Defining a natural killer cell-enriched molecular rejection-like state in lung transplant transbronchial biopsies

In lung transplantation, antibody-mediated rejection (AMR) diagnosed using the International Society for Heart and Lung Transplantation criteria is uncommon compared with other organs, and previous studies failed to find molecular AMR (ABMR) in lung biopsies. However, understanding of ABMR has changed with the recognition that ABMR in kidney transplants is often donor-specific antibody (DSA)-negative and associated with natural killer (NK) cell transcripts. We therefore searched for a similar molecular ABMR-like state in transbronchial biopsies using gene expression microarray results from the INTERLUNG study (#NCT02812290). After optimizing rejection-selective transcript sets in a training set (N = 488), the resulting algorithms separated an NK cell-enriched molecular rejection-like state (NKRL) from T cell-mediated rejection (TCMR)/Mixed in a test set (N = 488). Applying this approach to all 896 transbronchial biopsies distinguished 3 groups: no rejection, TCMR/Mixed, and NKRL. Like TCMR/Mixed, NKRL had increased expression of all-rejection transcripts, but NKRL had increased expression of NK cell transcripts, whereas TCMR/Mixed had increased effector T cell and activated macrophage transcripts. NKRL was usually DSA-negative and not recognized as AMR clinically. TCMR/Mixed was associated with chronic lung allograft dysfunction, reduced one-second forced expiratory volume at the time of biopsy, and short-term graft failure, but NKRL was not. Thus, some lung transplants manifest a molecular state similar to DSA-negative ABMR in kidney and heart transplants, but its clinical significance must be established.

Comparison of peripheral blood saturation with brain oxygenation in patients undergoing thoracic surgery

Introduction

Near-infrared spectroscopy (NIRS) is a non-invasive method of regional tissue oxygenation measurement. Intraoperative use of NIRS to monitor brain oxygenation (BO) during surgery might be beneficial to identify cerebral desaturations.

Aim

To compare peripheral blood saturation (SpO2) with BO measurements and evaluate the utility of BO in thoracic surgery.

Material and methods

We took BO and SpO2 measurements in a group of 100 patients undergoing standard thoracic surgery. Measurements were made every 15 minutes. The Mann-Whitney U test was used to compare study groups. Spearman's rank correlation coefficient was used to determine correlation between studied parameters.

Results

We found a negative correlation between patients' age and BO at the beginning of surgery. Operations lasted between 30 and 200 minutes. We found a positive correlation between BO and SpO2 between 15 and 90 minutes of surgery. Subsequently, BO remained at a low level while SpO2 returned to baseline values. Higher minimum SpO2 values were noted in patients undergoing left-sided procedures.

Conclusions

Cerebral oxygenation does not return to baseline values until the end of the surgery as opposed to the SpO2. Furthermore, both SpO2 and BO correlate negatively with the overall duration of thoracic surgery. In addition, after 90 minutes of surgery, SpO2 stopped reflecting brain oxygenation.

Arterial sleeve lobectomy for lung cancer invading chest wall

Lung cancer is a leading cause of cancer-related deaths worldwide. Non-small cell lung cancer (NSCLC) is a predominant subtype and treatment may include immunotherapy, radiotherapy, chemotherapy, and surgery. Tumors of bigger size infiltrating large bronchi and vessels require more invasive resection such as pneumonectomy. To save lung parenchyma, sleeve lobectomy can be performed in certain patients.We report the case of a patient with NSCLC infiltrating the chest wall who underwent arterial sleeve lobectomy with rib resection. Furthermore, we discuss other surgical treatment strategies.A 58-year-old female patient was admitted to the hospital in 2020 with pain in her left posterolateral chest. Radiological imaging revealed a tumor (5.0×3.5×4.8 cm) in the top of the left lung, infiltrating pulmonary artery and ribs. Therefore, left upper sleeve lobectomy together with resection of rib blocks II to V was performed. The surgery was uncomplicated, but a few weeks postoperatively, the patient experienced repeated episodes of consciousness disturbances. Contrast CT revealed a cerebral malformation in the patient who died 3.5 months after surgery.Sleeve lobectomy can be safely performed in patients with lung tumors infiltrating larger bronchi and vessels who would not tolerate pneumonectomy.

The molecular features of chronic lung allograft dysfunction in lung transplant airway mucosa

BACKGROUND

Many lung transplants fail due to chronic lung allograft dysfunction (CLAD). We recently showed that transbronchial biopsies (TBBs) from CLAD patients manifest severe parenchymal injury and dedifferentiation, distinct from time-dependent changes. The present study explored time-selective and CLAD-selective transcripts in mucosal biopsies from the third bronchial bifurcation (3BMBs), compared to those in TBBs.

METHODS

We used genome-wide microarray measurements in 324 3BMBs to identify CLAD-selective changes as well as time-dependent changes and develop a CLAD classifier. CLAD-selective transcripts were identified with linear models for microarray data (limma) and were used to build an ensemble of 12 classifiers to predict CLAD. Hazard models and random forests were then used to predict the risk of graft loss using the CLAD classifier, transcript sets associated with rejection, injury, and time.

RESULTS

T cell-mediated rejection and donor-specific antibody were increased in CLAD 3BMBs but most had no rejection. Like TBBs, 3BMBs showed a time-dependent increase in transcripts expressed in inflammatory cells that was not associated with CLAD or survival. Also like TBBs, the CLAD-selective transcripts in 3BMBs reflected severe parenchymal injury and dedifferentiation, not inflammation or rejection. While 3BMBs and TBBs did not overlap in their top 20 CLAD-selective transcripts, many CLAD-selective transcripts were significantly increased in both for example LOXL1, an enzyme controlling matrix remodeling. In Cox models for one-year survival, the 3BMB CLAD-selective transcripts and CLAD classifier predicted graft loss and correlated with CLAD stage. Many 3BMB CLAD-selective transcripts were also increased by injury in kidney transplants and correlated with decreased kidney survival, including LOXL1.

CONCLUSIONS

Mucosal and transbronchial biopsies from CLAD patients reveal a diffuse molecular injury and dedifferentiation state that impacts prognosis and correlates with the physiologic disturbances. CLAD state in lung transplants shares features with failing kidney transplants, indicating elements shared by the injury responses of distressed organs.

Lung transplantation in patients with a history of anatomical native lung resection

OBJECTIVES

History of anatomical lung resection complicates lung transplantation (LTx). Our aim was to identify indications, intraoperative approach, and outcome in these challenging cases in a retrospective multicentre cohort analysis.

METHODS

Members of the ESTS Lung Transplantation Working Group were invited to submit data on patients undergoing LTx after a previous anatomical native lung resection between 01/2005 and 07/2020. The primary end-point was overall survival (Kaplan-Meier estimation).

RESULTS

Out of 2690 patients at 7 European centers, 26 (1%) patients (14 male; median age 33 years) underwent LTx after a previous anatomical lung resection. Median time from previous lung resection to LTx was 12 years. The most common indications for lung resection were infections (n = 17), emphysema (n = 5), lung tumour (n = 2), and others (n = 2). Bronchiectasis (cystic fibrosis (CF) or non-CF related) was the main indication for LTx (n = 21), followed by COPD (n = 5). Two patients with a previous pneumonectomy underwent contralateral single LTx and 1 patient with a previous lobectomy had ipsilateral single LTx. The remaining 23 patients underwent bilateral LTx. Clamshell incision was performed in 12 (46%) patients. Moreover, LTx was possible without extracorporeal life support in 13 (50%) patients. 90-day mortality was 8% (n = 2) and the median survival was 8.7 years.

CONCLUSIONS

History of anatomical lung resection is rare in LTx candidates. The majority of patients are young and diagnosed with bronchiectasis. Although the numbers were limited, survival after LTx in patients with previous anatomical lung resection, including pneumonectomy is comparable to reported conventional LTx for bronchiectasis.

Right Heart Echocardiography Parameters and Other Predictors to Evaluate Mechanical Cardiac Support Necessity During Lung Transplantation

BACKGROUND

Lung transplantation (LuTx) is a challenge when right heart function fails. Mechanical circulatory support (MCS) is then necessary.

METHODS

We aimed to investigate whether preoperative transthoracic echocardiography (TTE) can predict MCS use and help to exclude the sickest patients. Between 2011 and 2018, 52 patients at our institution received LuTx and qualified for this study: 35 bilateral, 16 single, 1 lobar [1] and 1 retransplantation procedure. Of these, 22 were operated using MCS and 30 without MCS. The patients were aged between 18 and 65 years, and 23 were women. The indications were lung fibrosis for 18 patients, chronic obstructive lung disease for 16, cystic fibrosis for 15, primary pulmonary hypertension for 2 and bronchiectasis for 1. TTE was performed up to 30 days before treatment and 1 to 7 days after.

RESULTS

Patients undergoing MCS versus patients not undergoing MCS: preoperative right ventricular systolic pressure 56.5 (30) vs 37.8 (11.5) mm Hg (P = .03); tricuspid regurgitation pressure gradient 48.7 (27) vs 30.2 (10.8) mm Hg (P = .015); tricuspid annular plane systolic excursion 17.8 (4.3) vs 19.9 (2.8) mm Hg (P = .04); pulmonary artery diameter 27.5 (5.2) vs 23.9 (4.1) mm (P = .004); age 41.9 (14.1) vs 54.3 (11.8) years (P = .001). Patients who were Dead versus patients who were alive pulmonary valve acceleration time of 82.8 (24.1) vs 104.9 (27.2) ms (hazard ratio [HR] = 0.959, 95% confidence interval [CI] = 0.923-0.996 per ms, P = .02) and pulmonary artery diameter of 28.9 (5.8) vs 24.4 (4.1) mm HR = 1.225, 95% CI = 1.028-1.460 per 1 mm, P = .016 were predictors of death.

CONCLUSIONS

Preoperative TTE parameters: right ventricular systolic pressure, tricuspid regurgitation pressure gradient, tricuspid annular plane systolic excursion, and pulmonary artery diameter predicted MCS use during LuTx. Certain values of valve acceleration time and pulmonary artery diameter could help discern LuTx qualification.

Transcripts associated with chronic lung allograft dysfunction in transbronchial biopsies of lung transplants

Transplanted lungs suffer worse outcomes than other organ transplants with many developing chronic lung allograft dysfunction (CLAD), diagnosed by physiologic changes. Histology of transbronchial biopsies (TBB) yields little insight, and the molecular basis of CLAD is not defined. We hypothesized that gene expression in TBBs would reveal the nature of CLAD and distinguish CLAD from changes due simply to time posttransplant. Whole-genome mRNA profiling was performed with microarrays in 498 prospectively collected TBBs from the INTERLUNG study, 90 diagnosed as CLAD. Time was associated with increased expression of inflammation genes, for example, CD1E and immunoglobulins. After correcting for time, CLAD manifested not as inflammation but as parenchymal response-to-wounding, with increased expression of genes such as HIF1A, SERPINE2, and IGF1 that are increased in many injury and disease states and cancers, associated with development, angiogenesis, and epithelial response-to-wounding in pathway analysis. Fibrillar collagen genes were increased in CLAD, indicating matrix changes, and normal transcripts were decreased-dedifferentiation. Gene-based classifiers predicted CLAD with AUC 0.70 (no time-correction) and 0.87 (time-corrected). CLAD related gene sets and classifiers were strongly prognostic for graft failure and correlated with CLAD stage. Thus, in TBBs, molecular changes indicate that CLAD primarily reflects severe parenchymal injury-induced changes and dedifferentiation.

Central, peripheral ECMO or CPB? Comparsion between circulatory support methods used during lung transplantation

BACKGROUND

Chronic obstructive pulmonary disease, cystic fibrosis and usual interstitial pneumonia are three most common indications for lung transplantation (LuTx) in Poland. As a result of irreversible destruction of pulmonary parenchyma and extended respiratory insufficiency that appear afterwards, it is crucial to estimate the reserve of gas exchange in each lung before and during surgery. Altering conditions of gas exchange require adaptation in circulatory system as well. In some of the cases the use of extracorporeal life support appears to be necessary to undergo the transplantation successfully. Cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO) used during operation allow to replace the function of heart and lung, but they are also related to complications in the form of acute kidney failure, bleeding, heart arrhythmias or thromboembolic complications.

METHODS

We reviewed 77 LuTx from 2009 to 2020 performed at the Department of Thoracic Surgery and Transplantation. 40/77 (51%) patients required intraoperative extracorporeal assistance: 8 required CBP and 32 required ECMO. In the ECMO group 14/32 (44%) patients had peripheral cannulation and 18/32 (56%) had central one. We have calculated the survival rates and reviewed postoperative complications after lung transplantations. Cumulative Kaplan-Meier survival curves were calculated. Differences between the groups were evaluated by the Chi- square analysis for discontinuous variables and t-test for continuous variables.

RESULTS

The use of intraoperative central extracorporeal membrane oxygenator was associated with increased survival rates comparing to patients without external support (30-days, 1-year, 3-years, 5-years rates: 78%, 66%, 66%, 66% vs 83%, 65%, 59%, 44% respectively). Furthermore, survival was enhanced comparing to peripheral ECMO or cardiopulmonary bypass as well (50%, 41%, 41%, 33%; 75%, 50%, 50%, 38% respectively). Acute kidney injury and thromboembolic complications occurred statistically more often in case of patients that underwent lung transplantation with support devices (p = 0.005, p = 0.02 respectively). Frequency of other complications was comparable among groups.

CONCLUSIONS

The use of central extracorporeal membrane oxygenation should be favorized over peripheral cannulation or cardiopulmonary bypass. CPB should be no longer used during LuTx. Trial registration Not applicable.

Lung Cancer Occurrence-Correlation with Serum Chromium Levels and Genotypes

Lung cancer is the leading cause of cancer-related death worldwide. Exposure to environmental and occupational carcinogens is an important cause of lung cancer. One of these substances is chromium, which is found ubiquitously across the planet. The International Agency for Research on Cancer has classified chromium(VI) as a human carcinogen. The aim of this study was to assess whether serum chromium levels, as well as DNA variants in selected genes involved in carcinogenesis, xenobiotic-metabolism, and oxidative stress could be helpful in the detection of lung cancer. We conducted a study using 218 lung cancer patients and 218 matched healthy controls. We measured serum chromium levels and genotyped ten genetic variants in ERCC2, XRCC1, MT1B, GSTP1, ABCB1, NQ01, CRTC3, GPX1, SOD2 and CAT. The odds ratios of being diagnosed with lung cancer were calculated using conditional logistic regression with respect to serum chromium level and genotypes. The odds ratio for the occurrence of lung cancer increased with increasing serum chromium levels. The difference between the quartiles with the lowest vs. highest chromium level was more than fourfold in the entire group (OR 4.52, CI 2.17-9.42, p < 0.01). This correlation was significantly increased by more than twice when specific genotypes were taken into consideration (ERCC-rs12181 TT, OR 12.34, CI 1.17-130.01, p = 0.04; CRTC3-rs12915189 non GG, OR 9.73, CI 1.58-60.10, p = 0.01; GSTP1-rs1695 non AA, OR 9.47, CI 2.06-43.49, p = < 0.01; CAT-rs1001179 non CC, OR 9.18, CI 1.64-51.24, p = 0.01). Total serum chromium levels > 0.1 μg/L were correlated with 73% (52/71) of lung cancers diagnosed with stage I disease. Our findings support the role of chromium and the influence of key proteins on lung cancer burden in the general population.

Blood cadmium levels as a marker for early lung cancer detection

BACKGROUND

We assessed whether blood cadmium levels were associated with incident lung cancer and could be used in the context of a screening program for early-stage lung cancer.

MATERIAL AND METHODS

We measured blood cadmium levels among 205 lung cancer patients and 205 matched controls. Cases and controls were matched for sex, age and smoking history (total pack-years, years since cessation for former smokers).

RESULTS

The odds ratio for those in the highest quartile of cadmium level (versus lowest) was four-fold (OR = 4.41, 95 % CI:2.01-9.67, p < 0.01). The association was present in former smokers (OR = 16.8, 95 % CI:3.96-71.2, p < 0.01), but not in current smokers (OR = 1.23, 95 % CI: 0.34-4.38) or in never smokers (OR not defined). Among former smokers, the association was present in both early- and late-stage lung cancer.

CONCLUSION

Blood cadmium levels may be a marker to help with the early detection of lung cancer among former smokers.

Rare indications for a lung transplant. A European Society of Thoracic Surgeons survey

OBJECTIVES

The European Society of Thoracic Surgeons Lung Transplantation Working Group promoted a survey to evaluate overall survival in a large cohort of patients receiving lung transplants for rare pulmonary diseases.

METHODS

We conducted a retrospective multicentre study. The primary end point was overall survival; secondary end points were survival of patients with the most common diagnoses in the context of rare pulmonary diseases and chronic lung allograft dysfunction (CLAD)-free survival. Finally, we analysed risk factors for overall survival and CLAD-free survival.

RESULTS

Clinical records of 674 patients were extracted and collected from 13 lung transplant centres; diagnoses included 46 rare pulmonary diseases. Patients were followed for a median of 3.1 years. The median survival after a lung transplant was 8.5 years. The median CLAD-free survival was 8 years. The multivariable analysis for mortality identified CLAD as a strong negative predictor [hazard ratio (HR) 6.73)], whereas induction therapy was a protective factor (HR 0.68). The multivariable analysis for CLAD occurrence identified induction therapy as a protective factor (HR 0.51). When we stratified patients by CLAD occurrence in a Kaplan-Meier plot, the survival curves diverged significantly (log-rank test: P < 0.001). Patients with rare diseases who received transplants had chronic rejection rates similar to those of the general population who received transplants.

CONCLUSIONS

We observed that overall survival and CLAD-free survival were excellent. We support the practice of allocating lungs to patients with rare pulmonary diseases because a lung transplant is both effective and ethically acceptable.

Molecular T-cell‒mediated rejection in transbronchial and mucosal lung transplant biopsies is associated with future risk of graft loss

BACKGROUND

We previously developed molecular assessment systems for lung transplant transbronchial biopsies (TBBs) with high surfactant and bronchial mucosal biopsies, identifying T-cell‒mediated rejection (TCMR) on the basis of the expression of rejection-associated transcripts, but the relationship of rejection to graft loss is unknown. This study aimed to develop molecular assessments for TBBs and mucosal biopsies and to establish the impact of molecular TCMR on graft survival.

METHODS

We used microarrays and machine learning to assign TCMR scores to an expanded cohort of 457 TBBs (367 high surfactant plus 90 low surfactant) and 314 mucosal biopsies. We tested the score agreement between TBB-TBB, mucosal-mucosal, and TBB-mucosal biopsy pairs in the same patient. We also assessed the association of molecular TCMR scores with graft loss (death or retransplantation) and compared it with the prognostic associations for histology and donor-specific antibodies.

RESULTS

The molecular TCMR scores assigned in all the TBBs performed similarly to those in high-surfactant TBBs, indicating that variation in alveolation in TBBs does not prevent the detection of TCMR. Mucosal biopsy pieces showed less piece-to-piece variation than TBBs. TCMR scores in TBBs agreed with those in mucosal biopsies. In both TBBs and mucosal biopsies, molecular TCMR was associated with graft loss, whereas histologic rejection and donor-specific antibodies were not.

CONCLUSIONS

Molecular TCMR can be detected in TBBs regardless of surfactant and in mucosal biopsies, which show less variability in the sampled tissue than TBBs. On the basis of these findings, molecular TCMR appears to be an important predictor of the risk of future graft failure.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02812290.

Influence of the selenium level on overall survival in lung cancer

BACKGROUND

Although the results of studies in populations with low selenium status indicate an inverse correlation between body selenium levels and the risk of the lung cancer, the effect of this microelement on survival has not been studied.

MATERIALS AND METHODS

We performed a prospective study of 302 patients diagnosed with lung cancer in Szczecin, Poland. Selenium concentration in serum was measured at the time of diagnosis and before treatment. All patients were followed for a maximum of 80 months or until death. Vital status was obtained from the Polish National Death Registry.

RESULTS

Using Cox proportional hazard analysis, performed for all individuals with lung cancer, the hazard ratio (HR) for death from all causes was 1.25 (95% CI: 0.86-1.83, P = 0.99) for patients in the lowest tertile compared to those in the highest tertile of serum selenium levels. Among the patients with stage I disease this relationship was significant (HR-2.73; P = 0.01) for selenium level in tertile 1 (<57 μg/L) compared to tertile 3 (>69 μg/L, reference). The 80 months crude survival after diagnosis was 79.5% (95% CI: 68.5-92.4%) for individuals in the highest tertile and 58.1% (95% CI: 45.1-74.9%) for individuals in the lowest tertile with stage I lung cancer.

CONCLUSION

These results suggest that in patients undergoing treatment for stage I lung cancer, serum selenium levels at the time of diagnosis (>69 μg/L) may be associated with improved overall survival.

Clinicopathological comparison and therapeutic approach to Castleman disease-a case-based review

Castleman disease (CD) is a rare, B-cell lymphoproliferative disorder affecting lymph nodes and extranodal anatomical locations. Four types of clinical presentations can be distinguished after exclusion of mimics. The first division is into unicentric CD (UCD) and multicentric CD (MCD). MCD is classified further as HHV-8-negative (idiopathic), MCD associated with HHV-8 infection, and POEMS associated MCD. From the histological standpoint, UCD and MCD can be classified as hyaline-vascular (HV), plasma cell (PC), or mixed cellularity (MC) type, with a spectrum of histopathological manifestations. We present clinical and histopathological features and grading of 25 cases of CD classified according to CDCN histological criteria and according to this clinical algorithm, along with outcomes. Here we provide a fine-resolution description of the histological features of CD. We review and discuss the current diagnostic algorithm, grading system, and recently recommended treatment options. In the presented group of 25 patients with CD there were 14 women and 11 men in the age range 15-79 years. UCD was identified in 15 patients and it was most often located in mediastinum. MCD most frequently occurred as generalized lymphadenopathy. The most common type of CD was HV. All patients with UCD underwent complete surgical resection with a positive outcome. Patients with MCD had diagnostic partial surgical excision of the lesions, later followed by different types of treatment (corticosteroids, chemotherapy, radiotherapy, immunomodulatory agents) or 'watch and wait'. In four cases CD was associated with other malignancies (laryngeal cancer, small lymphocytic lymphoma, gallbladder cancer with hepatic metastases, primary squamous cell lung cancer). The accuracy of histopathological examination is essential and re-evaluation has to be performed in case of relapse or unexpected course of CD. Treatment tailored to fit the disease type and severity should follow the novel recommendations, including anti-IL-6 treatment in the case of MCD.

Prognostic Factors in Early-stage NSCLC: Analysis of the Placebo Group in the MAGRIT Study

BACKGROUND/AIM

The analysis of prognostic factors is important to identify determinants of disease-free survival (DFS) and overall survival (OS) in resected non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

We examined baseline characteristics associated with DFS and OS among 757 patients with resected, histologically proven, MAGE-A3-positive Stage IB-IIIA NSCLC assigned to placebo in the MAGRIT study (NCT00480025). We explored characteristics of NSCLC that could predict DFS and OS using Cox regression models.

RESULTS

The multivariate analysis showed that lower nodal stage, the presence of squamous cell carcinoma (SCC), a broader surgical resection in patients with SCC, and being female with non-SCC were significantly associated with longer DFS. Lower nodal stage and smaller tumor size were significantly associated with an improved OS. Compared to Other International, enrollment in East Asia was associated with an improved OS in patients with non-SCC.

CONCLUSION

This is the first prognostic factor analysis in NSCLC performed on data from a large prospective study. These results confirm retrospective studies and add that histopathology subtype is a strong determinant of DFS in resected MAGE-A3-positive NSCLC.

Adverse outcomes after percutaneous dilatational tracheostomy versus surgical tracheostomy in intensive care patients: case series and literature review

Tracheostomy is a routinely done procedure in the setting of intensive care unit (ICU) in patients requiring prolonged mechanical ventilation. There are two ways of making a tracheostomy: an open surgical tracheostomy and percutaneous dilatational tracheostomy. Percutaneous dilatational tracheostomy is associated with fewer complications than open tracheostomy. In this study, we would like to compare both techniques of performing a tracheostomy in ICU patients and to present possible complications, methods of diagnosing and treating and minimizing their risk.

[Primary pulmonary mucosa-associated lymphoid tissue lymphoma: a case report]

Primary pulmonary lymphoma accounts only 0,5% of all primary lung neoplasms. Mucosa-associated lymphoid tissue (MALT) lymphoma is a low grade B-cell extranodal lymphoma. It is a quite infrequent entity, however it constitutes from 72% to 90% of all pulmonary lung lymphomas. Long-term stimulation of bronchus-associated lymphoid tissue by antigens, smoking, inflammatory disorders or autoimmune diseases are thought to be leading to the development of MALT lymphoma. We present the case of primary pulmonary mucosa-associated lymphoid tissue lymphoma. A 76-year-old man with a history of heavy smoking (22.5 pack years) was admitted to the hospital for a further diagnostics of an abnormal finding in the right lung visualized on the chest X-ray. The diagnostic process, including imagining studies did not reveal the etiology of a lesion in the right lung. The patient was qualified for surgical diagnostics. The histological finding confirmed extranodal marginal low-grade B-cell lymphoma of mucosa -associated lymphoid tissue.

Surgeon's viewpoint on lung transplantation in cystic fibrosis patients - preliminary report

INTRODUCTION

The surgeon's viewpoint on a patient with cystic fibrosis differs from that of a pediatrician or internist. The problems a cystic fibrosis specialist encounters are different from those faced by the surgeon who takes over the patient in a very advanced, often terminal stage of the disease. Hence, the main problem for the surgeon is the decision concerning the surgery (lung transplantation, pneumonectomy, lobectomy). It is, therefore, important to lay down fundamental and appropriate rules concerning the indications and contraindications for lung transplantation, especially in patients with cystic fibrosis.

AIM

The aim of this study was to analyze the methods of qualifying and preparing patients for surgery, as well as carrying out the procedure of transplantation and postoperative short and long-term care.

MATERIAL AND METHODS

The investigation was carried out on 16 patients with cystic fibrosis. Three were operated on and 10 were on the waiting list for transplantation. Two patients on the waiting list died, one patient was disqualified from transplantation. During qualification for lung transplantation, strict indications, contraindications and other factors (such as blood type, patient's height, coexisting complications) were taken under consideration.

RESULTS

All the 3 patients after lung transplantation are alive and under our constant surveillance. Ten patients await transplantation, though four of them are suspended due to hepatitis C infection. Two patients on the waiting list died: one from respiratory insufficiency and the other in the course of bridge to-transplant veno-venous extracorporeal membrane oxygenation due to hepatic failure. One patient has been disqualified because of cachexia.

CONCLUSIONS

Since lung transplantation is the final treatment of the end-stage pulmonary insufficiency in cystic fibrosis patients, the number of such procedures in cystic fibrosis is still too low in Poland. The fast development of these procedures is highly needed. It is necessary to develop better cooperation between different disciplines and specialists, especially between pediatricians and surgeons. The correct choice of the suitable moment for lung transplantation is crucial for the success of the procedure.

Accelerated treatment of postpneumonectomy empyema - report of 12-year experience

We report 12-year experience in the accelerated treatment (AT) of postpneumonectomy empyema (PPE). There were 38 patients (7 females, 31 males) in age 19-80 years. 34 patients underwent pneumonectomy due to non-small cell lung cancer (NSCLC), 2 for other malignancies, and 2 for lung abscess. 19 right and 19 left pneumonectomies were performed. PPE was caused by bronchopleural fistula in 16 cases (42.1%) and by pleural infection in 22 patients (57.9%). The interval between first symptoms of PPE and AT ranged 1-47 months. The technique described by Schneiter et al. is based on repeated debridement/lavage of the postpneumonectomy cavity every second day performed a total of three times. 35 patients (92.1%) were free from empyema definitively. 4 of them required additional thoracomyoplasty and another 2 of them thoracostomy due to PPE recurrence. 1 patient (2.6%) during hospitalisation and 2 (5.2%) didn't complete treatment and remained drain carriers. AT alone without additional procedures healed 29 patients (76.3%). Follow up time for the NSCLC group was 8-148 months (median 67). Cancer recurrence or second malignancy rate was 8/36 (22%). Accelerated treatment of PPE is safe and effective. It provides cure for the vast majority of patients without thoracoplasty. Patients with cancer and PPE tend to live longer than similar patients without PPE.

Leczenie operacyjne nowotworów płuc u biorców przeszczepów narządów litych

Powikłania płucne u biorców narządów cechują się trudnościami diagnostycznymi, poważnym rokowaniem i często słabą odpowiedzią na leczenie. Niektóre z nich wymagają diagnostyki inwazyjnej i leczenia operacyjnego, a inne długotrwałego leczenia farmakologicznego. Gruźlica, zakażenia Pneumocystis sp. i zakażenia grzybicze należą do grupy powikłań infekcyjnych. Pierwotne i wtórne nowotwory płuc powstające w niedalekim odstępie czasowym od transplantacji narządu litego noszą miano powikłań onkologicznych, a oba typy powikłań mają swoje podłoże w immunosupresji. Wymóg kontynuacji immunosupresji dotyczy także okresu leczenia wyżej wymienionych powikłań, stawiając podwyższone wymagania dla zespołów terapeutycznych. Przedstawiono grupę 5 chorych (2 kobiety i 3 mężczyzn) po przeszczepieniach narządów leczonych w ośrodku autorów z powodu nowotworów płuc. Czterech chorych przebyło transplantację wątroby, a jeden serca. Trzech chorych leczono z powodu pierwotnego raka płuca, z czego u 1 dodatkowo wystąpił przerzut raka płuca, u 2 chorych rozwinęły się zmiany przerzutowe raka wątrobowokomórkowego (HCC) z wszczepionej z tego powodu wątroby. Czterech chorych operowano. Wykonano 2 lobektomie i 1 segmentektomię, uzupełnione o limfadenektomię w grupie zmian pierwotnych, jedną obustronną resekcję przerzutów (HCC) i jedną resekcję przerzutu raka płuca wcześniej zoperowanego. Wszystkie przypadki pierwotnego raka płuca miały charakter raka płaskonabłonkowego. Opisano przebiegi okołooperacyjne, schematy immunosupresji oraz dodatkowe powikłania infekcyjne (gruźlica, zakażenie uogólnione i zakażenie dróg żółciowych, kandydoza przełyku), jakie miały miejsce w tej grupie chorych, choć powikłania te nie były związane z obecnym procesem leczenia. Podkreślono znaczenie nikotynizmu w tej grupie chorych, bowiem każdy z nich był palaczem tytoniu.

1,25-Dihydroxycholecalciferol with low-calcium diet reduces acute rejection in rat lung allotransplantation

OBJECTIVES

The effect of 1,25-dihydroxycholecalciferol (calcitriol, vitamin D3) with a low-calcium diet on the acute lung allograft rejection in a rat unilateral left lung transplantation model was evaluated.

METHODS

Three transplantation groups were studied (n = 5, male Brown-Norway to Fischer F344, 235 ± 15 g body weight): calcitriol and low-calcium diet, low-calcium diet and normal diet. Calcitriol (4 μg/kg/day) was injected intraperitoneally for 5 days, starting from the day of transplantation. In addition, two non-transplantation groups were compared: (n = 3, Brown-Norway) to measure the level of cytokines, and Fischer F344 receiving calcitriol and a low-calcium diet to measure the serum calcium level. The recipients of transplantation were killed on Day 5 post-transplant. The contralateral right main bronchus and the pulmonary artery were occluded for 5 min and blood was drawn for the blood gas analysis, and the grafts were assessed for histology (International Society for Heart and Lung Transplantation 1996/rank scale). Lung levels of interleukin (IL)-2, IL-6, IL-12 and tumour necrosis factor-α (TNF-α) were assessed within the calcitriol and low-calcium diet, low-calcium diet and Brown-Norway groups. The serum calcium level was assessed in the Fischer F344 group. An analysis of variance with Tukey's post hoc test was used to compare the arterial blood oxygen pressure and the lung cytokine expression between groups. A non-parametric Kruskal-Wallis test followed by the Siegel and Castellan post hoc test was used to assess the differences between the groups according to the lung graft rejection grading. Student's paired t-test was used to compare the serum calcium level.

RESULTS

The arterial PaO(2) was significantly higher in the calcitriol and the low-calcium diet groups when compared with low-calcium diet or normal diet groups (356 ± 72 mmHg; P < 0.05 vs other groups). The arterial and bronchial rejection observed in calcitriol and low-calcium diet group was significantly milder than in the low-calcium diet or normal diet groups (A1-2, B1-2; P < 0.05 vs other groups). IL-2 and IL-6 levels were significantly higher in low-calcium diet vs calcitriol and low-calcium diet and Brown-Norway groups. IL-12 and TNF-α did not differ among the groups. There was no significant difference in serum calcium level before and after the treatment in the Fischer F344 group.

CONCLUSIONS

Calcitriol with a low-calcium diet treatment improves lung function, reduces lung allograft acute rejection, decreases IL-2 and IL-6 allograft expression and does not change the serum calcium level significantly.

[Surgical treatment of malignant lung tumors in solid organ recipients]

Diagnostic difficulties, serious prognosis and often insufficient response to treatment are all common features of pulmonary complications in solid organ recipients. Some of these complications need invasive diagnostic procedures and surgical treatment or prolonged pharmacological treatment. Tuberculosis, Pneumocystis and fungal infections are examples of infectious complications. Primary lung cancer or metastasis to the lungs developed shortly after solid organ transplantation are oncological complications. Infectious and noninfectious complications are connected with immunosuppression. Treatment of pulmonary complications in solid organ recipients and continuation of immunosuppression therapy can be challenge for therapeutic team. This article presents five cases (2 women and 3 men) of solid organ recipients treated in department of the authors due to lung neoplasms. Four of them were liver recipients and one was recipient of heart. Three patients were treated due to primary lung cancer, additionally in one of them metastasis of lung cancer occurred, two suffered from metastasis of liver cancer (hepatocellular carcinoma) to the lungs. Four patients underwent 6 operation: 2 lobectomies with lymphadenectomy, 1 segmentectomy with lymphadenectomy, 1 bilateral metastasectomy of HCC and 1 metastasectomy of lung cancer. In all cases of primary lung cancer pathological examination revealed squamous cell carcinoma. Immunosuppression schedule, perioperative courses and infectious complications (tuberculosis, disseminated infection, infection of biliary tract, oesophageal candidiasis) in this group were described. All of them were smokers.

Stricture caused by a plastic vascular clip used during an operation of minimally invasive esophagectomy

This article describes the case of a 62-year-old female who had had minimally invasive esophagectomy (Ivor-Lewis) for squamous cell carcinoma of the distal third of the esophagus. The anastomotic stenosis was accompanied by solid food dysphagia and the presence of a foreign body in the esophagus. The foreign body was fixed to the esophageal wall and could not be removed endoscopically. The patient was reoperated on through a 8 cm right thoracotomy. The anastomosis was reached via a gastrotomy, and the large-size plastic vascular clip was removed. The clip was primarily used to close the transsected azygos vein, it was then incorporated into the esophageal anastomotic region and subsequently partially protruded into the lumen of the gastrointestinal tract. After removal of the clip, backward dilatation of the anastomosis was performed by Savary-Gilliard dilators, with restoration of its proper diameter.

[The influence of immunosuppression on vancomycin concentration in the rat allogenic lung transplant]

AIM

To assess the influence of conventional immunosuppression on vancomycin concentration in the rat allogenic lung transplant basing on acute and hyperacute rejection models.

MATERIAL AND METHODS

Left lung allotransplantations were performed from Brown Norway donors to Fisher F 344 recipients in the acute rejection model (animals were sacrificed 5 days after transplantation), and from Brown Norway donors to Wistar recipients in the hyperacute rejection model (animals were sacrificed 2 days after transplantation). Immunosuppression (cyclosporin A 5 mg/kg b.w., aziathioprine 4 mg/kg b.w., methylprednisolone 4 mg/kg b.w.) was administered daily. Control rats received no immunosuppression and were sacrificed on day 2 or 5, respectively. Rejection grading was done on the basis of arterial pO2 and histology of the lung graft sample obtained at autopsy. A single 30 mg/kg b.w. dose ofvancomycin was injected intraperitoneally on day 2 or 5 depending on the model. Samples of blood and grafted lung were collected 30 min, 1 h, 2 h, 4 h, and 6 h from injection.

RESULTS

Arterial pO2 levels were significantly higher in the group with acute rejection and immunosuppression as compared with the control groups. Histology revealed attenuated rejection in the immunosuppression groups. Vancomycin concentration in the transplanted lung and the lung graft to plasma vancomycin concentration ratio did not differ in the immunosuppression and control groups.

CONCLUSIONS

Immunosuppression has no influence on vancomycin concentration in the transplanted lung.

The Usefulness of Scintigraphic Assessment of Thoracic Splenosis—A Case Report

Thoracic splenosis of the left lung and upper abdominal area was described. Left minithoracotomy was performed due to unclear results from a fine needle biopsy and following the suggestion to obtain a tissue sample. Clinical findings were similar to neoplasmatic disease; intraoperative extension of the disease was larger than CT view and correlated with postoperative assessment with 99mTc sulphur colloid. This confirmed the usefulness of scintigraphic assessment in preoperative diagnosis in order to avoid thoracotomy in such cases.

[Usefulness of the scintigraphic assessment of the thoracic splenosis -- a case report]

Thoracic splenosis of the left lung and upper abdominal area was described. Left minithoracotomy was performed due to unclear results from a fine needle biopsy and following the suggestion to obtain a tissue sample. Clinical findings were similar to neoplasmatic disease; intraoperative extension of the disease was larger than CT view and correlated with postoperative assessment with (99m)Tc sulphur colloid. This confirmed the usefulness of scintigraphic assessment in preoperative diagnosis in order to avoid thoracotomy in such cases.

Long-term survival after resection of giant chondrosarcoma of the chest wall weighing 9.6 kg

The case of a 43 year old male with giant chest wall tumor weighing 9.6 kg verified as chondrosarcoma is described. The patient was treated by multiple (six times) surgical procedures including left costopleuropneumonectomy and left subclavian artery end-to-end anastomosis between 1998 and 2005. Despite the palliative character of surgery, he achieved long-term survival but finally refused next surgery due to the risk of left upper limb amputation and died a few months later.

Colchicine against ischemia-reperfusion injury in experimental lung transplantation

BACKGROUND

To asses the influence of colchicine, a potent antinflammatory agent and neutrophile migration inhibitor, on Ischemia-Reperfusion Injury (IRI) in rat lung isogeneic transplantation.

MATERIAL/METHODS

Isogeneic, orthotropic single left lung transplantations were performed among male Wistar rats after total ischemic graft storage time of 12 or 18 hours in temperature of 4 degrees C. Recipients received either no specific treatment (control) or Colchicine 1.2 mg/kg/d ip. Twenty-four hours after transplantation, the native contralateral lung was occluded to assess graft gas exchange function (PaO(2)). The lung graft was excised and assessed for Wet/Dry ratio (W/D) as a measure of edema, Myeloperoxidase activity (MPO) as a measure of neutrophile migration and histology.

RESULTS

PaO(2) differences were not significant among all groups. Comparing colchicine to control group, the W/D ratio 3.93+/-0.66 vs. 1.86+/-0.32, p=0.002 and MPO 8.1+/-3.34 vs. 5.87+/-1.76, p=0.046 were significantly higher for 18 hours colchicine group. Comparing 18 to 12 hours time groups, the W/D ratio 5.70+/-1.53 vs. 1.86+/-0.32, p=0.007 for control groups and 5.40+/-1.49 vs. 3.93+/-0.66, p=0.049 for colchicine groups were significantly higher for both 12 h groups. Histology favored colchicine treated animals.

CONCLUSIONS

Colchicine in tested dose does not decrease edema after lung transplantation and does not improve lung function. 18 vs. 12 hours total ischemic graft storage time causes less lung edema.

Strong additive effect of 1,25-dihydroxycholecalciferol and cyclosporine A but not tacrolimus in rat lung allotransplantation

OBJECTIVES

1,25-Dihydroxycholecalciferol (calcitriol, vitamin D3) has immunosuppressive properties. This study evaluates the effect of calcitriol in combination with either cyclosporine A or tacrolimus on acute lung allograft rejection in a rat model of unilateral left lung allotransplantation.

METHODS

Unilateral left lung transplantation was performed in male rats (Brown-Norway to Fischer F344, 200-250 g body weight). For immunosuppression, the following subtherapeutic doses were used: calcitriol 0.5 microg/kg/day, cyclosporine A 2.5 mg/kg/day i.p., and tacrolimus 40 microg/kg i.m. Five groups (n = 5) were analyzed: cyclosporine A; cyclosporine A and calcitriol; calcitriol; tacrolimus and calcitriol; and tacrolimus. The injections were performed for 5 days starting from the day of transplantation. Recipients were sacrificed on day 5 post-transplant. The contralateral right main bronchus and pulmonary artery were occluded for 5 min and blood was drawn for blood gas analysis. The grafts were excised, fixed in formaline and embedded in paraffin. Histological evaluation was done in blinded fashion (ISHLT 1999/rank scale). The mean and standard error of the mean (PaO2) or the median and range (rejection grading) are given. ANOVA followed by planned comparison for the PaO2 and Kruskal-Wallis ANOVA for rejection grading were applied, p < 0.05 considered significant.

RESULTS

Arterial PaO2 on day 5 was very low in animals treated with subtherapeutic dosages of either cyclosporine A (48 +/- 10 mmHg), calcitriol (51 +/- 3) or tacrolimus (86 +/- 22). Combined treatment with cyclosporine A and calcitriol revealed a significant improvement (248 +/- 78; p < 0.05 vs. other groups), whereas the combination of tacrolimus with calcitriol did not reveal any benefit (65 +/- 9). Rejection grading with these subtherapeutic doses did not show any significant difference between groups.

CONCLUSIONS

Our data indicate that cyclosporine A, but not tacrolimus, has a strong additive effect with calcitriol on acute rat lung allograft rejection.

Model of single left rat lung transplantation. Relation between surgical experience and outcomes

PURPOSE

The model of unilateral orthotropic left rat lung transplantation is well known and established experimental procedure. The author's personal learning curve of mastery process of this microsurgical procedure is presented.

MATERIAL AND METHODS

During 18 months the author has performed 197 single left lung transplantations on the Thoracic Surgery Ward in University Hospital, Berne, Switzerland. There were 147 allogeneic and 50 isogeneic transplantations done. The allogeneic transplantations were carried out from Brown-Norway to Fischer F344 rats whereas isogeneic transplantations were done among Fischer F344 rats solely. Grafted lung was obtained from the intravenously anaesthetised, oxygen-ventilated donor. The implantation was carried out through left posterolateral thoracotomy on the gas anaesthetised, respirator ventilated recipient. The anastomoses of the vessels were done using the cuff technique, bronchi were sutured using continuous running over-and-over suture. Recipients were sacrificed on day 5 post-transplant. All recipients were divided into four consecutive groups. Warm ischaemia time and presence of perioperative pure technical complications were observed.

RESULTS

We observed time dependent decline of complications number of consecutive recipient groups, respectively 20, 5, 4, 1. The warm ischaemia time in minutes decreased from 35.6 +/- 5.4 in group I through 26.7 +/- 4.4 in group II, 24.8 +/- 2.3 in group III to 22.0 +/- 3.1 in group IV.

CONCLUSIONS

Continuous training of the procedure shortens the average warm ischaemia time and reduces the number of complications. This tedious microsurgical procedure is possible to master by the surgeon.

Non-viral gene delivery to atelectatic and ventilated lungs

BACKGROUND

Three different nonviral vectors and naked DNA were evaluated for in vivo transfer of plasmid DNA to rat lungs through airways in either atelectatic or ventilated lungs.

METHODS

The F344 rats underwent instillation of 300 microg DNA (pCIluc, luciferase) to the left lung. Naked DNA, linear polyethylenimine, branched polyethylenimine, and lipid GL-67 (in either atelectatic or ventilated lungs) were assessed (n = 5 per group). After 24 hours, left lung PaO2 (mm Hg) and luciferase activity (RLU/mg) were measured. The median (range) was given, and the analysis of variance was applied, followed by the planned comparison on log-transformed data.

RESULTS

In atelectatic lungs, lipid GL-67 was best (927 [330 to 4112] RLU/mg; p < 0.001 versus other groups of atelectatic lung; p < 0.001 versus all other groups), but highest luciferase activity in all groups was measured in ventilated lungs using linear polyethylenimine (1,240 [922 to 2519] RLU/mg; p < 0.001 versus other groups of ventilated lung; p < 0.001 versus all other groups). In comparison with naked DNA, all nonviral vector systems significantly impaired PaO2 24 hours after airway transfection (p < 0.001; naked DNA versus all other groups). Regardless of transfection technique, PaO2 was worst in lungs transfected by linear polyethylenimine.

CONCLUSIONS

Highest transfection was achieved with GL-67 in atelectatic lungs and with linear polyethylenimine in ventilated lungs. All gene delivery systems impaired gas exchange of the transduced lung in comparison with naked DNA.

Effects of linear polyethylenimine and polyethylenimine/DNA on lung function after airway instillation to rat lungs

Lung transplantation is an acceptable treatment option for various end-stage pulmonary diseases, but long-term survival currently lags behind that after transplantation of other solid organs. We hypothesized that gene transfer to grafts before transplantation may be a useful method to deliver antioxidant and/or anti-inflammatory genes to modulate these processes. For this purpose, we assessed the efficiency of gene transfer and effects on lung function of the synthetic polycation, linear polyethylenimine (PEI), after airway instillation to the lungs of Fischer rats. Twenty-four hours after gene delivery, reporter gene activity in DNA/PEI treated rats was approximately 12-fold higher than that in rats treated with naked DNA, but by 72 hours there was no significant difference between groups and activity had decreased by at least 85%. Function of the transfected left lung was assessed by measuring arterial PaO(2) levels and was found to be significantly lower at 24 and 72 hours after gene transfer in the PEI/DNA group compared with the naked DNA group. The deterioration in lung function correlated with histological findings. Rats treated with PEI alone and sacrificed after 72 hours showed an impairment in lung function similar to that seen with PEI/DNA treatment. Our studies highlight the importance of assessing the functional capacity of a graft after gene transfer to determine suitability for subsequent transplantation.

[Disruption of the middle bronchus]

Disruption of the middle lobe broncus as a result of blunt chest trauma is described. Patient underwent emergency reconstructive operation. Follow-up examination revealed normal postoperative chest radiogram but bronchoscopy showed decreased patency of bronchial anastomosis. Perfusion lung scintigraphy showed severely decreased perfusion of the entire right lung. Concomitant fracture of right clavicle resulted in false joint which required surgical intervention 4 weeks after the chest trauma.