Effective induction immunotherapy minimizes surgical invasiveness for locally advanced lung cancer.

Background: Immunotherapy has been recommended for neoadjuvant therapy in patients with locally advanced non-small cell lung cancer (NSCLC). However, its effect on surgical resection has not yet been examined. This study aimed to examine the effect of induction immunotherapy on surgical resection in terms of the surgical approach, resection extent, and perioperative recovery. Methods: We performed a real-world study comprising consecutive patients with clinical stage IB-IIIB NSCLC who received surgical resection after induction immunotherapy from January 2019 to September 2021. The perioperative outcomes were compared in terms of the surgical approach and resection extent. Results: Among 68 patients, 37 (54.4%) achieved a clinical objective response. Standard resection was performed in 37 patients (54.4%), while extended resection was necessary in the other 31 patients (45.6%). Minimally invasive surgery (MIS) was attempted in 37 cases (54.4%), with only 1 (2.7%) conversion. MIS was significantly more commonly accomplished in patients with a clinical objective response than those without (67.6% vs. 35.5%, P=0.008). Patients with a clinical objective response were more likely to have their tumors removed via MIS and/or standard resection (75.7% vs. 51.6%, P=0.04), while those without a clinical objective response more often required extended resection using an open approach. Patients receiving standard resection or MIS had significantly better perioperative outcomes than those who underwent extended resection or thoracotomy (all P<0.05). Conclusions: The results of this large single-center retrospective cohort indicate that in terms of a better clinical response, effective induction immunotherapy could help reduce the resection extent and/or provide more opportunities to perform MIS, resulting in better recovery.

Oncogenic tRNA-derived fragment tRF-Leu-CAG promotes tumorigenesis of lung cancer via targeting TCEA3 and increasing autophagy.

BACKGROUND: Lung cancer is a prevalent and severe form of malignant tumors worldwide. tRF-Leu-CAG, a recently discovered non-coding single-stranded small RNA derived from transfer RNA, has sparked interest in exploring its biological functions and potential molecular mechanisms in lung cancer. METHODS: The abundance of tRF-Leu-CAG was measured via quantitative real-time polymerase chain reaction (qRT-PCR) in 96 sets of lung cancer tissue samples obtained from clinical patients. Subsequently, both in vivo and in vitro experiments were conducted to validate the biological functions of tRF-Leu-CAG in lung cancer. Furthermore, an exploration of the potential target genes of tRF-Leu-CAG and its association with autophagy and drug resistance in lung cancer was undertaken. RESULTS: Our analysis revealed a significant upregulation of tRF-Leu-CAG in non-small cell lung cancer (NSCLC) tissues. Additionally, we observed that heightened expression of tRF-Leu-CAG significantly augmented the proliferation and migration of NSCLC cells, facilitated cell cycle progression, and suppressed apoptosis. Furthermore, we identified transcription elongation factor A3 (TCEA3) as a direct target gene of tRF-Leu-CAG. TCEA3 inhibited the proliferation and migration of NSCLC, and tRF-Leu-CAG promoted the proliferation and migration of NSCLC by mediating the silencing of TCEA3. Moreover, we demonstrated that the augmentation of paclitaxel resistance by tRF-Leu-CAG was contingent on autophagy. Finally, tRF-Leu-CAG notably accelerated tumor growth and promoted the process of epithelial-mesenchymal transition (EMT) in vivo. CONCLUSIONS: tRF-Leu-CAG promotes NSCLC tumor growth and metastasis by targeting TCEA3 and promotes paclitaxel resistance by enhancing cellular autophagy. These results provide potentially effective targets and therapeutic options for the clinical treatment of NSCLC.

China Anti-Cancer Association Guidelines for the diagnosis, treatment, and follow-up of thymic epithelial tumors (2023).

Background: Thymic epithelial tumors (TETs) are a relatively rare type of thoracic tumors with higher incidence in Asians. The diagnosis and treatment pattern has long been based mainly on clinical experience and expert consensus. In recent years, with an increasing number of TETs detected in physical examinations, there is an urgent need to develop the guidelines that apply to the Chinese population. Thus, we intend to develop a holistic integrative guideline for TETs. Methods: Under the leadership of the Chinese Anti-Cancer Association (CACA) Mediastinal Tumor Committee, a multidisciplinary guideline development group was established. Systemic literature review and two rounds of questionnaires regarding key clinical issues were carried out. The grading of recommendations assessment, development and evaluation (GRADE) approach was used to rate the quality of evidence and the strength of recommendations. Results: The CACA guideline provides recommendations for the clinical differential diagnosis of anterior mediastinal lesions, management of asymptomatic small anterior mediastinal nodules, pathological classification and staging systems of TETs, as well as principles of surgery, neoadjuvant and adjuvant therapies, systemic therapies for advanced TETs, and follow-up strategies after surgical resection. Conclusions: This guideline provides holistic integrative management strategies for TETs and would be a useful tool for clinicians on decision-making.

A Re-Examination of Neoadjuvant Therapy for Thymic Tumors: A Long and Winding Road.

For most patients with advanced thymic epithelial tumors (TETs), a complete resection is a strong indicator of a better prognosis. But sometimes, primary surgery is unsatisfactory, and preoperative therapy is needed to facilitate complete resection. Neoadjuvant chemotherapy is the most used form of preoperative therapy. But studies on neoadjuvant chemotherapy have included mainly patients with thymoma; its efficacy in patients with thymic carcinoma is less known. Neoadjuvant chemoradiation has also been explored in a few studies. Novel therapies such as immunotherapy and targeted therapy have shown efficacy in patients with recurrent/metastatic TETs as a second-line option; their role as preoperative therapy is still under investigation. In this review, we discuss the existing evidence on preoperative therapy and the insight it provides for current clinical practice and future studies.

Internal jugular vein pressure monitoring guided venous reconstruction could improve perioperative safety after superior vena cava resection for mediastinal tumors: a cohort study.

INTRODUCTION: After superior vena cava (SVC) resection, the decision on unilateral or bilateral reconstruction was mostly based on the expertise of surgeons without objective measurements. This study explored the use of internal jugular vein pressure (IJVP) monitoring to guide the SVC reconstruction strategy. METHODS: In a retrospective cohort, perioperative outcomes of unilateral and bilateral reconstruction based on surgeons' experience were compared. Then, IJVP threshold was measured when temporarily clamping the left innominate vein in a testing cohort. Venous reconstruction according to IJVP monitoring was performed in a prospective validation cohort afterward. Perioperative outcomes were compared between the prospective and the retrospective cohorts. For some interested variables, intuitive explanations would be given using Bayesian methods. Potential risk factors for postoperative complications were investigated by multivariable analysis. RESULTS: From March 2009 to September 2022, 57 patients underwent SVC reconstruction based on surgeons' experience. Bayesian analysis indicated a posterior probability of 80.49% that unilateral reconstruction had less blood loss than bilateral reconstruction (median 550 ml vs. 1200 ml). Cerebral edema occurred in two patients after unilateral reconstruction. In the testing cohort, median IJVP was 22.7 (18-27) cmH 2 O after temporary left innominate vein clamping in 10 patients. In the prospective cohort, unilateral reconstruction only was performed if the contralateral IJVP was <30 cmH 2 O in 16 patients. Bilateral reconstruction was performed if IJVP was ≥30 cmH 2 O after unilateral bypass in nine patients. No cerebral edema occurred in the prospective cohort. Less postoperative complications occurred in the prospective cohort than the retrospective cohort (12.0 vs. 38.6%, P =0.016). Upon multivariable analysis, IJVP-monitoring guided SVC reconstruction was associated with significantly less postoperative complications ( P =0.033). CONCLUSIONS: Intraoperative IJVP-monitoring is a useful strategy for selection of unilateral or bilateral SVC reconstruction and improving perioperative safety in patients with mediastinal tumors.

Genetic insights into thymic carcinomas and thymic neuroendocrine neoplasms denote prognosis signatures and pathways.

BACKGROUND: Thymic carcinomas (TCs) and thymic neuroendocrine neoplasms (TNENs) are two aggressive subtypes of thymic malignancy. Traditional therapy for advanced TCs and TNENs has limited outcome. New genomic profiling of TCs and TNENs might provide insights that contribute to the development of new treatment approaches. METHODS: We used gene panel sequencing technologies to investigate the genetic aberrations of 32 TC patients and 15 TNEN patients who underwent surgery at Shanghai Chest Hospital between 2015 and 2017. Patient samples were sequenced using a 324-gene platform with licensed technologies. In this study, we focused on clinically relevant genomic alterations (CRGAs), which are previously proven to be pathogenic alterations, to identify the pathology-specific mutational patterns, prognostic signatures of TCs and TNENs. RESULTS: The mutational profiles between TCs and TNENs were diverse. The genetic alterations that ranked highest in TCs were in CDKN2A, TP53, ASXL1, CDKN2B, PIK3C2G, PTCH1, and ROS1 , while those in TNENs were in MEN1, MLL2, APC, RB1 , and TSC2 . Prognostic analysis showed that mutations of ROS1, CDKN2A, CDKN2B, BRAF, and BAP1 were significantly associated with worse outcomes in TC patients, and that mutation of ERBB2 indicated shortened disease-free survival (DFS) and overall survival (OS) in TNEN patients. Further investigation found that the prognosis-related genes were focused on signal pathways of cell cycle control, chromatin remodeling/DNA methylation, phosphoinositide 3-kinases (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR), and receptor tyrosine kinase (RTK)/RAS/mitogen-activated protein kinase (MAPK) signaling. CONCLUSION: We profiled the mutational features of 47 Chinese patients with thymic malignancy of diverse pathologic phenotypes to uncover the integrated genomic landscape of these rare tumors, and identified the pathology-specific mutational patterns, prognostic signatures, and potential therapeutic targets for TCs and TNENs.

Erratum: miR-199a-3p/5p regulate tumorgenesis via targeting Rheb in non-small cell lung cancer: Erratum.

[This corrects the article DOI: 10.7150/ijbs.70312.].

HNRNPA2B1 as a potential therapeutic target for thymic epithelial tumor recurrence: An integrative network analysis.

Thymic epithelial tumors (TETs) are rare malignant tumors, and the molecular mechanisms of both primary and recurrent TETs are poorly understood. Here we established comprehensive proteomic signatures of 15 tumors (5 recurrent and 10 non-recurrent) and 15 pair wised tumor adjacent normal tissues. We then proposed an integrative network approach for studying the proteomics data by constructing protein-protein interaction networks based on differentially expressed proteins and a machine learning-based score, followed by network modular analysis, functional enrichment annotation and shortest path inference analysis. Network modular analysis revealed that primary and recurrent TETs shared certain common molecular mechanisms, including a spliceosome module consisting of RNA splicing and RNA processing, but the recurrent TET was specifically related to the ribosome pathway. Applying the shortest path inference to the collected seed gene module identified that the ribonucleoprotein hnRNPA2B1 probably serves as a potential target for recurrent TET therapy. The drug repositioning combined molecular dynamics simulations suggested that the compound ergotamine could potentially act as a repurposing drug to treat recurrent TETs by targeting hnRNPA2B1. Our study demonstrates the value of integrative network analysis to understand proteotype robustness and its relationships with genotype, and provides hits for further research on cancer therapeutics.

Minimally Invasive Thymectomy Could Be Attempted for Locally Advanced Thymic Malignancies: A Real-World Study With Propensity Score-Matched Analysis.

INTRODUCTION: Increasing evidence supports minimally invasive thymectomy (MIT) for early stage thymic malignancies than open median sternotomy thymectomy (MST). Nevertheless, whether MIT could be attempted for locally advanced disease remains unclear. METHODS: The clinical data of consecutive patients with stage T2-3NxM0 (eighth edition TNM staging) thymic malignancies who underwent MIT or MST were identified from a prospectively maintained database. The co-resected structures were rated with a resection index to evaluate surgical difficulty. The impact of surgical approach on treatment outcomes was investigated through propensity score-matched analysis and multivariable analysis. RESULTS: From January 2008 to December 2019, a total of 128 patients were included; MIT was initially attempted in 58 (45.3%) cases, and eight (13.8%) were converted to MST during surgery. The conversion group had similar perioperative outcomes to the MST group, except for a longer operation time. After propensity score matching, the resection index scores were similar between the MIT and MST groups (3.5 versus 3.7, p = 0.773). The MIT group had considerably less blood loss (p < 0.001), fewer postoperative complications (p = 0.048), a shorter duration of chest drainage (p < 0.001), and a shorter hospitalization duration (p < 0.001) than the MST group. The 5-year freedom from recurrence rate was not different between the two groups (78.2% versus 78.5%, p = 0.942). In multivariable analysis, surgical approach was not associated with freedom from recurrence (p = 0.727). CONCLUSIONS: MIT could be safely attempted in carefully selected patients with locally advanced thymic tumors. Conversion did not compromise the surgical outcomes. Patients may benefit from the less traumatic procedure and thus better recovery, with comparable long-term oncologic outcomes.

Phytolith-occluded carbon in leaves of Dendrocalamus Ronganensis influenced by drought during growing season.

Being an important carbon (C) sink, phytolith-occluded carbon (PhytOC) has been investigated in various soil-plant systems. However, the effects of environmental factors (i.e., drought) on phytoliths, including altered deposition in plant tissues, morphological variation, and amounts of carbon occluded within phytoliths, are less studied. In this study, we analyzed the monthly variations of phytolith production and PhytOC in the leaves of Dendrocalamus ronganensis grown on a karst mountain in southwestern China during a drought year. This study thus sought to understand the effects of drought on phytolith formation, morphological variations and carbon sequestration within phytoliths in plants. Our results showed that the phytolith assemblages and PhytOC between new and old leaves differed significantly and varied with plant growth stages. The average PhytOC values of old leaves and tip leaves were 3.2% and 2.2%, respectively. In particular, both PhytOC and proportions of ELONGATE, BULLIFORM FLABELLATE, and STOMA phytoliths in tip leaves significantly decreased from September to January the following year because of drought effects. This study suggests that PhytOC in plants varies between phytolith morphotypes and is significantly affected by plant growth stage and hydrologic conditions. This indicates that we can improve the efficiency of phytolith carbon sequestration in plants by improving the soil water conditions required for plant growth.

miR-199a-3p/5p regulate tumorgenesis via targeting Rheb in non-small cell lung cancer.

Lung cancer is one of the deadliest cancers, in which non-small cell lung cancer (NSCLC) accounting for 85% and has a low survival rate of 5 years. Dysregulation of microRNAs (miRNAs) can participate in tumor regulation and many major diseases. In this study, we found that miR-199a-3p/5p were down-expressed in NSCLC tissue samples, cell lines, and the patient sample database. MiR-199a-3p/5p overexpression could significantly suppress cell proliferation, migration ability and promote apoptosis. Through software prediction, ras homolog enriched in brain (Rheb) was identified as a common target of miR-199a-3p and miR-199a-5p, which participated in regulating mTOR signaling pathway. The same effect of inhibiting NSCLC appeared after down-regulating the expression of Rheb. Furthermore, our findings revealed that miR-199a can significantly inhibit tumor growth and metastasis in vivo, which fully demonstrates that miR-199a plays a tumor suppressive role in NSCLC. In addition, miR-199a-3p/5p has been shown to enhance the sensitivity of gefitinib to EGFR-T790M in NSCLC. Collectively, these results prove that miR-199a-3p/5p can act as cancer suppressor genes to inhibit the mTOR signaling pathway by targeting Rheb, which in turn inhibits the regulatory process of NSCLC. Thus, to investigate the anti-cancer effect of pre-miR-199a/Rheb/mTOR axis in NSCLC, miR-199a-3p and miR-199a-5p have the potential to become an early diagnostic marker or therapeutic target for NSCLC.

miRNA-199a-5p/SLC2A1 axis regulates glucose metabolism in non-small cell lung cancer.

Lung cancer is acknowledged as a common cancer with high morbidity and mortality. MicroRNAs (miRNAs), kind of non-coding single-stranded RNA molecules, can be used in cancer clinical treatments. In this research, miR-199a-5p was seen lowly expressed in NSCLC sera samples. miR-199a-5p suppressed the cell proliferation, migration and arrested cell cycle in NSCLC cell lines. The results showed that SLC2A1 (glucose transporter 1, GLUT1) was a direct target of miR-199a-5p. Downregulation of SLC2A1 could not only inhibit cell proliferation, migration and cell cycle, but also promote cell apoptosis. The data suggests that miR-199a-5p can inhibit glucose metabolism in NSCLC by targeting SLC2A1.This study proves that miR-199a-5p / SLC2A1 can play an essential role in the development of NSCLC by targeting SLC2A1. It puts forward a new approach for clinical treatments of NSCLC.

Management of incidentally detected small anterior mediastinal nodules: Which way to go?

OBJECTIVES: With increasing use of CT screening for lung cancers, there is a tendency toward increased detection of asymptomatic small anterior mediastinal nodules (SAMNs). In face of high rate of non-therapeutic surgery in these patients, workup and follow-up strategy for such lesions remains to be established. MATERIALS AND METHODS: This is a real-world study in patients with SAMNs (baseline diameter ≤ 3 cm) during 2013-2018. Interval growth of the nodules was reviewed. Accuracy of preoperative diagnosis was evaluated, and tumor doubling time (TDT) was calculated in resected tumors. RESULTS: A total of 419 patients were entered into the study, among them 91 received surgery. Eighty-four patients (92.3%) turned out to have thymic tumors, with a non-therapeutic surgery rate of only 6.6%. For 73 patients receiving both CT and MRI examinations, the sensitivity for diagnosing thymic tumors by CT alone was merely 72.1%, which was significantly improved to 97.1% (p < 0.001) when MRI was incorporated. Among 38 thymic tumor patients who had previous CT scan before surgery, significant difference in median TDT was seen between low-grade tumors and intermediate-/high-grade tumors (23.8 vs. 10.1 months, p = 0.021). Of the 328 patients not receiving surgery, 269 (82.0%) were diagnosed of having benign cysts by CT + MRI, followed by 24 (7.3%) lymph nodes, 22 (6.7%) thymic hyperplasia, and 13 (4%) thymic tumors. During follow-up (median 33 months), 319 (97.3%) lesions remained unchanged. CONCLUSION: The majority of incidentally detected SAMNs remain stable during long-term follow-up. Incorporating MRI with CT scan is helpful in differentiating benign cysts from small thymic tumors, thus avoiding non-therapeutic intervention. Follow-up is safe and warranted upon first detection when high-grade malignancies could be ruled out by careful imaging studies.

Study protocol of an open-label prospective phase II umbrella study of precise neoadjuvant therapy for patients with stage II-IIIB resectable non-small cell lung cancer (PURPOSE).

Background: The outcomes of locally advanced non-small cell lung cancer (LA-NSCLC) are unfavorable mainly due to a high risk of cancer recurrence. Only around 5% of patients can benefit from perioperative chemotherapy which is the current standard treatment. Recently, promising results with neoadjuvant targeted and immune-therapy therapy have been seen. However, most clinical trials are looking for patients eligible for certain drugs, instead of seeking suitable treatments for certain patients. Therefore, it is necessary to look for more efficient perioperative therapies to increase resectability, reduce recurrence and improve prognosis. Methods/Design: The study is an open-label, prospective, phase II, umbrella trial, enrolling patients diagnosed with treatment-naïve potentially resectable Stage II-IIIB NSCLC. Next-generation sequencing (NGS) using a 68-gene panel is performed for biopsies of tumor tissues from eligible patients. Enrolled patients are then stratified into six independent cohorts based on the status of gene mutations and PD-L1 status in tumor tissues, that is, ①EGFR 19del group, ②EGFR 21 L858R group, ③EGFR rare mutation group, ④Other driver mutation group, ⑤Drive mutation-negative group with PD-L1≥1%, ⑥Drive mutation-negative group with PD-L1<1%. A Simon's two-stage design is performed in each cohort independently and patients receive corresponding standard therapies accordingly. We aim to enroll 26 patients in each cohort and totally 156 patients will be enrolled. The primary endpoint is objective response rate (ORR). Secondary endpoints include oncological prognosis and perioperative outcomes. Exploratory endpoint is to investigate patient-specific minimal residual disease (MRD) in predicting treatment efficacy and oncological prognosis. Discussions: This is the first umbrella trial focusing on the safety and efficacy of precise neoadjuvant therapy for patients diagnosed with potentially resectable LA-NSCLC based on NGS results. The results of this trial would help improve overall treatment results in LA-NSCLC patients. Trial registration: Chinese Clinical Trial Registry. Trial registration number: ChiCTR2100053021. Advantages and limitations of this study: There is no neoadjuvant umbrella trial focusing on LA-NSCLCs. This is the first neoadjuvant umbrella trial, using a precise individualized approach and seeking suitable drugs for LA-NSCLC patients, with the aim to improve overall treatment outcomes. Clinical trial registration: https://www.chictr.org.cn/, identifier ChiCTR2100053021.

Autologous Blood Pleurodesis: What Is the Optimal Time Interval and Amount of Blood?

BACKGROUND: Air leak is the most common complication after lung resection and leads to increased length of hospital (LOH) stay or patient discharge with a chest tube. Management by autologous blood patch pleurodesis (ABPP) is controversial because few studies exist, and the technique has yet to be standardized. METHODS: We retrospectively reviewed patients undergoing ABPP for prolonged air leak (PAL) following lobectomy in three centers, between January 2014 and December 2019. They were divided into two groups: Group A, 120 mL of blood infused; Group B, 60 mL. Propensity score-matched (PSM) analysis was performed, and 23 patients were included in each group. Numbers and success rates of blood patch, time to cessation of air leak, time to chest tube removal, reoperation, LOH, and complications were examined. Univariate and multivariate analysis of variables associated with an increased risk of air leak was performed. RESULTS: After the PSM, 120 mL of blood is statistically significant in reducing the number of days before chest tube removal after ABPP (2.78 vs. 4.35), LOH after ABPP (3.78 vs. 10.00), and LOH (8.78 vs. 15.17). Complications (0 vs. 4) and hours until air leak cessation (6.83 vs. 3.91, range 1-13) after ABPP were also statistically different (p < 0.05). Air leaks that persisted for up to 13 hours required another ABPP. No patient had re-operation or long-term complications related to pleurodesis. CONCLUSION: In our experience, 120 mL is the optimal amount of blood and the procedure can be repeated every 24 hours with the chest tube clamped.

Autologous Blood Patch Pleurodesis: A Large Retrospective Multicenter Cohort Study.

BACKGROUND: Prolonged air leaks (PAL) complicate 10% to 15% of lung resections, delaying chest tube removal and prolonging length of hospital stay. No consensus exists for managing this common complication, despite favorable results for autologous blood patch pleurodesis (ABPP) in the literature. The aim of this study was to evaluate the effectiveness and safety of ABPP. METHODS: We retrospectively reviewed medical records of 510 patients with PAL after lobectomy in four centers between January 2010 and December 2019. They were divided into two groups: group A consisted of patients who received ABPP for PAL of more than 5 days; and group B was patients for whom no ABPP or other procedure was performed for PAL unless strictly necessary. Propensity score matched analysis was performed, and 109 patients were included in each group. Time to cessation of air leak and chest tube removal, length of hospital stay, reoperation, and complications rate were examined. RESULTS: After the propensity score matching, ABPP significantly reduced the number of days before chest tube removal (8.12 vs 9.30, P = .004), and length of hospital stay (10 vs 11 days, P = .045) with fewer perioperative complications (6 vs 17, P = .015). Furthermore, ABPP was related to lower incidence of any additional invasive procedures (0 vs 9, P = .002) and reoperation (0 vs 4, P = .044). No patient in the ABPP group had long-term complications related to pleurodesis. CONCLUSIONS: Autologous blood patch pleurodesis is safe and effective in reducing length of hospital stay and leads to earlier chest tube removal without increasing complications.

Novel Tumor-Specific Antigens for Immunotherapy Identified From Multi-omics Profiling in Thymic Carcinomas.

Thymic carcinoma (TC) is the most aggressive thymic epithelial neoplasm. TC patients with microsatellite instability, whole-genome doubling, or alternative tumor-specific antigens from gene fusion are most likely to benefit from immunotherapies. However, due to the rarity of this disease, how to prioritize the putative biomarkers and what constitutes an optimal treatment regimen remains largely unknown. Therefore, we integrated genomic and transcriptomic analyses from TC patients and revealed that frameshift indels in KMT2C and CYLD frequently produce neoantigens. Moreover, a median of 3 fusion-derived neoantigens was predicted across affected patients, especially the CATSPERB-TC2N neoantigens that were recurrently predicted in TC patients. Lastly, potentially actionable alterations with early levels of evidence were uncovered and could be used for designing clinical trials. In summary, this study shed light on our understanding of tumorigenesis and presented new avenues for molecular characterization and immunotherapy in TC.

Electromagnetic bronchoscopy guided microwave ablation for early stage lung cancer presenting as ground glass nodule.

BACKGROUND: Patients with early-stage lung cancer are sometimes medically inoperable, and for patients with multiple primary lung cancers, surgical resection alone sometimes proves to be impractical. Local treatments like microwave ablation (MWA) are investigational alternatives for these patients. Most reported MWA procedures for lung cancers are performed percutaneously under CT guidance. MWA navigated by electromagnetic bronchoscopy (ENB) has been limitedly studied. In this study, we aimed to evaluate the safety and feasibility of MWA under ENB guidance in patients with inoperable early-stage lung cancers or multiple primary lung cancers which cannot be completely resected. METHODS: From June 2019 to December 2020, preliminary attempts of ENB-guided MWA were made in five medically inoperable patients with a single early-stage lung cancer and ten patients with multiple primary lung cancers which were difficult to resect at the same time. For patients with concomitant pulmonary nodules which needed surgical resection, thoracoscopic resections were performed following ENB-guided MWA. The safety, feasibility, and technique effectiveness of treatments were evaluated. RESULTS: ENB-guided MWA for 15 ground glass nodules (GGNs) in 15 patients was completed in accordance with the planned protocol. Biopsy of 13 GGNs showed malignancy. Five patients received simple ENB-guided MWA without simultaneous surgical resection and ten patients received simultaneous surgical resection for 13 concomitant pulmonary nodules. CT scan by the first postoperative week showed technique effectiveness of ablation for 11 nodules indicated for MWA. Four patients had mild complications after the procedure and recovered shortly after treatment. CONCLUSIONS: For medically inoperable patients with a single GGN manifesting early-stage lung cancer and patients with multiple primary early-stage lung cancers which cannot be resected at the same time, ENB-guided MWA might be a safe and feasible alternative local treatment, whether combined with surgical resection or not. However, large, prospective, randomized, multicenter studies are needed to confirm its role in the treatment of early-stage lung cancer.

Surgical resection of superior pulmonary sulcus tumor after neoadjuvant chemoradiation via the anterior transmanubrial approach: a case report.

Superior pulmonary sulcus tumor is a cancer arising in the apex of the lung that with potential invasion of the brachial plexus, upper ribs, vertebrae, subclavian vessels, and stellate ganglion. Induction concurrent chemoradiotherapy followed by radical surgical resection with lobectomy combined with any structures in the thoracic inlet invaded by tumor and thorough mediastinal lymph node dissection is the preferred treatment. Both anterior and posterior approaches are applied for resection. Here, we report a 61-year-old man with an 8.6 cm × 5.1 cm mass arising from the right upper lobe invading the apex of the chest wall. Brachial plexus magnetic resonance imaging suggested tumor invasion of the inferior trunk of the brachial plexus, anterior portion of the first 2 ribs, and suspicious involvement of the subclavian artery. Biopsy of the mass showed stage cT4N2M0, IIIB, poorly differentiated adenocarcinoma. The patient was treated by induction concurrent chemoradiotherapy, which was followed by surgical resection of the right upper lobe and the affected chest wall via the transmanubrial approach. The patient suffered prolonged postoperative air leak and empyema. After continuous chest tube drainage and intrapleural fibrinolytic therapy, he recovered well and was discharged safely. Final pathology showed no viable residue tumor, pathologic complete response of the tumor to induction treatment, a tumor size of 4.1 cm, and no lymph nodes; therefore, the final stage was ypT0N0M0. The transmanubrial approach is feasible for resection of tumor invading the branches of the subclavian artery; however, postoperative empyema which might have resulted from prolonged air leak should be carefully treated by meticulous air leak management.