Can stage-IIB lung cancer be divided into subgroups in terms of prognosis? A modelling study.

INTRODUCTION: Whether changes should be made to the TNM classification of non-small cell lung cancer (NSCLC) according to the newly proposed nodal classification is unclear. We aim to compare the survival between stage-IIB subsets using a modelling study performed using the newly proposed nodal classification. PATIENTS AND METHODS: A total of 682 patients with stage-IIB NSCLC based on the 8th TNM classification were analysed. Hazard ratio (HR) values calculated from survival comparisons between stage-IIB subgroups were used to create a model for patients with stage-IIB NSCLC, and modelling was performed according to the HR values that were close to each other. RESULTS: Patients with T1N1a cancer had the best survival rate (58.2%), whereas the worst prognosis was observed in those with T2bN1b cancer (39.2%). The models were created using the following HR results: Model A (T1N1a, n = 85; 12.4%), Model B (T2a/T2bN1a and T3N0, n = 438; 64.2%), and Model C (T1/T2a/T2bN1b, n = 159; 23.4%). There was a significant difference between the models in terms of overall survival (p = 0.03). The median survival time was 69 months in Model A, 56 months in Model B, and 47 months in Model C (Model A vs. Model B, p = 0.224; Model A vs. Model C, p = 0.01; and Model B vs. Model C, p = 0.04). Multivariate analysis showed that age (p < 0.001), pleural invasion (p < 0.001), and the developed modelling system (p = 0.02) were independently negative prognostic factors. CONCLUSION: There was a prognostic difference between stage-IIB subsets in NSCLC patients. The model created for stage-IIB lung cancer showed a high discriminatory power for prognosis.

Comparative evaluation of staging algorithms proven N2 non-small cell lung cancer treated by lung resection after neoadjuvant therapy.

Background: In this study, we aimed to compare the performances of clinical methods, minimally invasive methods, mediastinoscopy, and re-mediastinoscopy used in the restaging of patients receiving neoadjuvant therapy for pathologically proven N2. Our secondary objective was to determine the most optimal algorithm for initial staging and restaging after neoadjuvant therapy. Methods: Between April 2003 and August 2017, a total of 105 patients (99 males, 6 females; mean age: 54.5±8.2 years; range, 27 to 73 years) who were diagnosed with pathologically proven Stage 3A-B N2 non-small cell lung cancer and received neoadjuvant therapy and subsequently lung resection were retrospectively analyzed. Staging algorithm groups (Group 1=first mediastinoscopy-second clinic, Group 2=first mediastinoscopy-second minimally invasive, Group 3=first mediastinoscopy-second re-mediastinoscopy, and Group 4=first minimally invasive-second mediastinoscopy) were created and compared. Results: In the first stage, N2 diagnosis was made in 90 patients by mediastinoscopy and in 15 patients by minimally invasive method. In the second stage, 44 patients were restaged by the clinical method, 23 by the minimally invasive method, 23 by re-mediastinoscopy, and 15 by mediastinoscopy. The false negativity rates of Groups 1, 2, 3, and 4 were 27.2%, 26.1%, 21.8%, and 13.3%, respectively. The most reliable staging algorithm was found to be the minimally invasive method in the first step and mediastinoscopy in the second step. The mean overall five-year survival rate was 46.3±4.4%, and downstaging in lymph node involvement was found to have a favorable effect on survival (54.3% vs. 21.8%, respectively; p=0.003). Conclusion: The staging method to be chosen before and after neoadjuvant therapy is critical in the treatment of Stage 3A-B N2 non-small cell lung cancer. In re-mediastinoscopy, the rate of false negativity increases due to technical difficulties and insufficient sampling. As the most optimal staging algorithm, the minimally invasive method is recommended in the first step and mediastinoscopy in the second step.

Does anatomical location-based metastatic lymph node density affect prognosis in lung cancer patients?

OBJECTIVES: The newly proposed N subclassification (new-N) was compared with the combined anatomical location and ratio of the number of metastatic lymph nodes to the total number of resected lymph nodes (anatomic-LNR) in terms of prognosis in resected lung cancer patients. METHODS: Between 2005 and 2018, 961 patients who underwent lung cancer resection were catergorized into the pN1-single (N1a; n = 281), pN1-multiple (N1b; n = 182), pN2-single with skip metastasis (N2a1; n = 116), pN2-single with N1 metastasis (N2a2; n = 222) and pN2-multiple (N2b; n = 160) groups based on new-N. The optimal cut-off points for survival in pN1 and pN2 patients were determined using the best sensitivity and specificity scores, calculated using receiver operating characteristic analysis. RESULTS: The difference in survival between N1a and N1b patients was statistically significant (P = 0.001), but there was no significant difference in the survival rates of N1b and N2a1 (P = 0.52). The survival curves for N2a1 and N2a2 patients almost overlapped (P = 0.143). N2a2 patients showed a better survival rate than N2b patients, with no significant difference (P = 0.132). The cut-off points for LNR were 0.10 and 0.25 for pN1 and pN2 patients, respectively, according to receiver operating characteristic analysis for survival. Based on receiver operating characteristic analysis, pN patients were categorized into the N1-lowLNR (n = 232), N1-highLNR (n = 231), N2-lowLNR (n = 266) and N2-highLNR (n = 232) groups. The 5-year survival rate was 62.9%, 49.8%, 41.1% and 27.1% for N1-lowLNR, N1-highLNR, N2-lowLNR and N2-highLNR, respectively (P < 0.001). CONCLUSIONS: LowLNR is associated with better survival than highLNR in resected lung cancer patients. Anatomic-LNR shows a high discriminatory power for prognosis.

Comparison of Thoracic Epidural and Intravenous Analgesia from the Perspective of Recovery of Respiratory Function in the Early Post-Thoracotomy Period in Lung Cancer Surgery.

OBJECTIVE: Thoracic epidural analgesia (TEA) reduces pulmonary complications after thoracotomy. Hypothetically, this advantage is partially because of the preserved pulmonary function, which is achieved by the reduction of postoperative pain and immobility. This study aimed to compare the principal methods of analgesia through early postoperative spirometric performance and gas exchange parameters after elective lung cancer surgery. TEA or intravenous analgesia (IVA) involving pethidine was used as the principal method in our sample population. MATERIAL AND METHODS: A total of 62 patients operated via the posterolateral thoracotomy approach were enrolled. Postoperative analgesia was secured using multimodal analgesia with either TEA with 0.1% bupivacaine or IVA. Pain perception was assessed with the visual analog scale (VAS) while at rest and on coughing. Arterial blood samples were collected at 1, 24, and 72 hours postoperatively. Preoperative and third postoperative day spirometric measurements were recorded. RESULTS: There were no significant differences among the groups in terms of demographic characteristics, properties of surgical technique, and disease-associated conditions. VAS scores of the TEA group were lower at the 72-hour follow-up, but a considerable fraction of these differences did not reach statistical significance. Reduction in the forced expiratory volume in the first second and forced vital capacities was more prominent in the IVA group on the third postoperative day, but these were not statistically significant either. Oxygenation parameters favored TEA but remained comparable. Finally, the pH values were significantly lower in the IVA group at 1 and 72 hours postoperatively (p=0.008 and p=0.02, respectively). CONCLUSION: We believe that TEA is advantageous over IVA with alteration of respiratory volumes during the early postoperative period.

Prognostic Factors and Survival in Resected T4 Non-small Cell Lung Cancer: Is There Any Difference in the T4 Subgroups?

INTRODUCTION: The eighth edition of the TNM classification revised the subgroups of T4 non-small cell lung cancer (NSCLC). This study aimed to compare the T4-NSCLC subgroups that underwent surgical treatment in terms of mortality, morbidity, survival, and prognostic factors based on the new classification. MATERIALS AND METHODS: Between 2000 and 2014, a total of 284 T4-NSCLC patients who underwent lung resection (mediastinal organ invasion, n = 114; ipsilateral different lobe tumors, n = 32; and tumors larger than 7 cm, n = 138) were included in the present study. RESULTS: Surgical mortality and morbidity were 5.6% (n = 16) and 23.9% (n = 68), respectively. The 5-year survival rates were 46% for ipsilateral different lobe tumors, 45.4% for tumours larger than 7 cm, and 36.6% for mediastinal organ invasion (28% for patients with heart/atrium invasion, 43.3% for carina invasion, 37.5% for large vessel invasion) (p = 0.223). Age above 65 (p = 0.002, HR = 1.781), pN2 versus pN0/1 (p < 0.0001, HR = 2.564), incomplete resection (p = 0.003, HR = 2.297), and pneumonectomy (p = 0.02, HR = 1.524) were identified as poor prognostic survival factors. According to multivariate analysis, mediastinal lymph node metastasis (p = 0.001) and incomplete resection (p = 0.0026) were the independent negative risk factors for survival. CONCLUSION: According to the results of our study, surgical treatment is a good option in T4-NSCLC patients who have no mediastinal lymph node metastasis and are completely resectable. There is no difference in terms of survival among the T4 subgroups. The eighth edition of the TNM classification has a better prognostic definition than the previous version.

Does the carinal involvement have the same surgical outcome as the main bronchus involvement in patients with non-small cell lung cancer?

OBJECTIVE: Carinal and main bronchus involvement were compared in terms of the survival of patients with N0-1 non-small cell lung cancer (NSCLC). METHODS: Sixty-six NSCLC patients who underwent complete surgical carinal resection/reconstruction (Carina group) and complete resection because of main bronchus involvement (Main Bronchus group) between 2006 and 2016 were retrospectively analyzed. The Carina group included 30 patients and the Main Bronchus group included 36. In the Carina group, conditions other than carinal involvement that rendered patients pathological (p) T4, and in the Main Bronchus group, conditions that would upstage the pT status from pT2 were excluded. Patients with mediastinal lymph node metastases were excluded. Thus, an isolated main bronchial invasion and isolated carinal invasion patient population was tried to be obtained. RESULTS: The overall 5-year survival rate was 49.4% (median 61.5 ± 19.9 months). The 5-year survival rates of patients in the Carina group was 49.2% (median 63.3 months), and that of patients in the Main Bronchus group was 46.4% (median 55.9 months). The difference between survival rates was not statistically significant (p = 0.761). The survival rates of pN0 and pN1 patients also did not differ significantly (63.2% vs. 45.5%, p = 0.207). Recurrence was significantly more common in the Main Bronchus group than the Carina group (28.1% vs. 7.1%; p = 0.04). CONCLUSIONS: Isolated carinal invasion had a comparable outcome to isolated main bronchus invasion in pN0-1 patients with NSCLC who are undergoing anatomical surgical resection.

Is There a Prognostic Difference Between Stage IIIA Subgroups in Lung Cancer?

BACKGROUND: Treatment of stage IIIA lung cancer remains controversial because it includes a very heterogeneous group of patients. The purpose of our study was to compare survival between stage IIIA subsets and to externally validate our results with another center's database. METHODS: Patients with completely resected stage IIIA/B lung cancer were retrospectively analyzed. There were 424 patients with stage IIIA and 82 patients with stage IIIB (T3/4 N2) (study cohort). Stage IIIA was divided into 2 subsets according to the tumor localization and tumor size (T3 N1-T4 N0/1, IIIA-T group; n = 308) and the extension of nodal disease (T1/2 N2, IIIA-N2 group; n = 116). The study cohort results were used to create a model for stage IIIA patients, which was validated with another center's database (validation cohort). RESULTS: The multivariate analyses showed age, stage IIIB, and pN2 were independent negative prognostic factors (P < .0001). Survival at 5 years was 51.3% (median, 64 months) for patients in the IIIA-T group and was 25.7% (median, 31 months) in the IIIA-N2 patients (hazard ratio, 1.834; P < .0001). There was no statistical difference in survival between the IIIA-N2 and stage IIIB groups (25.7% vs 25.3%, P = .442). The created model was performed on patients in the validation cohort as a model IIIA-T (T3 N1-T4 N0/1, n = 139) and model IIIA-N2 (T1/2 N2, n = 104). Model IIIA-T patients had a statistically better survival rate than model IIIA-N2 patients (median, 62 months vs 37 months; hazard ratio, 1.707, P < 0.001). CONCLUSIONS: There is a prognostic difference between stage IIIA subgroups in lung cancer patients who undergo surgical treatment.

The prognostic impact of the mediastinal fat tissue invasion in patients with non-small cell lung cancer.

BACKGROUND: The prognosis of the mediastinal fat tissue invasion in non-small cell lung cancer (NSCLC) patients has not yet been clearly defined. The present study aimed to investigate the prognostic impact of the mediastinal fat tissue invasion in NSCLC patients. METHOD: We analyzed 36 patients who were found mediastinal fat tissue invasion by pathological evaluation (mediastinal fat group) and 248 patients who were classified as T4-NSCLC according to the 8th TNM classification (T4 group; invasion of other mediastinal structures in 78 patients, ipsilateral different lobe satellite pulmonary nodule in 32 patients, and tumor diameter > 7 cm in 138 patients). RESULT: Resection was regarded as complete (R0) in 255 patients (89.7%). Mediastinal fat group showed significantly higher incidence of incomplete resection (R1) and more left-sided tumors than the T4 group (p = 0.01, and p = 0.002, respectively). The survival was better in T4 group than mediastinal fat group (median 57 months versus 31 months), although it was not significant (p = 0.205). Even when only N0/1 or R0 patients were analyzed, the survival was not different between two groups (p = 0.420, and p = 0.418, respectively). 5-year survival rates for T4 subcategories (invasion of other structures, ipsilateral different lobe pulmonary nodule, and tumor diameter > 7 cm) were 39.4%, 41.9%, and 50.3%, respectively (p = 0.109). Multivariate analysis showed that age (p < 0.0001), nodal status (p = 0.0003), and complete resection (p < 0.0001) were independently influenced survival. CONCLUSION: There is no significant difference in the prognosis between mediastinal fat tissue invasion and T4 disease in NSCLC patients.

A Comparison of the Currently Used Nodal Stage Classification with the Number of Metastatic Lymph Nodes and the Number of Metastatic Lymph Node Stations for Non-Small Cell Lung Cancer; Which of These Is the Best Prognostic Factor?

OBJECTIVES: We aimed to compare the currently used nodal staging system (pN) with the number of metastatic lymph node (LN) stations (sN) and the number of metastatic LNs (nN) on survival in patients with NSCLC. METHODS: Between 2010 and 2017, 1038 patients resected for NSCLC were analyzed. We performed three-different stratifications of LN status assessment: pN-category (pN0, pN1 and pN2); sN-category (sN0, sN1; one station metastasis, sN2; two-three stations metastases, and sN3; ≥ 4 stations metastasis); nN-category (nN0, nN1; one-three LNs metastasis, nN2; four-six Lns metastasis, and nN3; ≥ 7 LNs metastasis). RESULTS: Five-year survival rate was 70.1% for N0 in all classifications. It was 54.3% for pN1, and 26.4% for pN2 (p < 0.0001). Five-year survival rates for N1, N2, and N3 categories were 54.1%, 42.4% and 16.1% according to sN, and 51.4%, 36.1%, and 7.9% according to nN, respectively (p < 0.0001). In multivariate analysis, sN and nN were independent risk factors such as pN (p < 0.0001). Hazard ratios versus N0 for N1, N2, and N3 were more significant for sN and nN than pN (1.597, 2.176, and, 3.883 for sN, 1.645, 2.658, and, 4.118 for nN, and 1.576, 3.222 for pN, respectively). When the subcategories of sN and nN were divided into pN1 and pN2 subgroups, the anatomic location of the LN involvement lost importance as tumor burden and tumor spreading increased. CONCLUSION: The number of metastatic LN stations and the number of metastatic LNs are better prognostic factors than currently used nodal classification in NSCLC.

The incidence of hoarseness after mediastinoscopy and outcome of video-assisted versus conventional mediastinoscopy in lung cancer staging.

Objectives Theoretically, video-assisted mediastinoscopy (VM) should provide a decrease in the incidence of hoarseness in comparison with conventional mediastinoscopy (CM). Methods An investigation of 448 patients with the NSCLC who underwent mediastinoscopy (n = 261 VM, n = 187 CM) between 2006 and 2010. Results With VM, the mean number of sampled LNs and of stations per case were both significantly higher (n = 7.91 ± 1.97 and n = 4.29 ± 0.81) than they were for CM (n = 6.65 ± 1.79 and n = 4.14 ± 0.84) (p < 0.001 and p = 0.06). Hoarseness was reported in 24 patients (5.4%) with VM procedures resulting in a higher incidence of hoarseness than did CM procedures (6.9% and 3.2%) (p = 0.08). The incidence of hoarseness was observed to be more frequent in patients with left-lung carcinoma who had undergone a mediastinoscopy (p = 0.03). Hoarseness developed in 6% of the patients sampled at station 4L, whereas this ratio was 0% in patients who were not sampled at 4L (p = 0.07). A multivariate analysis showed that the presence of a tumor in the left lung is the only independent risk factor indicating hoarseness (p = 0.09). The sensitivity, NPV, and accuracy of VM were calculated as to be 0.87, 0.95, and 0.96, respectively. The same staging values for CM were 0.83, 0.94, and 0.95, respectively. Conclusion VM, the presence of a tumor in the left-lung, and 4L sampling via mediastinoscopy are risk factors for subsequent hoarseness. Probably due to a wider area of dissection, VM can lead to more frequent hoarseness.

Long-term Outcome of Patients With Undiagnosed Pleural Effusion.

INTRODUCTION: The cause of exudative pleural effusion cannot be determined in some patients. The longterm outcomes of patients with undiagnosed pleural effusion were analyzed. METHODS: Patients with exudative pleural effusion whose diagnostic procedures included pleural biopsy using video-assisted thoracoscopic surgery carried out between 2008 and 2012 were evaluated retrospectively. Patients diagnosed with non-specific pleuritis were included. Fifty-three patients with available follow-up data were included in the study. RESULTS: Forty men and 13 women (mean age 53.9±13.9 years) were included. Median follow-up time was 24 months. No diagnosis was given in 27 patients (51%), and a clinical diagnosis was given in 26 patients (49%) during the follow-up period. Malignant disease (malignant mesothelioma) was diagnosed in 2 (3.7%) patients. Other diseases were parapneumonic effusion in 12, congestive heart failure in 8, and miscellaneous in 4 patients. Volume of effusion at the time of initial examination and re-accumulation of fluid after video-assisted thoracoscopic surgery were associated with malignant disease (P=.004 and .0001, respectively). CONCLUSION: Although the probability is low, some patients with exudative pleural effusion undiagnosed after pleural biopsy via video-assisted thoracoscopic surgery may have malignant disease. Patients with an initially large volume of effusion that re-accumulates after examination should be closely monitored.

The Prognostic Significance of Metastasis to Lymph Nodes in Aortopulmonary Zone (Stations 5 and 6) in Completely Resected Left Upper Lobe Tumors.

INTRODUCTION: We investigated the prognostic effect of lymph nodes metastasis in aortopulmonary (AP) zone in resected non-small cell lung cancer of the left upper lobe (LUL). METHODS: Between 1998 and 2010, 181 patients with LUL carcinoma underwent complete resection and were retrospectively analyzed. The patients were divided into four groups according to N status: N0 (n = 68, 37.6%), N1 (n = 64, 35.3%), N2(5,6+) (only metastasized to stations 5 and/or 6, n = 36, 19.9%), and N2(7+) (only metastasized to stations 7, n = 13, 7.2%). N1 were divided according to single and multiple (N1(single) n = 49, N1(multiple) n = 15) or peripheral and hilar (N1(peripheral) n = 39, N1(hilar) n = 25). RESULTS: Overall 5-year survival rate was 55.1%. Five-year survivals were 76.1% for N0, 54.3% for N1, and 20.7% for N2. N1(peripheral) had a better survival than N1(hilar) (60.3 vs. 29.4%, p = 0.09). Five-year survival of N1(single) was 60.1%, whereas it was 36.6% for N1(multiple) (p = 0.02). Five-year survival rate was 24.6% for N2(5,6+). Skip metastasis for lymph nodes in AP zone (n = 13) was a factor of better prognosis as compared to nonskip metastasis (n = 23) (29.9 vs. 19.2%). There was no statistically significant difference between the N2(5,6+) and N1(hilar) (p = 0.772), although N1(peripheral) had a significantly better survival than N2(5,6+) (p = 0.02). AP zone metastases alone had a significantly worse survival than N1(single) (p = 0.008), whereas there was no statistically significant difference between the N1(multiple) and N2(5,6+) (p = 0.248). N2(7+) was not expected to survive 3 years after operation. They had a significantly worse prognosis than N2(5,6+) (p = 0.02). CONCLUSION: LUL tumors with metastasis in the AP zone lymph nodes, especially skip metastasis, were associated with a more favorable prognosis than other mediastinal lymph nodes. However, the therapy of choice for lung cancer with N2(5,6+) has not been clarified yet.

The effects of thoracic surgery operations on quality of life: a multicenter study.

OBJECTIVE: Some treatment modalities may cause losses in patients' life comfort because of the treatment process. Our aim is to determine the effects of thoracic surgery operations on patients' quality of life. MATERIALS AND METHODS: This is a multicenter and prospective study. A hundred patients, who had undergone posterolateral thoracotomy (PLT) and/or lateral thoracotomy (LT), were included in the study. A quality of life questionnaire (SF-36) was used to determine the changes in life comfort. SF-36 was performed before the operation, on the first month, third month, sixth month and twelfth month after the operation. RESULTS: Seventy-two percent (n = 72) of the patients were male. PLT was performed in 66% (n = 66) of the patients, and LT was performed in 34% (n = 34) of the patients. The types of resections in patients were pneumonectomy in four patients, lobectomy in 59 patients and wedge resection in 11 patients. No resection was performed in 26 patients. Thoracotomy caused deteriorations in physical function (PF), physical role (RP), bodily pain (BP), health, vitality and social function scores. The deteriorations observed in the third month improved in the sixth and twelfth months. The PF, RP, BP and MH scores of the patients with lung resection were much more worsened compared with the patients who did not undergo lung resection. CONCLUSION: Thoracic surgery operations caused substantial dissatisfaction in life comfort especially in the third month postoperatively. The worsening in physical function, physical role, pain and mental health is much more in patients with resection compared with the patients who did not undergo resection.

Anterior muscle and neurovascular-sparing thoracotomy and posterolateral thoracotomy: postoperative pain and morbidity assessment.

BACKGROUND: We conducted this study to evaluate the thoracotomy approaches commonly used nowadays for treating thoracic pathologies and to decide whether it was necessary to make a choice between them for different situations. We used prospective analysis to compare hospital stay, analgesic usage, morbidity and postoperative chest pain between anterior muscle and neurovascular-sparing thoracotomy (AST) with disconnection of anterior rib cartilage, and serratus-sparing posterolateral thoracotomy (PLT). We also looked for a correlation between localization of the lesion and thoracotomy type for this factors. MATERIALS AND METHODS: A total of 152 patients who had undergone a thoracotomy for major lung surgery from January through November 2011 were recruited in this study. Of these, 52 patients received AST and 100 underwent PLT. Location of the lesions in the thoracic cavity and all detected postoperative complications were documented. Postoperative chest pain was evaluated using a PIQ-6 pain questionnaire. Analgesic usage and duration of hospitalization were also noted. RESULTS: Pain questionnaire scores were equivalent for both groups in all of the evaluations. Postoperative total median narcotic analgesic usage was lower in AST group than in PLT group. Complication rates were close in both groups. Median hospital stay was also shorter in patients who received AST. CONCLUSION: We conclude that AST is a reasonable thoracotomy alternative to standard PLT for major lung surgery. But our study fails to demonstrate a clear advantage regarding postoperative pain and complications.

Size of pneumothorax can be a new indication for surgical treatment in primary spontaneous pneumothorax: a prospective study.

PURPOSE: Surgical treatment of primary spontaneous pneumothorax (PSP) is usually performed in cases of prolonged air leak (PAL) or recurrence. We investigated the effect of the size of pneumothorax in surgically treated PSP cases. METHODS: Between 2007 and 2008, 181 patients hospitalized with the diagnosis of PSP were prospectively recorded. The size of pneumothorax was calculated in percentages by the method defined by Kircher and Swartzel. Patients were divided into two groups, according to pneumothorax size: Group A (large pneumothorax, ≥50%), and Group B (small or moderate pneumothorax, <50%). RESULTS: The mean size of pneumothorax was 80.5 ± 10.4% in Group A (n = 54, 29%) and 39.5 ± 6.5% in Group B (n = 127, 71%). History of smoking and smoking index were significantly higher in Group A patients (p = 0.02, p <0.001, respectively). Fifty-five patients (29.3%) required surgery because of PAL or ipsilateral recurrence. The rate of patients requiring surgical operation was significantly higher in Group A (51.9%) than in Group B (n = 25; p <0.001). Rates of PAL and recurrence were higher in Group A than in Group B (p = 0.007, p = 0.004, respectively). CONCLUSION: The size of pneumothorax is larger in those with a smoking history and a higher smoking index. Surgical therapy can be considered in cases with a pneumothorax size ≥50% after the first episode immediately.

Does video-assisted mediastinoscopy offer lower false-negative rates for subcarinal lymph nodes compared with standard cervical mediastinoscopy?

OBJECTIVES: Theoretically, video-assisted mediastinoscopy (VAM) offers improved staging of subcarinal lymph nodes (LNs) compared with standard cervical mediastinoscopy (SCM). Materials and METHODS: Between 2006 and 2011, 553 patients (SCM, n = 293; VAM, n = 260) with non-small cell lung carcinoma who underwent mediastinoscopy were investigated. Mediastinoscopy was performed only in select patients based on computed tomography (CT) or positron emission tomography CT scans in our center. RESULTS: The mean number of LNs and stations sampled per case was significantly higher with VAM (n = 7.65 ± 1.68 and n = 4.22 ± 0.83) than with SCM (n = 6.91 ± 1.65 and 3.92 ± 86.4; p < 0.001). The percentage of patients sampled in station 7 was significantly higher with VAM (98.8%) than with SCM (93.8%; p = 0.002). Mediastinal LN metastasis was observed in 114 patients by mediastinoscopy. The remaining 439 patients (203 patients in VAM and 236 in SCM) underwent thoracotomy and systematic mediastinal lymphadenectomy (SML). SML showed mediastinal nodal disease in 23 patients (false-negative [FN] rate, 5.2%). The FN rate was higher with SCM (n = 14, 5.9%) than with VAM (n = 9, 4.4%), although this difference was not statistically significant (p = 0.490). Station 7 was the most predominant station for FN results (n = 15). The FN rate of station 7 was found to be higher with SCM (n = 9, 3.8%) than with the VAM group (n = 6, 2.9%; p = 0.623). CONCLUSION: FN were more common in mediastinoscopy of subcarinal LNs. VAM allows higher rates of sampling of mediastinal LN stations and station 7, although it did not improve staging of subcarinal LNs.

Endotracheal ectopic parathyroid adenoma mimicking asthma.

Primary benign tumors of the trachea are uncommon. These tumors may cause tracheal occlusion and lead to a misdiagnosis of asthma. Ectopic parathyroid adenoma (EPA) can be seen anywhere between the mandibular angle and the mediastinum. The distal part of the trachea is a rare location for EPA, and EPA obstructing the endotracheal lumen has not been reported in the literature. We herein describe a 52-year-old female with a several-year history of asthma treatment who presented with progressive dyspnea. Computed tomography revealed a mass that was obstructing the tracheal lumen. Total mass excision was performed via endobronchial treatment, and pathologic examination revealed EPA.

Impact of extended cervical mediastinoscopy in staging of left lung carcinoma.

BACKGROUND: Extended cervical mediastinoscopy (ECM) is a method for staging lung carcinoma. We aimed to demonstrate the impact of ECM in the staging of lung carcinoma. METHODS: Between 1998 and 2011, 159 patients with left lung carcinoma who underwent ECM simultaneously with standard cervical mediastinoscopy (SCM), were retrospectively analyzed. Until 2006, ECM had been performed routinely (n = 90, routine ECM), however, after 2006 ECM was performed only in patients selected based on computed tomography and positron emission tomography scans (n = 69, selective ECM). RESULTS: Mediastinal lymph node metastasis was present in 36 patients by mediastinoscopy. Aortopulmonary window (APW) lymph node metastasis was present in 26 patients (10 in the routine group, 16 in the selective group), whereas the 10 patients who had mediastinal lymph node metastasis that could only be accessed by SCM, but had no APW lymph node metastasis, were excluded. The remaining 123 patients (72 in the routine group, 51 in the selective group) were identified as cN0/N1 by SCM/ECM, and lobectomy, pneumonectomy, and exploratory thoracotomy were performed on 64, 43, and 16 of these patients, respectively. According to the lymphadenectomy, APW lymph node metastasis was determined in 11 patients (seven in the routine group, four in the selective group). Sensitivity, negative predictive value (NPV), and accuracy of ECM were calculated as 0.70, 0.90, and 0.92, respectively. Staging values of routine/selective ECM protocols were 0.58/0.80, 0.89/0.91 and 0.91/0.94, respectively. The complication rate was 5% (n = 8). CONCLUSIONS: ECM has an adequate NPV and accuracy in determining metastasis to the APW lymph nodes in patients with left lung carcinoma.

Carinal resection and reconstruction for respiratory tumors using Miyamoto's technique.

PURPOSE: Surgical processes that involve the carina pose a serious challenge to thoracic surgeons. Although techniques to allow resection and reconstruction have been developed, few institutions have accumulated sufficient experience to achieve meaningful results. There is still a debate about the indications and the morbidity and mortality rates for this type of surgery. METHODS: We have operated on six patients using a modified version of the tracheobronchial end-to-end and bronchial end-to-side anastomosis technique that was developed by Miyamoto and coworkers and reported in the English-language literature by Yamamoto and associates. RESULTS: Five patients underwent tracheal sleeve right upper lobectomy, and one underwent carinal resection only with two main bronchi and the trachea. None of the patients we operated on had any postoperative complications. CONCLUSIONS: We concluded that when used with adequate surgical performance this seldom-used technique can be applied safely and provide great benefits in particular cases.

Prognostic stratification of patients with T3N1M0 non-small cell lung cancer: which phase should it be?

In the 1997 revision of the TNM staging system for lung cancer, patients with T3N0M0 disease were moved from stage IIIA to stage IIB since these patients have a better prognosis. Despite this modification, the local lymph node metastasis remained the most important prognostic factor in patients with lung cancer. The present study aimed to evaluate the prognosis of patients with T3N1 disease as compared with that of patients with stages IIIA and IIB disease. During 7-year period, 313 patients with non-small cell lung cancer (297 men, 16 women) who had resection were enrolled. The patients were staged according the 2007 revision of Lung Cancer Staging by American Joint Committee on Cancer. The Kaplan-Meier statistics was used for survival analysis, and comparisons were made using Cox proportional hazard method. The 5-year survival of patients with stage IIIA disease excluding T3N1 patients was 40%, whereas the survival of the patients with stage IIB disease was 66% at 5 years. The 5-year survival rates of stage III T3N1 patients (single-station N1) was found to be higher than those of patients with stage IIIA disease (excluding pT3N1 patients, P = 0.04), while those were found to be similar with those of patients with stage IIB disease (P = 0.4). Survival of the present cohort of patients with T3N1M0 disease represented the survival of IIB disease rather than IIIA non-small cell lung cancer. Further studies are needed to suggest further revisions in the recent staging system regarding T3N1MO disease.