 months.

RESULTS

The mean age of the patients was 19.6 ± 6.7 years. The Cobb angle was statistically significantly increased in all patients (P = 0.01), male patients (P = 0.01) and children (P = 0.046) but not in adults (P = 0.11) and female patients (P = 0.54). The Cobb angle was increased in patients with severe (HI ≥ 3.5) but not in patients with moderate (3.2 < HI < 3.5) or mild (2.0 < HI < 3.2) PE deformity.

CONCLUSIONS

The present study shows that the Cobb angle indicates that the severity of thoracic scoliosis increases following the Nuss procedure, particularly in male patients, in patients with mild and moderate sternal torsion angle and in those with a high preoperative HI. This alteration might be due to correctional forces and torque applied by the bar. Patients undergoing the Nuss procedure for the correction of PE should be followed up strictly for timely diagnosis and management of the scoliosis.

Thoracic cancer surgery during the COVID-19 pandemic: a consensus statement from the Thoracic Domain of the Asian Society for Cardiovascular and Thoracic Surgery

OBJECTIVES

Healthcare resources have been mobilized to combat the COVID-19 pandemic of 2020. The Thoracic Domain of the Asian Society for Cardiovascular and Thoracic Surgery reports a consensus statement on the provision of thoracic cancer surgery during this pandemic.

METHODS

A Thoracic Experts Panel was convened by the Society. A consensus on the provision, safety, and setting of thoracic cancer surgery during the pandemic was obtained through a Delphi process.

RESULTS

Responses were received from 26 panel members (96% response rate) from 10 regions across Asia. The Society recommended that elective thoracic cancer surgery services may need to be reduced or postponed if medical resources were needed for COVID-19 patients, especially intensive care unit beds and ventilators. However, thoracic cancer surgery should proceed as normal for all solid tumors, without restrictions based on disease stage, availability of non-surgical treatment options, or patient condition (unless there is a high likelihood of postoperative intensive care unit stay). Aerosol-forming procedures should be avoided intra- and perioperatively. The surgical approach does not make a difference in terms of safety. Services for thoracic cancer patients should be offered only in hospitals that maintain isolation wards for patients with confirmed or suspected COVID-19.

CONCLUSIONS

Services for patients with thoracic cancer should be maintained during the COVID-19 pandemic. The position of the Society is that thoracic surgeons have a responsibility to perform good surgical management of thoracic cancer during the pandemic, to advocate for patients' rights to receive it, and to safeguard patients and staff from infection.

General thoracic surgery services across Asia during the 2020 COVID-19 pandemic

The COVID-19 pandemic of 2020 posed an historic challenge to healthcare systems around the world. Besides mounting a massive response to the viral outbreak, healthcare systems needed to consider provision of clinical services to other patients in need. Surgical services for patients with thoracic disease were maintained to different degrees across various regions of Asia, ranging from significant reductions to near-normal service. Key determinants of robust thoracic surgery service provision included: preexisting plans for an epidemic response, aggressive early action to "flatten the curve", ability to dedicate resources separately to COVID-19 and routine clinical services, prioritization of thoracic surgery, and the volume of COVID-19 cases in that region. The lessons learned can apply to other regions during this pandemic, and to the world, in preparation for the next one.

Effect of trail C1595T variant and gene expression on the pathogenesis of non-small cell lung cancer

It is known that disorders in apoptosis function play an important role in the pathogenesis of many types of cancer, including lung cancer. Tumor necrosis factor related apoptosis inducing ligand (TRAIL), a type II transmembrane protein, is a death ligand capable of inducing apoptosis by activating distinctive death receptor. Our purpose in this study is to investigate the gene polymorphisms in TRAIL molecular pathway and TRAIL gene expression levels in non-small cell lung cancer (NSCLC) patients in terms of pathogenesis and prognosis of the disease. In this study, TRAIL C1595T polymorphism was genotyped using polymerase chain reaction-restriction fragment length polymorphism analysis in 158 patients with NSCLC and 98 healthy individuals. Surgically resected tissues were examined and classified histopathologically. In addition, TRAIL gene expression levels in tumor tissue and tumor surrounding tissue samples of 48 patients with NSCLC were determined using real-time polymerase chain reaction. TRAIL gene expression levels of NSCLC patients were detected significantly 28.8 fold decrease in the tumor tissue group compared to the control group (p=0.026). When patients were compared to tumor stage, expression of TRAIL gene in advanced tumor stage was found to be significantly 7.86 fold higher than early tumor stage [p=0.028]. No significant relationship was found between NSCLC predisposition and prognostic parameters of NSCLC with TRAIL genotypes, but the frequency of TRAIL gene 1595 CT genotype was observed to be lower in the patients compared to the other genotypes, and the difference was found to be very close to statistical significance (p=0.07). It can be suggested that TRAIL may play an important role in the development of NSCLC and may be an effective prognostic factor in tumor progression.: It is known that disorders in apoptosis function play an important role in the pathogenesis of many types of cancer, including lung cancer. Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), a type II transmembrane protein, is a death ligand capable of inducing apoptosis by activating distinctive death receptor. Our purpose in this study is to investigate the gene polymorphisms in TRAIL molecular pathway and TRAIL gene expression levels in non-small cell lung cancer (NSCLC) patients in terms of pathogenesis and prognosis of the disease.

Programmed Death-Ligand-1 Expression in Non-Small Cell Lung Cancer and Prognosis

Background:

Prognostic significance of the programmed death-ligand-1 status in non-small cell lung carcinoma remains controversial

Aims:

To show the programmed death-ligand-1 expression status in patients with non-small cell lung carcinoma and its effect on the prognosis and the relationship with clinicopathologic data.

Study Design:

Retrospective cross-sectional study.

Methods:

The study included 208 cases who were diagnosed with NSCLC and who underwent surgical resection between 2001 and 2012. Programmed death-ligand-1 (SP142 clone) was applied to the histological sections acquired from the microarray paraffin blocks with immunohistochemistry. Staining intensity was scored as weak (+, 1), moderate (++, 2), and strong (+++, 3). Percentage (0%-100%) was multiplied by staining intensity (1-2-3) to calculate the H score. Four different cut-off values were used; 1: ≥1% (independent of intensity), 2: ≥5% (independent of intensity), 3: ≥5% moderate/strong staining (except for weak staining), 4: H score ≥30 values were considered positive. In this study, staining a single cell at any intensity was considered positive.

Results:

Thirty-four out 208 cases (16.3%) had PDL-1 positive staining. PDL-1 expression was observed in patients with non-small cell lung carcinoma independent of the histological type or subtype (range; 0-25%). When the cut-off level was set to ≥5% with moderate and strong staining, the median overall survival was 45 months for the PD-L1 positive group and not reached for the PD-L1 negative group (p-value 0.024). PD-L1 positivity was significantly higher in patients over the age of 60 years and in cases with a tumor diameter of more than 5 cm (p=0.023 and 0.025, respectively).

Conclusion:

PD-L1 expression is positive in 16.3% of patients with non-small cell lung cancer and may have a negative prognostic value.

Polymorphisms in the Microsomal Epoxide Hydrolase Gene: Role in Lung Cancer Susceptibility and Prognosis

Aims and background

The aim of this study was to investigate the relationship between EPHXI exon 3 Tyr113His and exon 4 His139Arg polymorphisms, predicted microsomal epoxide hydrolase (mEH) activity, and lung cancer development. mEH is a protective enzyme involved in oxidative defences against a number of environmental chemicals and pollutants, but it is also responsible for the xenobiotic activation of carcinogens.

Methods

We investigated the two polymorphisms of the mEH gene (EPHX1) in 58 lung cancer patients and 41 controls using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP).

Results

The exon 3 Tyr113His polymorphism was associated with lung cancer (P <0.001). The frequency of the His113His homozygote genotype in exon 3 was significantly increased in patients compared with controls (P <0.001). In contrast, there was no significant difference in exon 4 polymorphisms between patients and controls. When the exon 3 and 4 polymorphisms were considered together, the combined EPHX1 His113His113/His139His139 genotype (very low predicted enzyme activity) was found to be associated with an increased risk of lung cancer (P = 0.044, OR = 3.063, CI = 0.932–10.069). We observed that patients with T3 + T4 tumors had an approximately 3-fold higher risk of the Tyr113/His113 genotype than patients with T1 + T2 tumors. Lung cancer patients carrying aheterozygote Tyr113/His113 genotype had a 2-fold increased risk of lymph node metastases (P = 0.051).

Conclusion

These findings suggest that the exon 3 Tyr113His and exon 4 His139Arg polymorphisms of EPHXI may be associated with a increased risk of lung cancer and a worse prognosis. Free full text available at www.tumorionline.it

Mediastinal staging by videomediastinoscopy in clinical N1 non-small cell lung cancer: a prospective multicentre study

A quarter of patients with clinical N1 (cN1) non-small cell lung cancer (NSCLC) based on positron emission tomography-computed tomography (PET-CT) imaging have occult mediastinal nodal involvement (N2 disease). In a prospective study, endosonography alone had an unsatisfactory sensitivity (38%) in detecting N2 disease. The current prospective multicentre trial investigated the sensitivity of preoperative mediastinal staging by video-assisted mediastinoscopy (VAM) or VAM-lymphadenectomy (VAMLA).Consecutive patients with operable and resectable (suspected) NSCLC and cN1 after PET-CT imaging underwent VAM(LA). The primary study outcome was sensitivity to detect N2 disease. Secondary endpoints were the prevalence of N2 disease, negative predictive value (NPV) and accuracy of VAM(LA).Out of 105 patients with cN1 on imaging, 26% eventually developed N2 disease. Invasive mediastinal staging with VAM(LA) had a sensitivity of 73% to detect N2 disease. The NPV was 92% and accuracy 93%. Median number of assessed lymph node stations during VAM(LA) was 4 (IQR 3-5), and in 96%, at least three stations were assessed.VAM(LA) has a satisfactory sensitivity of 73% to detect mediastinal nodal disease in cN1 lung cancer, and could be the technique of choice for pre-resection mediastinal lymph node assessment in this patient group with a one in four chance of occult-positive mediastinal nodes after negative PET-CT.

Validity of the updated European Society of Thoracic Surgeons staging guideline in lung cancer patients

OBJECTIVE

The European Society of Thoracic Surgeons (ESTS) has proposed a revised preoperative lymph node staging guideline for patients with potentially resectable non-small cell lung cancer (NSCLC). We aimed to assess the validity of this revised ESTS guideline and survival results in our patient cohort.

METHODS

A total of 571 patients with potentially resectable NSCLC seen between January 2004 and November 2013 were included in the study. The preoperative mediastinal staging was performed by video-assisted cervical mediastinoscopy or video-assisted mediastinoscopic lymphadenectomy in all patients except those with peripheral cT1N0 nonadenocarcinoma tumors. Resection via thoracotomy or video-assisted thoracoscopic surgery was done in patients with no mediastinal lymph node metastasis. Surgical pathological results were compared with the ESTS staging guideline, and the validity of the guideline was tested.

RESULTS

In this series, mediastinal lymph node metastasis was revealed preoperatively in 266 patients (46.6%). A total of 305 patients underwent anatomic lung resection. The sensitivity, specificity, positive and negative predictive values, and accuracy of the guidelines were calculated as 95.0%, 100%, 100%, 94.6%, and 97.2%, respectively.

CONCLUSIONS

The ESTS revised preoperative lymph node staging guidelines for patients with NSCLC seem to be effective and valid, and may provide high survival following resectional surgery.

A prospective randomized trial comparing homologous and autologous fibrin sealants for the control of alveolar air leak

Background

Postoperative air leak is a common complication seen after pulmonary resection. It is a significant reason of morbidity and also leads to greater hospital cost owing to prolonged length of stay. The purpose of this study is to compare homologous sealant with autologous one to prevent air leak following pulmonary resection.

Methods

A total of 57 patients aged between 20 and 79 (mean age: 54.36) who underwent pulmonary resection other than pneumonectomy (lobar or sublobar resections) were analyzed. There were 47 males (83%) and 10 females (17%). Patients who intraoperatively had air leaks were randomized to receive homologous (Tisseel; n=28) or autologous (Vivostat; n=29) fibrin sealant. Differences among groups in terms of air leak, prolonged air leak, hospital stay, amount of air leak were analyzed.

Results

Indications for surgery were primary lung cancer in 42 patients (71.9%), secondary malignancy in 5 patients (8.8%), and benign disease in 10 patients (17.5%). Lobectomy was performed in 40 patients (70.2%), whereas 17 patients (29.8%) had wedge resection. Thirteen (46.4%) patients developed complications in patients receiving homologous sealant while 11 (38.0%) patients had complication in autologous sealant group (P=0.711). Median duration of air leak was 3 days in two groups. Time to intercostal drain removal was 3.39 and 3.38 days in homologous and autologous sealant group respectively (P=0.978). Mean hospital stay was 5.5 days in patients receiving homologous sealant whereas it was 5.0 days in patients who had autologous agent (P=0.140). There were no significant differences between groups in terms of measured maximum air leak (P=0.823) and mean air leak (P=0.186). There was no significant difference in the incidence of complications between two groups (P=0.711).

Conclusions

Autologous and heterologous fibrin sealants are safe and acts similarly in terms of air leak and hospital stay in patients who had resectional surgery.