Lingular division of the left lung: Only superior and inferior bronchi?

The lingular segment bronchi usually bifurcate into superior lingular (B4 ) and inferior lingular (B5 ) segmental bronchi. We report 32 horizontally bifurcated lingular segment bronchi cases, analyzing the bronchovascular variations and the perioperative outcomes. All patients with pulmonary lesions underwent three-dimensional computed tomography bronchography and angiography between January 2019 and January 2022. The bronchovascular patterns were analyzed for each patient. A consecutive 5280 patients were included, and 32 cases of this malformation were identified. The incidence of the lateral (B4 ) and medial (B5 ) lingular segmental bronchi is 0.6%. The A4 and A5 arise separately in 21 (65.6%) patients. In 9 (28.1%) patients, the A4 a arises from the common trunk of A4 + 5 . In 2 (6.3%) patients, the A4 arises from the interlobe artery, while A5 is a mediastinal lingular artery. The common trunk of V4 a + b is found in 19 (59.4%) patients. The V5 is the least changeable of the segmental bronchi veins. Among the 32 patients, five patients had an LS4 segmentectomy. The surgical details of the five patients are summarized. The laterally and medially bifurcated lingular bronchus pattern is a rare anomaly. It implies that the lingular bronchus is not only superiorly and inferiorly bifurcated.

Thoracoscopic Anatomical Enucleation of GGO.

BACKGROUND: Enucleation was commonly used in the surgery of the eye or prostate. The implication in the treatment of GGO is never reported. METHODS: In this multimedia article, we described a thoracoscopic enucleation of GGO between S7 and S8 in the right lower lobe. According to the pre-operative 3D-CTBA, few bronchovascular structures were passing through the border of RS7 and RS8-a primarily pulmonary parenchyma region. Therefore, an enucleation of GGO is feasible with a low risk of injuring adjacent structures. The main utility incision and observing port were inserted in the fourth and seventh intercostal space in the anterior axillary line. Two assistant incisions were made in the seventh intercostal space in the mid-axillary line and the ninth intercostal space in the posterior axillary line. The GGO is invisible and unpalpable, so it cannot be located intraoperatively. The surgery was initiated by dividing the lung parenchyma alongside the anatomic landmark of A7 on the left. On the right, the common trunk of A8-10 was dissected until A8 was identified. The last anatomic landmark is V8b, which lies posteriorly. The lung parenchyma was dissected by electrocautery hook along with the A7, A8, and V8b to the diaphragmatic surface. Using an electrocautery hook during dissection is preferable, whose terminal is sharper and more flexible. The ultrasonic scalpel is not recommended. A glove is utilized for the specimen retrieval to avoid implantation metastasis. RESULTS: The operative time was 0.5 h with an estimated blood loss of 10 ml. With no chest tube, the patient was discharged on postoperative day 1. The final pathological finding was minimally invasive adenocarcinoma (pTmiN0M0). DISCUSSION: Considering the natural history and excellent prognosis of GGO, the safe margin is the primary concern for GGO resection.1,2 We use the anatomic landmark to secure a safe margin in enucleation. Besides, dissection of the anatomic intersegmental plane by electrocautery (but not by stapling) reduces unfavorable recurrent local failure at the margin and allows full expansion of the preserved adjacent segments to result in maximal pulmonary function.3.

Boyden's triad in the left lung: an interesting phenomenon.

OBJECTIVES: Boyden's triad of the right lung was first proposed in 2021. Here, we report 5 cases of this malformation found in the left lung. METHODS: A total of 5280 patients with pulmonary lesions underwent three-dimensional computed tomography bronchography and angiography between January 2019 and January 2021, prior to surgery; 5 cases of this malformation were identified in the left lung. Bronchovascular patterns were analysed in each patient. RESULTS: The incidence rate of Boyden's triad in the left lung was 0.1%. This malformation was further divided into B3 on B4+5 type and B3 on B4 type. In B3 on B4+5 type, B3 was shifted downwards on the common trunk of B4+5, and A3 arose from the common trunk of A4+5 running alongside B3. In B3 on B4 type, B3 was shifted downwards on B4. A4 and A5 appeared separately. A3 arose from A4, running alongside B3; A5 arose from the common trunk of A8 - 10, and there was also an extraordinary 'posterior vein' (V. post): V1+2c. The incidence of V. post was 0.17%. An additional 'fissure' lies longitudinally between S1+2 and S3+4+5, nearly perpendicular to the oblique fissure, dividing the upper lobe into 'two lobes'. CONCLUSIONS: The B3 downwards-shifting malformation can be found on both lungs, and this is the first description of Boyden's triad in the left lung; it appears to be much rarer than that in the right lung, with some accompanying unique variations.

Vein or artery-first resection in right middle lobe segmentectomy: which preserves more lung?

We report the thoracoscopic RS5 segmentectomy with VVBA (V, vein; V, ventilation; B, bronchus; A, artery) method and confirmed that the segmental plane visualized by vein-first resection is slightly narrower than the traditional artery-first resection.

The VVBA method for thoracoscopic right middle lobe segmentectomy.

The right middle lobe segments (RS4 and RS5) are very small and the technique for segmentectomy is rarely reported. Here, we report 3 cases of thoracoscopic RS4 segmentectomy with VVBA (V, vein; V, ventilation; B, bronchus; A, artery) method. The VVBA method for thoracoscopic segmentectomy is a simple, safe, and effective procedure for RS4 segmentectomy with clear procedural steps. It overcomes the difficulty in manipulation of incomplete lung fissures and simplifies the surgical procedures.

Analysis of the variation pattern in left upper division veins and establishment of simplified vein models for anatomical segmentectomy.

BACKGROUND: Three-dimensional computed tomography bronchography and angiography (3D-CTBA) is a powerful tool to analyze pulmonary anatomy. We used 3D-CTBA to analyze variations of the pulmonary veins of the left upper division (LUD) and created a simplified LUD vein model. METHODS: Between January 2019 and October 2019, 124 patients with left-sided pulmonary lesions were admitted and underwent 3D-CTBA prior to surgery. We reviewed the anatomical variations of the LUD veins in these patients using 3D-CTBA images and classified them according to their position in relation to the bronchus. To facilitate this process, the same nomenclature as that used to describe the veins of the right upper lobe (RUL) is used for the LUD. RESULTS: The pattern of LUD veins could be classified into three forms: an anterior + central form, an anterior form and a central form. For the central form, V 1+2 a, V 1+2 b, V 1+2 c and V 1+2 d drained into V. cent. For the anterior form, V 1+2 d drained into V. ant. The anterior + central form could be further classified into three subtypes (V abc, V ab and V a). CONCLUSIONS: This is the first report to categorize the pattern of veins in the LUD. This may facilitate the creation of simplified models for use in pre-operative planning for segmentectomy.

The B1 defective type of bifurcated right upper lobe bronchus.

BACKGROUND: As the more application of high-resolution computed tomography (HRCT), a great number of ground glass opacity (GGO) is identified. Video-assisted thoracoscopic surgery (VATS) segmentectomy is technically more difficult than lobectomy because of the anatomical complexity. Three-dimensional computed tomography bronchography angiography (3D-CTBA) is a powerful tool for thoracic surgeons to analyze pulmonary anatomy, allowing a better understanding of the pulmonary anatomy in each patient. Here we encountered seven cases of bifurcated right upper bronchus (B1 defective). The variation in vascular pattern of these patients is analyzed. METHODS: Between October 2018 and December 2018, a consecutive 162 patients with pulmonary lesions were admitted and underwent 3D-CTB prior to surgery. A total of seven cases of bifurcated right upper bronchus (B1 Defective) were identified. Then 3D-CTBA reconstruction was performed by Syngo MultiModality Workplace (Software: Syngo MMWP, Version: VF40A). Radiology colleagues processed all 3D images and thoracic surgeons confirmed the validity of all reconstructions. RESULTS: The mean age of the seven patients (3 females and 4 males) is 54 years. According to the branches of artery, they are divided into two types: "Tr. sup + A. asc" (2/7, 28.6%) and "Tr. sup + Tr. inf + A. asc" (5/7, 71.4%). According to the branches of A2 asc, another two types can be divided: type A, two branches of A2a asc + A2b asc (4/7, 57.1%) and type B, only one branch of A2b asc (3/7, 42.9%). Types can also be divided according to the branches of A2 rec: A, no A2 rec (4/7, 57.1%); B, one branch of A2a rec (2/7, 28.6%); C, two branches of A2a rec + A2b rec (1/7, 14.3%). According to the origins of A3, three types can be divided: A, A3 origins from Tr. inf (1/7, 14.3%); B, A3 origins from Tr. sup (2/7, 28.6%); C, A3 origins from both Tr. sup and Tr. inf (4/7, 57.1%). CONCLUSIONS: The "defective B1" type of bifurcated right upper lobe (RUL) bronchus is relatively rare. A pre-operative understanding of its anatomical features, especially the vascular variation patterns, may be helpful for completing a satisfactory segmentectomy. 3D-CTBA is a powerful tool, allowing a better understanding of the pulmonary anatomy in each patient before and during surgical procedures.

The Effects of Different Surgical Approaches on the Perioperative Level of Circulating Tumor Cells in Patients with Non-Small Cell Lung Cancer.

Background To observe and compare the effects of video-assisted thoracoscopic surgery (VATS) and conventional thoracotomy on the levels of circulating tumor cells (CTCs) in patients with non-small cell lung carcinoma (NSCLC). Methods Seventy-nine patients with a diagnosis of NSCLC were enrolled in the study. Forty-three were treated with VATS and 36 were treated with conventional thoracotomy. Blood samples were collected 3 days prior to surgery (d-3), during surgery (d0), and 3 days after surgery (d3). After epithelial cell adhesion molecule (EpCAM)-labeled immunomagnetic cell enrichment, anti-CK-PE and anti-CD45-FITC fluorescent-labeled monoclonal antibodies were added to sort CTCs. Quantification of CTCs was performed using multiparameter flow cytometry. Results The number of CTCs on d0 was significantly higher than on d-3 (5.730 ± 4.266 vs. 4.142 ± 3.971, p = 0.033) in both groups. There was no significant difference in the change of CTCs from before surgery to during surgery in the VATS and conventional thoracotomy (open) groups (1.363 ± 2.924 vs. 1.500 ± 2.315, p = 0.329). However, the increase in number of CTCs from before surgery to after surgery was significantly lower in the VATS group than in the conventional thoracotomy (open) group (2.181 ± 2.962 vs. 9.666 ± 15.641, p = 0.015). Thirty of the 79 patients tested positive for CTCs before surgery (37.97%). All benign lung disease patients and volunteers tested negative for CTCs. Conclusion A smaller increase in CTCs was seen in patients treated with VATS lobectomy than in patients treated with conventional thoracotomy. This reduction in number of postoperative CTCs may improve long-term survival.

Quantification of serum HBXAP DNA in lung cancer patients by quantitative fluorescent polymerase chain reaction.

Hepatitis B virus x associated protein (HBXAP), as a subunit of chromatin remodeling and spacing factor, plays a critical role in cancer development through gene amplification. In this study, we aimed to quantify the levels of serum HBXAP DNA, to analyze and compare its diagnostic value with existing clinical parameters in lung cancer, and to potentially provide a novel tumor marker for lung cancer. Serum HBXAP DNA from 65 lung cancer patients and 20 healthy controls was quantified using real-time fluorescent quantitative polymerase chain reaction (FQ-PCR) analysis. The data were analyzed by statistical software SPSS 13.0. We found that serum HBXAP DNA levels in lung cancer patients were higher compared to healthy controls (u = 219.0, p = 0.001) and were closely associated with TNM stage and lymph node metastasis (p = 0.015 and p = 0.016, respectively). However, serum HBXAP DNA levels were not associated with patient age, gender, smoking status, histological type, or tumor size (p > 0.05). We identified a sensitivity of 61.9 % and a specificity of 93.7 % for the ability of HBXAP DNA levels to detect lung cancer at a cutoff value of 1,557.6 copies/µl. The sensitivity for existing lung-tumor markers, such as squamous cell carcinoma antigen, cytokeratin fragment 21-1, and neuron specific enolase, was increased from 35.7 %, 53.5 %, and 56.0 % to 75.0 %, 86.0 %, and 80.0 %, respectively, by inclusion of serum HBXAP DNA. Taken together, quantification of serum HBXAP DNA by FQ-PCR could potentially serve as a novel complementary tool for the clinical screening and detection of lung cancer.

Primary idiopathic chylopericardium: a rare case with a synopsis of the literature.

Primary idiopathic chylopericardium is a rare clinical entity characterised by the collection of chyle within the pericardial cavity without a definitive cause. This case report describes the history, physical examination, evaluation, diagnosis and treatment of a 19-year-old boy with primary idiopathic chylopericardium. Radiological findings and biochemical analysis of the pericardial fluid following pericardiocentesis sustained this diagnosis. Initial conservative management failed, and the patient was surgically treated subsequently. He recovered well postoperatively and remained asymptomatic thereafter. Primary idiopathic chylopericardium is a rare pathology with very few cases reported till date, and the symptoms are commonly due to cardiac compression. Computed tomography of the chest and bipedal lymphoscintigraphy are considered the standard methods for accurate diagnosis, and in cases of failed medical treatment, open and thoracoscopic thoracic duct ligation with pericardiectomy have been described as the best surgical options.

[Genetic fingerprinting of human lung squamous cancer with lymphatic metastasis].

OBJECTIVE: To identify the differentially expressed genes related to lymphatic metastasis of lung squamous cell carcinoma. METHODS: Specimens of primary lung squamous cancer tissues and regional lymph nodes were obtained from 10 patients undergoing complete surgical resection of the tumor. The samples were classified into 3 groups, namely the primary tumor with lymphatic metastasis (TxN+, n=5), primary tumor without lymphatic metastasis (TxN-, n=5) and matched tumor cells from the metastatic lymph nodes (N+, n=5). The total RNA extracted from the laser microdissected primary tumor or metastatic nodes was labeled and hybridized with the microarray containing 6 000 known human genes or ESTs. Data analysis was performed using GeneSpring(TM) 6.2 software. Immunohistochemical staining was used to detect the expression of CCL20 in the specimens. RESULTS: A total of 37 genes showed differential expressions between TxN+ and TxN- tissues, among which 8 genes were upregulated and 29 were downregulated in TxN+ group. No genes, however, showed distinct differential expressions between N+ and TxN+ tissues. The expression of CCL20 was significantly higher in TxN- than in TxN+ tissues (P<0.05). CONCLUSION: The acquisition of the metastatic phenotype may occur early in the development of lung squamous cancer. The gene expression signature of lung squamous cell carcinoma is valuable to elucidate the molecular mechanisms regarding lymphatic metastasis of the malignancy, and may provide important clues for exploring novel therapeutic targets.

[Gene expression signature for lymphatic metastasis of human lung adenocarcinoma].

BACKGROUND AND OBJECTIVE: Distant metastasis is a major cause of mortality for patients with lung adenocarcinoma. So far, the mechanism of tumor metastasis is unknown. This study was to screen the gene expression signature in relation to lymphatic metastasis of human lung adenocarcinoma. METHODS: Primary lung adenocarcinoma tissues and regional lymph nodes were obtained from 22 patients underwent radical resection. The samples were classified into three groups: 11 cases of primary lung adenocarcinoma without lymphatic metastasis (TxN-), 11 cases of primary lung adenocarcinoma with lymphatic metastasis (TxN+), and 11 cases of the corresponding tumor cells from metastatic lymph nodes(N+). Total RNA was extracted from laser microdissected tumor samples. Adequate RNA starting materials from the primary tumors or metastatic nodes were labeled and then hybridized into the same microarray containing 6000 known human genes or expressed sequence tags (ESTs). After scanning, data analyses were performed using GeneSpring 6.2. RESULTS: Among 17 differentially expressed genes between the TxN+ and TxN-groups, 12 genes were significantly elevated and five genes were significantly downregulated in the TxN+ group compared with the TxN-group. There were 53 differentially regulated genes between the N+ and TxN+ groups, among which 25 genes were overexpressed and 28 genes were suppressed in the N+ group. CONCLUSION: The combination of early oncogenic alterations and later acquisition of a set of genetic alterations may determine the metastatic potential of lung adenocarcinoma.

Observation of circulating tumour cells in patients with non-small cell lung cancer by real-time fluorescent quantitative reverse transcriptase-polymerase chain reaction in peroperative period.

PURPOSE: To assess whether surgical manoeuvre or resection of lung cancer could lead to haematogenous dissemination of malignant cells. In the mean time, the relationship between the sequence of vessel ligation and the haematogenous dissemination of cancer cells during operation was determined. METHODS: Exploiting cytokeratin 19 (CK19)/carcinoembryonic antigen (CEA) mRNA as markers, 69 peripheral blood samples were collected from 23 consecutive patients with non-small cell lung cancer (NSCLC) who underwent surgical resection with curative intention in preoperative, intraoperative and postoperative period, respectively. Before the operation, all patients were randomly assigned to one of the two surgical procedure groups according to the order of vessel ligation, PV-first group and PA-first group. Additionally, the ten patients with benign lung disease served as control subjects undergoing surgical resection. The quantity and timing of the shedding of lung cancer cells into the circulation of patients were also monitored by fluorescent quantitative-reverse transcriptase-polymerase chain reaction before, during and after surgery. RESULTS: (1) The CK19 diagnostic test: the value of CK19 mRNA in operation was significantly higher than that of preoperation (5.246+/-0.196 vs. 4.472+/-0.164, P=0.000) and postoperation (5.246+/-0.196 vs. 4.694+/-0.177, P=0.013). The values between adenocarcinoma and squamous carcinoma were strikingly different (4.9110+/-1.0315 vs. 4.1891+/-0.4126, t=2.364, P=0.028). The values between PV-first group and PA-first group during perioperative period appear to be different (4.503 vs. 5.085, P=0.086). Before operation, of the 23 cases studied, 14 cases were positive (60.9%). Surprisingly, circulating epithelial cells were detected in two patients resected for benign lung disease. (2) The CEA diagnostic test: the level of CEA mRNA ascended continuously within this period. The postoperative values were significantly higher than those of preoperation (4.874 vs. 4.483, P=0.000) and those of operative day (4.874 vs. 4.537, P=0.000). The values between PV-first group and PA-first group appear to reach statistical significance (4.397 vs. 4.817, P=0.075). At the same time, there was a correlation between preoperative T-stage and perioperative CEA mRNA (4.267 vs. 4.760, P=0.025). Among the 23 cases, 10 cases were positive (43.5%). Both patients with benign lung disease served as control subjects undergoing surgical resection and the volunteers were negative. CONCLUSIONS: A considerable proportion of patients who appear to have resectable NSCLC might be regarded as having systemic disease, which is often undetectable by current tumour staging method. In terms of a marker used for the NSCLC patients who undergo operation, CEA is more suitable than CK19. The CK19-expressing epithelial cells are released intraoperatively into the circulation, meanwhile CEA-expressing tumour cells are disseminated mostly postoperatively. Surgical manipulation could promote the release of tumour cells into the bloodstream, but the ligation of pulmonary vein before the ligation of the pulmonary artery may partly prevent such release during surgery.

Detection of disseminated lung cancer cells in regional lymph nodes by assay of CK19 reverse transcriptase polymerase chain reaction and its clinical significance.

PURPOSE: To set up a molecular method (i.e. RT-PCR) that can be used to detect disseminated tumor cells (DTCs) in regional lymph nodes (LNs) in patients with lung cancer and to evaluate its clinical significance. METHODS: Cytokeratin 19 (CK(19)) was used as marker. Serial dilution study for LC-5 cells (a lung squamous cell line) was performed to detect sensitivity of the molecular protocol. Regional LNs (n = 261) and primary lung cancer tissue (n = 40) were obtained from 40 patients with lung cancer who underwent lobectomy or pneumonectomy. They were randomly categorized into two groups: group I (LN-based study, n = 20) and group II (patient-based study, n = 20). Each LN was halved. One half of a LN was subjected to histological examination (HE) and the other half was subjected to RT-PCR amplification of CK(19) mRNA. The effect on survival was analyzed. The cumulative survival was calculated by the Kaplan-Meier method and compared by the log rank test. The Cox model analyzed the prognostic factors. RESULTS: CK(19) mRNA expressed in all tumor tissues as well as LC-5, PAa cells (a lung adenocarcinoma cell line), but not in normal control LNs. Serial dilution study for LC-5 cells demonstrated that CK(19) mRNA was detectable at a concentration as low as 10 LC-5 cells in 1x10(7) LN cells. There was no significant difference between the detecting result of single LN and that of mixed LNs (P > 0.05). In 18 of 40 patients, the metastasis in regional LNs was found by both HE and RT-PCR. Of 22 patients without pathologically involved nodes, six (27%) were found to express CK(19) mRNA in regional LNs. According to the results of regional LNs in 40 patients by molecular assay, the presence of the CK(19) product in LNs was related to tumor size (chi(2) = 5.76, P < 0.025) as well as cell differentiation of the tumor (chi(2) = 7.08, P < 0.01). Following a median observation time of 26 months (range, 4 to 60 months), patients with DTCs in nodes showed significant shorter disease-free survival duration than node-negative patients (log-rank test, P = 0.001). The independence of this prognostic significance was demonstrated by a multivariate analysis (Cox regression model, P = 0.004). The results diagnosed by HE had no significant effect on prognoses (P = 0.455). CONCLUSIONS: Comparing with HE, RT-PCR can make more accurate assessment of metastatic status in LNs, which is helpful for screening the patients in whom the early subclinical metastasis exists and disclosing the intrinsic regulation of malignant metastasis. The presence of DTCs in LNs is an independent factor for prognosis. Molecular detection of DTCs in LNs is a supplement for current tumor staging in lung carcinoma.