Salvage pulmonary resection in stages IIIb-IV lung cancer after treatment with immune checkpoint inhibitors case series and literature review.

BACKGROUND AND OBJECTIVES: The role of salvage thoracic surgery in managing advanced-stage lung cancer following treatment with immune checkpoint inhibitors is currently unclear. We present a series of nine patients with advanced non-small-cell lung cancer who underwent pulmonary resection following treatment with pembrolizumab. METHODS: We performed a single-institution retrospective analysis of pulmonary resection undertaken following treatment with pembrolizumab for advanced-stage lung cancer. Nine patients met the inclusion criteria. RESULTS: In six cases, surgery was indicated for persistent localized disease after treatment, and in three cases for nonresponsive synchronous/metachronous lung nodules while on treatment for stage IV lung cancer. Dense hilar fibrosis was present in all patients. Minimal access surgery was achieved in five cases (video-assisted n = 2, robotic-assisted n = 3). There was no in-hospital mortality. One patient died within 60 days from community-acquired COVID-19 pneumonitis. Seven patients remain free of disease between 5 and 22 months follow-up. CONCLUSIONS: Pulmonary resection is safe and technically feasible following treatment with immune checkpoint inhibitors. Surgical challenges relate to postimmunotherapy fibrosis, but with increased experience and a robotic approach, minimal access surgery is achievable. Further prospective studies are required to assess the surgical impact on disease control and overall survival in this patient cohort.

Maintaining safe lung cancer surgery during the COVID-19 pandemic in a global city.

BACKGROUND: SARS-CoV-2 has challenged health service provision worldwide. This work evaluates safe surgical pathways and standard operating procedures implemented in the high volume, global city of London during the first wave of SARS-CoV-2 infection. We also assess the safety of minimally invasive surgery(MIS) for anatomical lung resection. METHODS: This multicentre cohort study was conducted across all London thoracic surgical units, covering a catchment area of approximately 14.8 Million. A Pan-London Collaborative was created for data sharing and dissemination of protocols. All patients undergoing anatomical lung resection 1st March-1st June 2020 were included. Primary outcomes were SARS-CoV-2 infection, access to minimally invasive surgery, post-operative complication, length of intensive care and hospital stay (LOS), and death during follow up. FINDINGS: 352 patients underwent anatomical lung resection with a median age of 69 (IQR: 35-86) years. Self-isolation and pre-operative screening were implemented following the UK national lockdown. Pre-operative SARS-CoV-2 swabs were performed in 63.1% and CT imaging in 54.8%. 61.7% of cases were performed minimally invasively (MIS), compared to 59.9% pre pandemic. Median LOS was 6 days with a 30-day survival of 98.3% (comparable to a median LOS of 6 days and 30-day survival of 98.4% pre-pandemic). Significant complications developed in 7.3% of patients (Clavien-Dindo Grade 3-4) and 12 there were re-admissions(3.4%). Seven patients(2.0%) were diagnosed with SARS-CoV-2 infection, two of whom died (28.5%). INTERPRETATION: SARS-CoV-2 infection significantly increases morbidity and mortality in patients undergoing elective anatomical pulmonary resection. However, surgery can be safely undertaken via open and MIS approaches at the peak of a viral pandemic if precautionary measures are implemented. High volume surgery should continue during further viral peaks to minimise health service burden and potential harm to cancer patients. FUNDING: This work did not receive funding.

Contraceptive implant migration to the lung.

A 27-year-old female presented with a 'missing' contraceptive implant. Chest imaging demonstrated a 4-cm linear opacity in a subsegmental branch of the pulmonary artery to the left lower lobe consistent with a migrated contraceptive implant. A mini-thoracotomy and arteriotomy was performed. The artery was opened distally to its third division. However, it was not possible to retrieve the implant, and the decision was made to proceed to segmentectomy. After resection, it was noted that the foreign body had significantly endothelialised within the wall of the artery and required sharp dissection for removal. This is the first case report to demonstrate the complete endothelialisation and subsequent difficulty in removal of an embolised contraceptive implant. We hope this report adds to the growing body of literature to guide management of this extremely rare but serious complication.

Low-cost simulation models in Urology: a systematic review of the literature.

INTRODUCTION: Simulation models have been found to be effective and valid for training in Urology. Due to increasing costs of surgical training, there is a need for low-cost simulation models to enable Urology trainees to improve their skills. MATERIAL AND METHODS: A literature review was performed using the PubMed and Embase databases until March 2020. A total of 157 abstracts were identified using the search criteria, of which 20 articles were identified describing simulation models for Urology training. Articles reviewed described simulation models created from materials costing less than $150. Data was extracted from the relevant articles in order to critically assess each paper for validity, ease of construct and educational impact. RESULTS: Models were found pertaining to suprapubic catheterization (6), cystoscopy (3), percutaneous nephrolithotomy (5), scrotal examination (1), circumcision (1), ureteroscopy (1), transurethral resection of the prostate and bladder (2), and open prostatectomy (1). 18/20 (90%) assessed for either face, content, or construct validity. None of the papers evaluated assessed for transferability of skills to performance in real patients. CONCLUSIONS: A plethora of low-cost simulation models for urological procedures are described in the literature, many of which can be easily constructed from cheap and accessible materials. However there is a need for further efforts to validate or assess for transferability of skills to clinical practice.

May-Thurner variant secondary to degenerative lumbar spondylolisthesis: a case report.

May-Thurner syndrome (MTS) is a rare condition in which patients develop iliofemoral deep venous thrombosis due to an anatomical variant in which the right common iliac artery overlies and compresses the left common iliac vein against the lumbar spine. We report a case of variant MTS, where vascular distortion secondary to spontaneous spinal arthrodesis of degenerative lumbar spondylolisthesis resulted in left common iliac vein compression and iliofemoral deep vein thrombosis. While the common complications of degenerative spondylolisthesis, such as spinal stenosis, are well described; the potential for pelvic vascular distortion secondary to anterior translation of the lumbar spine is not well recognized. The purpose in presenting this case is to describe the mechanism by which this variant of MTS occurs and highlight the need for vigilance for this unusual clinical entity.