Lymph node metastasis in early invasive lung adenocarcinoma: Prediction model establishment and validation based on genomic profiling and clinicopathologic characteristics.

BACKGROUND: The presence of lymph node (LN) metastasis directly affects the treatment strategy for lung adenocarcinoma (LUAD). Next-generation sequencing (NGS) has been widely used in patients with advanced LUAD to identify targeted genes, while early detection of pathologic LN metastasis using NGS has not been assessed. METHODS: Clinicopathologic features and molecular characteristics of 224 patients from Ruijin Hospital were analyzed to detect factors associated with LN metastases. Another 140 patients from Huashan Hospital were set as a test cohort. RESULTS: Twenty-four out of 224 patients were found to have lymph node metastases (10.7%). Pathologic LN-positive tumors showed higher mutant allele tumor heterogeneity (p < 0.05), higher tumor mutation burden (p < 0.001), as well as more frequent KEAP1 (p = 0.001), STK11 (p = 0.004), KRAS (p = 0.007), CTNNB1 (p = 0.017), TP53, and ARID2 mutations (both p = 0.02); whereas low frequency of EGFR mutation (p = 0.005). A predictive nomogram involving male sex, solid tumor morphology, higher T stage, EGFR wild-type, and TP53, STK11, CDKN2A, KEAP1, ARID2, KRAS, SDHA, SPEN, CTNNB1, DICER1 mutations showed outstanding efficiency in both the training cohort (AUC = 0.819) and the test cohort (AUC = 0.780). CONCLUSION: This study suggests that the integration of genomic profiling and clinical features identifies early-invasive LUAD patients at higher risk of LN metastasis. Improved identification of LN metastasis is beneficial for the optimization of the patient's therapy decisions.

Ultra-short-period perioperative pulmonary rehabilitation on short-term outcomes after surgery in smoking patients with lung cancer: A randomized clinical trial.

BACKGROUND: Pulmonary rehabilitation is essential for airway management after thoracic surgery. Most current pulmonary rehabilitations are composed of 2-4-week exercises, which require significant consumption of medical resources and concerns about disease progression. MATERIALS AND METHODS: This single-center, prospective, randomized controlled trial enrolled smoking patients with pulmonary masses or nodules suitable for lobectomy, aged 18-80, with smoking history (≥20 pack-years). Eligible patients were randomized in a 1:1 ratio into two groups. Patients in the intervention group underwent perioperative breathing exercises based on positive pressure vibration expectoration and three-day preoperative lower limb endurance training. Patients in the control group received routine perioperative care. The primary outcome was in-hospital incidence of postoperative pulmonary complications. Secondary outcomes included postoperative hospital stay, total hospitalization cost, postoperative drainage time, drainage volume, semiquantitative cough strength score, pain score, Borg scale-assessed fatigue, and walking distance on postoperative days 1 and 2. RESULTS: A total of 194 patients were included in the study with 94 in the intervention group and 100 in the control group. Our ultrashort pulmonary rehabilitation program potentially reduced pulmonary complications incidence (24.5% vs. 33.0%), but without statistical significance (P=0.190). No significant differences were found in other perioperative outcomes, except for postoperative semiquantitative cough strength score (3 [interquartile range, 3-3.75] vs. 3 [interquartile range, 2-3], P<0.001) and change in walking distance from postoperative days 1 to 2 (60 [interquartile range, 40-82.5] vs. 30 [interquartile range, 10-60], P=0.003). CONCLUSION: There were no significant differences in postoperative complications and other hospitalizations, but our ultrashort rehabilitation program improved patients' semiquantitative cough strength score and walking distance, indicating potential for better outcomes. This treatment is a safe and effective means of airway management for thoracic surgery in the era of enhanced recovery. (ClinicalTrials.gov Identifier: XXX).

Smoking cessation in Chinese patients undergoing thoracic surgery: A multicenter prospective observational study.

INTRODUCTION: The multicenter CHAMPION study aimed to assess the impact of smoking cessation on post-operative complications (PCs) and smoking cessation patterns in Chinese patients undergoing lung surgery. METHODS: Patients undergoing elective lung surgery were prospectively enrolled from three major tertiary centers in China. Patients were categorized as smokers or quitters before surgery. Baseline characteristics and smoking status were analyzed. The incidence of PCs and pulmonary PCs (PPCs), smoking relapse rate, and causes within six months post-operatively were investigated. The questionnaire was conducted in all patients and 30 healthcare professionals (HCPs), regarding the awareness and effectiveness of smoking cessation methods. RESULTS: Of the 276 enrolled patients, 213 (77.2%) were smokers and 63 (22.8%) were quitters; 76.4% were diagnosed with primary lung cancer. PCs occurred in 13.8% of patients, with similar proportions in smokers (14.1%) and quitters (12.7%). PPCs occurred in 9.8% of patients with no significant differences between smokers and quitters (9.4% vs 11.1%, p=0.70). At six months, 9.2% of patients relapsed, with a lower rate in quitters compared to smokers (3.3% vs 11.0%, p=0.01). HCPs exhibited higher awareness of smoking cessation methods than patients. Perceived effectiveness of smoking cessation methods from the patients were low. CONCLUSIONS: In patients undergoing lung surgery with a low risk of PCs, active smoking does not significantly increase the risk of PCs or PPCs relative to quitters, suggesting that there is likely no need to postpone lung surgery for those who have not yet quit smoking. However, further large-scale studies are necessary to confirm these findings.

High-dimensional single-cell proteomics analysis of esophageal squamous cell carcinoma reveals dynamic alterations of the tumor immune microenvironment after neoadjuvant therapy.

BACKGROUND: Dynamic alterations of the tumor immune microenvironment in esophageal squamous cell carcinoma (ESCC) after different neoadjuvant therapies were understudied. METHODS: We used mass cytometry with a 42-antibody panel for 6 adjacent normal esophageal mucosa and 26 tumor samples (treatment-naïve, n=12; postneoadjuvant, n=14) from patients with ESCC. Single-cell RNA sequencing of previous studies and bulk RNA sequencing from The Cancer Genome Atlas were analyzed, flow cytometry, immunohistochemistry, and immunofluorescence analyses were performed. RESULTS: Poor tumor regression was observed in the neoadjuvant chemotherapy group. Radiotherapy-based regimens enhanced CD8+ T cells but diminished regulatory T cells and promoted the ratio of effector memory to central memory T cells. Immune checkpoint blockade augmented NK cell activation and cytotoxicity by increasing the frequency of CD16+ NK cells. We discovered a novel CCR4+CCR6+ macrophage subset that correlated with the enrichment of corresponding chemokines (CCL3/CCL5/CCL17/CCL20/CCL22). We established a CCR4/CCR6 chemokine-based model that stratified ESCC patients with differential overall survival and responsiveness to neoadjuvant chemoradiotherapy combined with immunotherapy, which was validated in two independent cohorts of esophageal cancer with neoadjuvant treatment. CONCLUSIONS: This work reveals that neoadjuvant therapy significantly regulates the cellular composition of the tumor immune microenvironment in ESCC and proposes a potential model of CCR4/CCR6 system to predict the benefits from neoadjuvant chemoradiotherapy combined with immunotherapy.

A feasible technique for distinguishing the intersegmental plane by transbronchial injection of iron sucrose.

Objectives: Pulmonary segmentectomy should be the standard surgical procedure for patients in certain clinical scenarios. However, detecting the intersegmental planes both on the pleural surface and within the lung parenchyma remains a challenge. We developed an intraoperative novel method for distinguishing intersegmental planes of the lung via transbronchial injection of iron sucrose (ClinicalTrials.gov number, NCT03516500). Methods: We first performed a bronchial injection of iron sucrose to identify the intersegmental plane of the porcine lung. Then, we conducted a prospective study to evaluate the safety and feasibility of the technique in 20 patients who underwent anatomic segmentectomy. Iron sucrose was injected into the bronchus of target pulmonary segments, and the intersegmental planes were divided with electrocautery or stapler. Results: The median injection of iron sucrose was 90 mL (range, 70-120 mL), and the median time from injection of iron sucrose to demarcation of intersegmental plane was 8 minutes (range, 3-25 minutes). Qualified identification of the intersegmental plane was observed in 17 cases (85%). The intersegmental plane could not be recognized in 3 cases. All patients experienced no complications related to iron sucrose injection or complications of Clavien-Dindo grade 3 or more. Conclusions: Transbronchial injection of iron sucrose is a simple, safe, and feasible approach to identify the intersegmental plane (NCT03516500).

Robotic versus thoracoscopic combined anatomic subsegmentectomy for early-stage lung cancer: early results of a cohort study.

Background: Combined anatomic subsegmentectomy performed by video-assisted thoracic surgery or robot-assisted thoracic surgery is an emerging minimally invasive surgical technique for patients with early-stage non-small cell lung cancer (NSCLC). However, the early results of these two methods have barely been studied. Methods: A retrospective analysis of medical records from Shanghai Ruijin Hospital between July 2017 and August 2021 included 62 patients, 32 of whom underwent video-assisted combined anatomic pulmonary subsegmentectomy and 30 underwent robot-assisted combined anatomic pulmonary subsegmentectomy. Perioperative outcomes were compared. Results: Sixty-two patients with comparable baseline characteristics were included in this study. No significant difference was found in the length of postoperative hospital stay, operation duration, intraoperative blood loss and the rate of overall complications between the robot-assisted and video-assisted groups. A higher cost was observed in the robot-assisted group compared to the video-assisted group. There were more N1 lymph nodes and N1 stations dissected in the robot-assisted group compared with the video-assisted group; the same results were observed with regard to the number of N2 lymph nodes and N2 stations dissected. Conclusions: It is safe and feasible for the patients with early-stage NSCLC to be treated with combined anatomic subsegmentectomy performed via robot-assisted or video-assisted thoracic surgery. The robotic approach may contribute to the potential improvements in N1 and N2 lymph node retrieval.

Effects of pre-operative enteral immunonutrition for esophageal cancer patients treated with neoadjuvant chemoradiotherapy: protocol for a multicenter randomized controlled trial (point trial, pre-operative immunonutrition therapy).

BACKGROUND: Neoadjuvant chemoradiation followed by esophagectomy has been established as the first-line treatment for locally advanced esophageal cancer. Postoperative enteral nutrition has been widely used to improve perioperative outcomes. However, whether to implement preoperative nutritional intervention during neoadjuvant therapy is yet to be verified by prospective studies. METHODS: POINT trial is a multicenter, open-labeled, randomized controlled trial. A total of 244 patients with surgically resectable esophageal cancer are randomly assigned to nutritional therapy group (arm A) or control group (arm B) with a 2:1 ratio. Both groups receive neoadjuvant chemotherapy with concurrent radiotherapy based on the CROSS regimen followed by minimally invasive esophagectomy. The primary endpoint is the rate of nutrition and immune-related complications after surgery. Secondary endpoints include completion rate of neoadjuvant chemoradiation and related adverse events, rate of pathological complete response, perioperative outcomes, nutritional status, overall survival, progression-free survival and quality of life. DISCUSSION: This trial aims to verify whether immunonutrition during neoadjuvant chemoradiation can reduce the rate of complications and improve perioperative outcomes. Frequent communication and monitoring are essential for a multicenter investigator-initiated trial. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04513418. The trial was prospectively registered on 14 August 2020, https://www. CLINICALTRIALS: gov/ct2/show/NCT04513418 .

Robotic-assisted Versus Video-assisted Thoracoscopic Lobectomy: Short-term Results of a Randomized Clinical Trial (RVlob Trial).

OBJECTIVE: To determine whether RAL affects perioperative outcomes and long-term efficacy in NSCLC patients, compared with traditional VAL. SUMMARY OF BACKGROUND DATA: RAL is a promising treatment for NSCLC. However, its efficacy has not been fully evaluated. METHODS: A single-center, open-labeled prospective randomized clinical trial was launched in May 2017 to compare the efficacy of RAL and VAL. By May 2020, 320 patients were enrolled. The perioperative results of RAL and VAL were compared. RESULTS: The 320 enrolled patients were randomly assigned to the RAL group (n = 157) and the VAL group (n = 163). Perioperative outcomes were comparable between the 2 groups, including the length of hospital stay (P = 0.76) and the rate of postoperative complications (P = 0.45). No perioperative mortality occurred in either group. The total amount of chest tube drainage {830 mL [interquartile range (IQR), 550-1130 mL] vs 685 mL [IQR, 367.5-1160 mL], P = 0.007} and hospitalization costs [$12821 (IQR, $12145-$13924) vs $8009 (IQR, $7014-$9003), P < 0.001] were significantly higher in the RAL group. RAL group had a significantly higher number of LNs harvested [11 (IQR, 8-15) vs 10 (IQR, 8-13), P = 0.02], higher number of N1 LNs [6 (IQR, 4-8) vs 5 (IQR, 3-7), P = 0.005], and more LN stations examined [6 (IQR, 5-7) vs 5 (IQR, 4-6), P < 0.001]. CONCLUSIONS: Both RAL and VAL are safe and feasible for the treatment of NSCLC. RAL achieved similar perioperative outcomes, together with higher LN yield. Further follow-up investigations are required to evaluate the long-term efficacy of RAL. (ClinicalTrials.gov identifier: NCT03134534).

Effects of preoperative nutrition on postoperative outcomes in esophageal cancer: a systematic review and meta-analysis.

Postoperative enteral nutrition has been widely implemented in esophageal cancer, but the efficacy and safety of preoperative nutrition, particularly immune-enhancing nutrition (IEN), remain controversial. This meta-analysis aims to provide a quantitative synthesis of whether preoperative nutrition improves postoperative morbidity and mortality in patients with resectable esophageal cancer. A systematic search was conducted in Medline, Embase, Cochrane, and databases of clinical trials dated up to December 2019. Randomized controlled trials and observational studies comparing postoperative outcomes between esophageal cancer patients with and without preoperative nutritional support were included. Random-effects model was applied in the meta-analysis of primary outcomes (overall complication rate, in-hospital mortality) and secondary outcomes (infectious complication rate, anastomotic leak rate, length of postoperative hospital stay). Complications of feeding tube access and perioperative weight loss were evaluated by qualitative synthesis. Subgroup analyses were performed by stratifying immunonutrition and standard nutrition before surgery. Subgroup analysis of randomized controlled trials alone was also done. A total of 15 studies enrolling 1864 participants were included. The overall meta-analysis found that preoperative nutrition could reduce infectious complications (odds ratio [OR] = 0.51, 95% confidence interval [CI] [0.26, 0.98]; I2 = 48%) and length of hospital stay (mean difference = -2.10 day, 95% CI [-3.72, -0.47]; I2 = 78%) after esophagectomy, whereas no significant difference was revealed in the incidence of overall complications (OR = 0.76, 95% CI [0.52, 1.11]; I2 = 32%), in-hospital mortality (OR = 1.03, 95% CI [0.41, 2.61]; I2 = 12%), and anastomotic leak (OR = 1.05, 95% CI [0.69, 1.58]; I2 = 0%). Subgroup of preoperative immunonutrition showed more prominent benefits. The complication rate of feeding tube access was low (1.6-16%). In conclusion, preoperative nutrition is safe in esophageal cancer, but benefits are observed in infectious complication rate and length of stay on a limited scale. IEN holds more advantages over standard nutrition. Randomized trials in the context of nutritional support during neoadjuvant therapy are in demand.

Management of middle lobe veins during single-portal video-assisted thoracoscopic surgery lobectomy via the fifth intercostal approach (case series): why the subcarinal triangular right base angle is helpful.

Background: The fifth intercostal space is the preferred approach during uniportal video-assisted thoracoscopic surgery (VATS) lobectomy. However, managing the right middle lobe pulmonary vein (RML PV) through this approach is technically challenging for inexperienced surgeons. To facilitate the surgical procedure, we describe our surgical strategy for managing the middle lobe vein via the fifth intercostal space and define the approach [subcarinal triangular right base angle (SCT-RBA)] utilized to manage the middle lobe vein. Case Description: Based on the characteristics of uniportal surgery, we designed a new method of managing middle lobar veins via the fifth intercostal approach, which also facilitates the dissection of the subcarinal lymph nodes. We described the short-term surgical outcomes of 7 patients who underwent single-port middle lobe resection from January 2021 to January 2022 in the Department of Thoracic Surgery, Ruijin Hospital North Campus, Shanghai Jiaotong University School of Medicine. No conversion and mortality were observed in 7 patients who underwent single-port VATS middle lobe resection. One patient had bronchial asthma and air leakage, which led to delayed drainage and hospitalization. There were no complications or delayed discharge reported among the other patients. Conclusions: Our initial results indicate that this new technique is a feasible strategy to manage the middle lobe veins and facilitate the dissection of subcarinal lymph nodes.

The multiple roles and therapeutic potential of clusterin in non-small-cell lung cancer: a narrative review.

Worldwide, lung cancer is the most common form of cancer, with an estimated 2.09 million new cases and 1.76 million of death cause in 2018. It is categorized into two subtypes, small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC). Although platinum-based chemotherapy or molecular targeted drugs is recommended for advanced stages of NSCLC patients, however, resistance to drug and chemotherapy are hindrances for patients to fully beneficial from these treatments. Clusterin (CLU), also known as apolipoprotein J, is a versatile chaperone molecule which produced by a wide array of tissues and found in most biologic fluids. There are studies reported high expression of CLU confers resistance to chemotherapy and radiotherapy in different lung cancer cell lines. By silencing CLU using Custirsen (OGX-011), a second-generation antisense oligonucleotide (ASO) that inhibits CLU production, not only could sensitized cells to chemo- and radiotherapy, also could decreased their metastatic potential. We will review here the extensive literature linking CLU to NSCLC, update the current state of research on CLU for better understanding of this unique protein and the development of more effective anti- CLU treatment.

Interactions between the enhanced recovery after surgery pathway and risk factors for lung infections after pulmonary malignancy operation.

BACKGROUND: Lung infection is a common complication after thoracic surgery and can lead to severe consequences. Our study was designed to explore the risk factors for postoperative lung infections (POLI) following pulmonary malignancy operation and assess the protective effect of enhanced recovery after surgery (ERAS) and their potential interactive relationships. METHODS: A retrospective study included 1,768 patients who underwent surgery between 2013 and 2017 in Ruijin Hospital, Shanghai Jiaotong University School of Medicine was performed. Uni- and multivariate analyses were performed to identify risk factors. Andersson's model was applied to evaluate the additive interaction between these factors. RESULTS: Smoking [95% confidence interval (CI): 1.178-2.198], preoperative heart disease (95% CI: 1.448-4.091), and massive intraoperative blood loss (95% CI: 1.568-3.674) were independent risk factors for postoperative lung infections (POLI), whereas ERAS implementation was protective (95% CI: 0.249-0.441). Interaction analyses indicated that non-ERAS was reciprocally independent with smoking and surgical procedure. It had a synergistic interaction with heart disease [attributable proportion due to interaction (AP) =0.540 (95% CI: 0.179-0.901), synergy index (S) =2.580 (95% CI: 1.016-6.551)], and poor lung function [AP =0.395 (95% CI: 0.016-0.775)], as well as a tendency of antagonistic interaction with blood loss. CONCLUSIONS: Intraoperative blood loss, heart disease, and smoking are independent risk factors of POLI. ERAS implementation is a protective factor and is firstly verified to be more effective on reducing POLI in patients with heart diseases, poor lung function, and less intraoperative blood loss. We provide evidences to implement ERAS and a clue of the most optimal indications for ERAS.

Uniportal video-assisted thoracic surgery for the treatment of lung cancer: a consensus report from Chinese Society for Thoracic and Cardiovascular Surgery (CSTCVS) and Chinese Association of Thoracic Surgeons (CATS).

Uniportal video-assisted thoracoscopic surgery (UniVATS) has been widely adopted in China, where several ultra-high volume thoracic surgical and training centers are located. The objective of this consensus from Chinese experts was to summarize the current application and give reference for the future development of UniVATS in the treatment of lung cancer. A panel of 41 experts from 21 Chinese hospitals was invited to join this project. The Delphi method was used in this consensus consisting of two rounds of voting. The questionnaire was based on the current clinical evidence. Forty (97.6%) experts completed the 2 rounds of questionnaires. The experts' experience was relatively similar. We defined the UniVATS as monitor-dependent surgery, no use of rib-spreading and single incision less than 4 cm. Tumor with stage of T1-T3 and N0-N2 is considered amenable to UniVATS. Other consensus was reached on several points outlining the safety and feasibility, surgical skills, learning curve, short-term and long-term outcomes for lung cancer, and current application of subxiphoid and nonintubated UniVATS approach. This consensus statement represents a collective agreement among Chinese experts to suggest that UniVATS is an effective alternative to multi-portal approach, although high-level evidence is expected in the future. Some agreements can be referred in the training of young surgeons.

Robot-assisted thoracoscopic surgery for mediastinal masses: a single-institution experience.

BACKGROUND: The objectives of this study were to evaluate the feasibility and safety of robot-assisted thoracic surgery (RATS) using the da Vinci robotic system for mediastinal mass resection and to describe the surgical approach for masses in different mediastinal regions. METHODS: We retrospectively reviewed data from 84 patients who underwent RATS for resection of a mediastinal mass from June 2015 to April 2019. The results were analyzed with descriptive statistics. RESULTS: The mediastinal mass was resected successfully in all patients, with one patient requiring conversion to conventional open surgery. There were no intraoperative complications. The most common diagnoses were thymoma (n=17), bronchogenic cyst (n=16), and schwannoma (n=12). The surgical approach was determined by the location of the lesion and the planned extent of surgical resection. Resection was performed in the lateral decubitus position in 29 patients with posterior mediastinal tumor, semi-lateral decubitus position in 42 patients who only need resection of anterior mediastinal mass, and reverse Trendelenburg position in 13 patients undergoing thymectomy. The mean (± standard deviation) operation time was 91.86±56.42 min, duration of chest tube use was 1.83±0.93 days, and postoperative hospital stay was 3.62±7.52 days. Three patients (3.5%) developed postoperative complications: one chylous fistula, which required reoperation, and one case each of atrial fibrillation and pulmonary infection, which were treated conservatively. CONCLUSIONS: Our experience demonstrated that different surgical approaches of RATS are safe and feasible for mediastinal mass resection. An appropriate approach can be selected based on the mediastinal region in which the tumor is located.

Methods for Dissecting Intersegmental Planes in Segmentectomy: A Randomized Controlled Trial.

BACKGROUND: The perioperative outcomes of the use of stapling devices versus electrocautery to dissect intersegmental planes in patients undergoing segmentectomy for small pulmonary lesions is still unclear. The aim of this randomized controlled trial was to compare the perioperative outcomes of these two methods. METHODS: A single-center, prospective, participant-blinded, randomized controlled trial (NCT03192904) was conducted with a preplanned sample size of 136. The primary outcome was the incidence of postoperative complications. Secondary outcomes included duration of operation, blood loss during operation, first-day drainage volume, duration of drainage, postoperative hospital stay, loss of lung function, and medical costs. RESULTS: The trial was stopped early as a result of a marked difference in the primary outcome between groups at a scheduled interim check of the data after recruiting 70 patients. The incidence of postoperative complications (eg, air leakage) was higher in the electrocautery group than in the stapler device group (11/32, 34.4% vs 2/33, 6.1%, P = .004). There were no differences in duration of operation, blood loss during operation, first-day drainage volume, duration of drainage, postoperative hospital stays, loss of lung function, or total medical cost, although the per-patient cost of medical materials was higher in the stapler device group (US$4214.6 ± 1185.4 vs $3260.1 ± 852.6, P < .001). CONCLUSIONS: Among patients undergoing segmentectomy, the use of stapler devices to divide intersegmental planes decreased postoperative complications without further compromising lung function or increasing economic burden.

Next-generation sequencing in thymic epithelial tumors uncovered novel genomic aberration sites and strong correlation between TMB and MSH6 single nucleotide variations.

Thymic epithelial tumors (TET) including thymomas and thymic carcinomas are rare, but they are common primary tumors in the anterior mediastinum. The etiology and tumorigenesis of TET remain unclear. To better understand the novel aberrations of this rare tumor and provide more significant mutation sites for targeted therapy, we performed next-generation sequencing detection on 55 patients with TET. Our results showed that most genes in 12 core pathways harbored aberrations of indeterminate potential. In 4 genes (ARID1A, KMT2C, TGFBR2 and MAP3K1), the indel frequency was above 90%. Dozens of genes, including TGFBR2, KMT2C, PRKDC, ATR, CHD2, SDHA, KDM5A, CHEK1, MSH6 and POLE, possessed frameshift indel with different frequencies in different hotspot sites, which could be the new targets of therapy for TET. For the first time, we revealed a strong correlation between the tumor mutational burden and single nucleotide variations, but not frameshift, on DNA mismatch repair gene MSH6 in TET.

Robotic Approach to Combined Anatomic Pulmonary Subsegmentectomy: Technical Aspects and Early Results.

BACKGROUND: Minimally invasive techniques are increasingly being used in pulmonary segmentectomy and combined subsegmentectomy. However, there are no reports as yet on robotic combined anatomic subsegmentectomy (CAS). In this report, we describe related clinical data and operative techniques and present our early results. METHODS: Clinical data of patients undergoing robotic CAS were retrospectively reviewed. A combined subsegmentectomy was defined as the resection of 2 or more subsegments that involved 2 or more adjacent segments. The study enrolled patients who underwent completely portal robotic CAS. RESULTS: Between May 2015 and January 2018, a single surgeon performed completely portal robotic CAS for 16 patients. In the CAS-treated patients, 75% of the lesions were located in the right upper lobe, and none required conversion to thoracotomy. Median operative time was 175 minutes (range, 75 to 294 minutes), and mean postoperative hospital stay was 4 days (range, 2 to 11 days). Although 1 patient experienced a prolonged air leak, the other 15 recovered uneventfully. Within a median follow-up period of 15 months, there were no deaths or tumor recurrences. CONCLUSIONS: Completely portal robotic CAS is a safe and effective procedure in a select subset of patients, proving quite suitable for smaller (<2 cm) multisegment lung cancers, particularly lesions of the right upper lobe. A robotics approach facilitates complex and challenging CAS, the disadvantage being lengthy operative times during early acquisition of skills.

The Role of Operation in the Treatment of Boerhaave's Syndrome.

PURPOSE: This study aims to discuss the appropriate treatment strategy for spontaneous esophageal rupture. METHODS: Clinical data from twenty-one cases were retrospectively analyzed. The parameters included etiology, time interval between onset and treatment, therapy methods, prognosis, and length of stay. RESULTS: The ratio of males/females was 17/4, age range was 32-82 years (mean = 43.1), and the time interval between onset and treatment was as follows: <24 h: nine cases (42.8%); 24-48 h: six cases (28.6%); and >72 h: six cases (28.6%). All patients underwent operative treatment, and the following primary healing rates were achieved: <24 h: 88.9%, 24-48 h: 66.7%, and >72 h: 0. No patients died in this study. All patients were discharged with recovery, and the average hospitalization times were 18.1 days (<24 h), 27.8 days (24-48 h), and 51.2 days (>72 h). CONCLUSIONS: Surgical treatment remains an effective method for treating spontaneous esophageal rupture, and the shorter the time interval between onset and treatment, possibly the better the prognosis.

Detection of Epithelial-Mesenchymal Transition Status of Circulating Tumor Cells in Patients with Esophageal Squamous Carcinoma.

PURPOSE: To investigate the correlation between the status of epithelial-mesenchymal transition (EMT) of circulating tumor cells (CTCs) and esophageal squamous cell carcinoma (ESCC). METHODS: The demographic data and blood samples of 21 patients with ESCC were collected retrospectively. CTCs were enriched by using optimized CanPatrolTM CTC enrichment technique. CTCs were identified and characterized according to the EMT markers (e-CTCs: epithelial CTCs; mix-CTCs: epithelial-mesenchymal-mixed CTCs; m-CTCs: mesenchymal CTCs). The correlation between CTCs and demographic data was analyzed. RESULTS: Total 129 CTCs were detected in all the patients: 11(8.5%) CTCs of them were e-CTCs, 76(58.9%) were mix-CTCs, and 42(32.6%) were m-CTCs. The average number of CTCs from each patient was 6.1 ± 7.1 which included 0.5 ± 0.9 of e-CTCs, 3.6 ± 5.2 of mix-CTCs, and 2.0 ± 2.7 of m-CTCs; the difference between the three groups was significant (P = 0.017): the number of total CTCs was correlated with the number of mix-CTCs (R2 = 0.883, P < 0.01) and m-CTCs (R2 = 0.639, P < 0.01) but not e-CTCs (R2 = 0.012, P = 0.641) and the number of CTCs was correlated with the N stage and TNM stage in this study (R2 = 0.698 and R2 = 0.359). CONCLUSIONS: Mix-CTCs and m-CTCs might play an important role in progression of ESCC; the number of CTCs in ESCC might have the potential to be a predictor of prognosis.