Evaluation of the effects of postoperative pleural empyema on survival rates of patients after pneumonectomy due to non-small cell lung cancer.

Introduction: Postpneumonectomy empyema (PPE) is a severe and often fatal complication of pneumonectomy, but some benefits of PPE were reported in patients who underwent either lobe or an entire lung resection due to lung cancer. Aim: To compare the survival outcomes of patients with non-small-cell lung carcinoma (NSCLC), who developed PPE after pneumonectomy with uneventful recoveries available in our center's database. Material and methods: Outcomes of 928 pneumonectomies performed due to NSCLC between 1995 and 2009 were evaluated. The selection of the control group took into account the requirements for propensity score matching in terms of follow-up period, age, sex, tumor histopathology, TNM classification and the side of surgery. Results: Thirty-two patients with a PPE syndrome and 96 patients without complications after pneumonectomy were included. The estimated 5- and 10-year survival rates were 71% and 59%, respectively. The average and median survival was almost two- and three-fold longer compared to the group with uneventful recoveries. A 2-fold lower cancer-related mortality rate and a 1.5-fold higher cancer-unrelated mortality rate were noted in the PPE group as opposed to the group without complications. Having recovered from PPE, the patients had their risk of death reduced by 2.5-fold and 3.5-fold due to all causes and cancer, respectively. Conclusions: Pleural empyema in NSCLC patients who underwent pneumonectomy seems to improve the survival outcomes compared to patients with uneventful recoveries.

Comparison of peripheral blood saturation with brain oxygenation in patients undergoing thoracic surgery.

Introduction: Near-infrared spectroscopy (NIRS) is a non-invasive method of regional tissue oxygenation measurement. Intraoperative use of NIRS to monitor brain oxygenation (BO) during surgery might be beneficial to identify cerebral desaturations. Aim: To compare peripheral blood saturation (SpO2) with BO measurements and evaluate the utility of BO in thoracic surgery. Material and methods: We took BO and SpO2 measurements in a group of 100 patients undergoing standard thoracic surgery. Measurements were made every 15 minutes. The Mann-Whitney U test was used to compare study groups. Spearman's rank correlation coefficient was used to determine correlation between studied parameters. Results: We found a negative correlation between patients' age and BO at the beginning of surgery. Operations lasted between 30 and 200 minutes. We found a positive correlation between BO and SpO2 between 15 and 90 minutes of surgery. Subsequently, BO remained at a low level while SpO2 returned to baseline values. Higher minimum SpO2 values were noted in patients undergoing left-sided procedures. Conclusions: Cerebral oxygenation does not return to baseline values until the end of the surgery as opposed to the SpO2. Furthermore, both SpO2 and BO correlate negatively with the overall duration of thoracic surgery. In addition, after 90 minutes of surgery, SpO2 stopped reflecting brain oxygenation.

Examination of resistance of various methods of pulmonary vessel occlusion to hydrostatic pressure.

Objective: The aim of this study was to compare pressure resistance of the most common methods of vessel occlusion during thoracic surgical procedures: ligations, clips, and vascular endostaplers. Methods: Pulmonary vessels were obtained during routine thoracic surgeries. A ball-tipped cannula was inserted through an opening in the side wall and secured with a linen ligature from slipping out. Subsequently, saline was infused into the vessel. We recorded the pressure on which a leakage occurred. Results: A total of 65 vessels, divided between 3 groups, were enrolled in the study. In the endostaplers group, median bursting pressures were 262.5 mmHg and 300 mmHg for arteries and veins, respectively. In the case of clips, it was over 750 mmHg in both types of the vessels. The same results were observed in the ligation group. Minimal bursting pressures in endostapler occlusion were 187.5 mmHg and 225 mmHg in arteries and veins, respectively. In the case of clips, it was 600 mmHg for arteries and 675 mmHg for veins. A total of 525 mmHg (arteries) and 750 mmHg (veins) were the minimal leaking values observed in vessels occluded with ligations. Comparative analysis showed statistically significant differences in endostapler-clips and endostapler-ligations pairs (p < 0.001). There were no differences between clips and ligations. Conclusions: The examined methods are capable of occluding pulmonary vessels under physiological conditions. Furthermore, ligations and clips are resistant to pressures highly exceeding physiological values.

Basic Operative Tactics for Pulmonary Echinococcosis in the Era of Endostaplers and Energy Devices.

Human echinococcosis is a zoonotic infection caused by the larvae of the tapeworm species Echinococcus. The liver is the most common location for a primary echinococcosis. However, the parasite may bypass or spread from the liver to the lungs, causing primary or secondary pulmonary echinococcosis, respectively. Pulmonary echinococcosis is a clinically challenging condition in which anthelminthic regiments are important, but surgery has the central role in removing the cysts and preventing recurrences. Surgical treatment may involve cystotomy, enucleation, capitonnage, or atypical resections, which occasionally are in combination with hepatic procedures. The utilization of modern devices is greatly underdescribed in surgery for thoracic infections, even though these facilitate much of the work. Therefore, this article aims to describe pulmonary echinococcosis and the role of modern surgical devices in the treatment process. Furthermore, we report surgical treatment of three different cases of pulmonary echinococcosis. Surgeries of uncomplicated and ruptured hepatic or pulmonary cysts are described. Simple small pulmonary echinococcal lesions can be excised by endostaplers both for diagnostic and curative reasons. Larger cysts can be removed by energy devices unless large bronchial air leaks occur. Complicated cysts require treatment by more extensive techniques. Inexperienced surgeons should not abstain but should carefully decide preoperatively how to proceed.

Benign Metastasizing Leiomyoma of the Lung: Diagnostic Process and Treatment Based on Three Case Reports and a Review of the Literature.

Uterine leiomyomas may occasionally spread to the lungs forming nodular lesions detectable on chest X-ray. This condition known as benign metastasizing leiomyoma (BML) usually occurs in females with a history of hysterectomy or myomectomy. We present three cases of BML demonstrating the diagnostic process and treatment approaches. Two patients presented with the more common multiple-nodule variant while the other had a single mass, but all were symptom-free. The age of presented patients at diagnosis of BML ranged from 46-53. The first patient was diagnosed with BML at the age of 50, and 12 years prior to the diagnosis, underwent a supracervical hysterectomy. The second patient had a myomectomy at 36, and BML was diagnosed 17 years later at the age of 53. The third patient had a hysterectomy with bilateral salpingo-oophorectomy at the age of 46, with lung lesions present before the hysterectomy. Immunohistochemical studies of postoperative materials showed positive staining of spindle cells with antibodies against desmin and smooth muscle actin, as well as estrogen and progesterone receptors. The final histopathological diagnoses were pulmonary BML. All patients are stable and symptom-free: two at two years follow-up and one at six months follow-up.

Right Heart Echocardiography Parameters and Other Predictors to Evaluate Mechanical Cardiac Support Necessity During Lung Transplantation.

BACKGROUND: Lung transplantation (LuTx) is a challenge when right heart function fails. Mechanical circulatory support (MCS) is then necessary. METHODS: We aimed to investigate whether preoperative transthoracic echocardiography (TTE) can predict MCS use and help to exclude the sickest patients. Between 2011 and 2018, 52 patients at our institution received LuTx and qualified for this study: 35 bilateral, 16 single, 1 lobar [1] and 1 retransplantation procedure. Of these, 22 were operated using MCS and 30 without MCS. The patients were aged between 18 and 65 years, and 23 were women. The indications were lung fibrosis for 18 patients, chronic obstructive lung disease for 16, cystic fibrosis for 15, primary pulmonary hypertension for 2 and bronchiectasis for 1. TTE was performed up to 30 days before treatment and 1 to 7 days after. RESULTS: Patients undergoing MCS versus patients not undergoing MCS: preoperative right ventricular systolic pressure 56.5 (30) vs 37.8 (11.5) mm Hg (P = .03); tricuspid regurgitation pressure gradient 48.7 (27) vs 30.2 (10.8) mm Hg (P = .015); tricuspid annular plane systolic excursion 17.8 (4.3) vs 19.9 (2.8) mm Hg (P = .04); pulmonary artery diameter 27.5 (5.2) vs 23.9 (4.1) mm (P = .004); age 41.9 (14.1) vs 54.3 (11.8) years (P = .001). Patients who were Dead versus patients who were alive pulmonary valve acceleration time of 82.8 (24.1) vs 104.9 (27.2) ms (hazard ratio [HR] = 0.959, 95% confidence interval [CI] = 0.923-0.996 per ms, P = .02) and pulmonary artery diameter of 28.9 (5.8) vs 24.4 (4.1) mm HR = 1.225, 95% CI = 1.028-1.460 per 1 mm, P = .016 were predictors of death. CONCLUSIONS: Preoperative TTE parameters: right ventricular systolic pressure, tricuspid regurgitation pressure gradient, tricuspid annular plane systolic excursion, and pulmonary artery diameter predicted MCS use during LuTx. Certain values of valve acceleration time and pulmonary artery diameter could help discern LuTx qualification.

Does postpneumonectomy empyema improve long-term survival for patients with lung cancer?

Postpneumonectomy empyema (PPE) is life-threatening morbidity that affects up to 10% of patients and carries a 9-13% mortality risk. Treatment can take a long time, and the prognosis is uncertain. Forty years ago, improved survival was reported among patients with lung cancer and pleural empyema compared to those with lung cancer and no empyema. Here we investigated this potential association among patients with PPE. The present study included 38 patients who underwent pneumonectomy between 1995-2007 (7 females, 31 males, median age of 62 years) and then developed PPE, which was treated with the accelerated treatment (AT) method. Thirty-five of these patients had been diagnosed with lung cancer (including one case of carcinoid with infiltration), of whom 31 were matched with 31 lung cancer patients who underwent uncomplicated pneumonectomy at the same center between 1997-2009. The two groups did not significantly differ regarding sex, age, histology, TNM, FEV1, major co-morbidities, or received neoadjuvant or adjuvant therapy. Thirty-five (92.1%) patients from the initial group were treated successfully and the 5- and 10-year survival rates were 69% and 51%, respectively. Comparison between the matched groups revealed longer survival rates in the empyema group (5-year, 70%; 10-year, 49%) compared to the group without empyema (5-year, 38%; 10-year, 18%). Compared to the group without empyema, the empyema group showed significantly longer survival for all-cause mortality (p=0.004) and a lower incidence of cancer-unrelated mortality (p=0.02). The two groups did not significantly differ with regard to cancer-related mortality (p=0.09). In conclusion, accelerated treatment is a safe and effective method for the treatment of pleural empyema after pneumonectomy. The presently achieved results indicate improvement in survival of lung cancer patients with PPE in comparison to lung cancer patients after uncomplicated pneumonectomy.

Central, peripheral ECMO or CPB? Comparsion between circulatory support methods used during lung transplantation.

BACKGROUND: Chronic obstructive pulmonary disease, cystic fibrosis and usual interstitial pneumonia are three most common indications for lung transplantation (LuTx) in Poland. As a result of irreversible destruction of pulmonary parenchyma and extended respiratory insufficiency that appear afterwards, it is crucial to estimate the reserve of gas exchange in each lung before and during surgery. Altering conditions of gas exchange require adaptation in circulatory system as well. In some of the cases the use of extracorporeal life support appears to be necessary to undergo the transplantation successfully. Cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO) used during operation allow to replace the function of heart and lung, but they are also related to complications in the form of acute kidney failure, bleeding, heart arrhythmias or thromboembolic complications. METHODS: We reviewed 77 LuTx from 2009 to 2020 performed at the Department of Thoracic Surgery and Transplantation. 40/77 (51%) patients required intraoperative extracorporeal assistance: 8 required CBP and 32 required ECMO. In the ECMO group 14/32 (44%) patients had peripheral cannulation and 18/32 (56%) had central one. We have calculated the survival rates and reviewed postoperative complications after lung transplantations. Cumulative Kaplan-Meier survival curves were calculated. Differences between the groups were evaluated by the Chi- square analysis for discontinuous variables and t-test for continuous variables. RESULTS: The use of intraoperative central extracorporeal membrane oxygenator was associated with increased survival rates comparing to patients without external support (30-days, 1-year, 3-years, 5-years rates: 78%, 66%, 66%, 66% vs 83%, 65%, 59%, 44% respectively). Furthermore, survival was enhanced comparing to peripheral ECMO or cardiopulmonary bypass as well (50%, 41%, 41%, 33%; 75%, 50%, 50%, 38% respectively). Acute kidney injury and thromboembolic complications occurred statistically more often in case of patients that underwent lung transplantation with support devices (p = 0.005, p = 0.02 respectively). Frequency of other complications was comparable among groups. CONCLUSIONS: The use of central extracorporeal membrane oxygenation should be favorized over peripheral cannulation or cardiopulmonary bypass. CPB should be no longer used during LuTx. Trial registration Not applicable.

Influence of the Levels of Arsenic, Cadmium, Mercury and Lead on Overall Survival in Lung Cancer.

The effects of heavy metals on cancer risk have been widely studied in recent decades, but there is limited data on the effects of these elements on cancer survival. In this research, we examined whether blood concentrations of the heavy metals arsenic, cadmium, mercury and lead were associated with the overall survival of lung cancer patients. The study group consisted of 336 patients with lung cancer who were prospectively observed. Blood concentrations of heavy metals were measured to study the relationship between their levels and overall survival using Cox proportional hazards analysis. The hazard ratio of death from all causes was 0.99 (p = 0.94) for arsenic, 1.37 (p = 0.15) for cadmium, 1.55 (p = 0.04) for mercury, and 1.18 (p = 0.47) for lead in patients from the lowest concentration quartile, compared with those in the highest quartile. Among the patients with stage IA disease, this relationship was statistically significant (HR = 7.36; p < 0.01) for cadmium levels in the highest quartile (>1.97-7.77 µg/L) compared to quartile I (0.23-0.57 µg/L, reference). This study revealed that low blood cadmium levels <1.47 µg/L are probably associated with improved overall survival in treated patients with stage IA disease.

Impact of copy number variant and single nucleotide polymorphism of the programmed death-ligand 1 gene, programmed death-ligand 1 protein expression and therapy regimens on overall survival in a large group of Caucasian patients with non-small cell lung carcinoma.

Anti-programmed death-1 or anti-programmed death-ligand 1 (PD-L1) blockade may be ineffective in some patients with non-small cell lung cancer (NSCLC) with high percentage of tumor cells with PD-L1 expression. In addition, immunotherapy may provide great benefits in patients without PD-L1 expression. The present study assessed PD-L1 protein expression by immunohistochemistry, copy number variation (CNV) of PD-L1 and two single nucleotide polymorphisms (SNPs), rs822335 and rs822336, in the promoter of PD-L1 by quantitative PCR in 673 patients with NSCLC. Overall survival time of patients with NSCLC depending on the assessed predictive factors (PD-L1 CNV or SNP) and the treatment methods (immunotherapy in first/second line of treatment or chemotherapy) was analyzed. The present study revealed significantly higher PD-L1 copies number in patients with ≥10% and ≥50% of tumor cells with PD-L1 expression compared to patients with lower percentage of PD-L1-positive tumor cells (P=0.02 and P=0.0002, respectively). There was a significant positive correlation (R=0.2; P=0.01) between number of PD-L1 copies and percentage of tumor cells with PD-L1 protein expression. Percentage of tumor cells with PD-L1 expression was lower in patients with TT genotype of the rs822335 polymorphism compared to those with CC genotype (P=0.03). The present study observed significantly higher risk of death in patients treated with chemotherapy compared to those treated with immunotherapy (P<0.0001; hazard ratio=2.4768; 95% confidence interval, 2.0120-3.0490). The present study demonstrated a close relationship between PD-L1 copies number, genotype of rs822335 PD-L1 polymorphism and PD-L1 protein expression on tumor cells. However, the impact of CNV and SNPs of PD-L1 on overall survival of patients with NSCLC requires further investigation.

Lung Cancer Occurrence-Correlation with Serum Chromium Levels and Genotypes.

Lung cancer is the leading cause of cancer-related death worldwide. Exposure to environmental and occupational carcinogens is an important cause of lung cancer. One of these substances is chromium, which is found ubiquitously across the planet. The International Agency for Research on Cancer has classified chromium(VI) as a human carcinogen. The aim of this study was to assess whether serum chromium levels, as well as DNA variants in selected genes involved in carcinogenesis, xenobiotic-metabolism, and oxidative stress could be helpful in the detection of lung cancer. We conducted a study using 218 lung cancer patients and 218 matched healthy controls. We measured serum chromium levels and genotyped ten genetic variants in ERCC2, XRCC1, MT1B, GSTP1, ABCB1, NQ01, CRTC3, GPX1, SOD2 and CAT. The odds ratios of being diagnosed with lung cancer were calculated using conditional logistic regression with respect to serum chromium level and genotypes. The odds ratio for the occurrence of lung cancer increased with increasing serum chromium levels. The difference between the quartiles with the lowest vs. highest chromium level was more than fourfold in the entire group (OR 4.52, CI 2.17-9.42, p < 0.01). This correlation was significantly increased by more than twice when specific genotypes were taken into consideration (ERCC-rs12181 TT, OR 12.34, CI 1.17-130.01, p = 0.04; CRTC3-rs12915189 non GG, OR 9.73, CI 1.58-60.10, p = 0.01; GSTP1-rs1695 non AA, OR 9.47, CI 2.06-43.49, p = < 0.01; CAT-rs1001179 non CC, OR 9.18, CI 1.64-51.24, p = 0.01). Total serum chromium levels > 0.1 µg/L were correlated with 73% (52/71) of lung cancers diagnosed with stage I disease. Our findings support the role of chromium and the influence of key proteins on lung cancer burden in the general population.

Blood cadmium levels as a marker for early lung cancer detection.

BACKGROUND: We assessed whether blood cadmium levels were associated with incident lung cancer and could be used in the context of a screening program for early-stage lung cancer. MATERIAL AND METHODS: We measured blood cadmium levels among 205 lung cancer patients and 205 matched controls. Cases and controls were matched for sex, age and smoking history (total pack-years, years since cessation for former smokers). RESULTS: The odds ratio for those in the highest quartile of cadmium level (versus lowest) was four-fold (OR = 4.41, 95 % CI:2.01-9.67, p < 0.01). The association was present in former smokers (OR = 16.8, 95 % CI:3.96-71.2, p < 0.01), but not in current smokers (OR = 1.23, 95 % CI: 0.34-4.38) or in never smokers (OR not defined). Among former smokers, the association was present in both early- and late-stage lung cancer. CONCLUSION: Blood cadmium levels may be a marker to help with the early detection of lung cancer among former smokers.

Influence of the selenium level on overall survival in lung cancer.

BACKGROUND: Although the results of studies in populations with low selenium status indicate an inverse correlation between body selenium levels and the risk of the lung cancer, the effect of this microelement on survival has not been studied. MATERIALS AND METHODS: We performed a prospective study of 302 patients diagnosed with lung cancer in Szczecin, Poland. Selenium concentration in serum was measured at the time of diagnosis and before treatment. All patients were followed for a maximum of 80 months or until death. Vital status was obtained from the Polish National Death Registry. RESULTS: Using Cox proportional hazard analysis, performed for all individuals with lung cancer, the hazard ratio (HR) for death from all causes was 1.25 (95% CI: 0.86-1.83, P = 0.99) for patients in the lowest tertile compared to those in the highest tertile of serum selenium levels. Among the patients with stage I disease this relationship was significant (HR-2.73; P = 0.01) for selenium level in tertile 1 (<57 µg/L) compared to tertile 3 (>69 µg/L, reference). The 80 months crude survival after diagnosis was 79.5% (95% CI: 68.5-92.4%) for individuals in the highest tertile and 58.1% (95% CI: 45.1-74.9%) for individuals in the lowest tertile with stage I lung cancer. CONCLUSION: These results suggest that in patients undergoing treatment for stage I lung cancer, serum selenium levels at the time of diagnosis (>69 µg/L) may be associated with improved overall survival.

Assessment of postoperative pain management and comparison of effectiveness of pain relief treatment involving paravertebral block and thoracic epidural analgesia in patients undergoing posterolateral thoracotomy.

BACKGROUND: TEA (thoracic epidural analgesia) is considered a basic method of analgesia used in thoracic surgeries. PVB (paravertebral block) is an alternative method. The thesis compares effectiveness of both methods in postoperative analgesia with particular focus on assessment of the postoperative pain management quality. METHODS: The study involved 2 groups of patients, each consisting of 30 patients undergoing posterolateral thoracotomy. The study group involved patients anesthetized applying PVB method, while the control group involved patients anesthetized with TEA. Hemodynamic and respiratory parameters as well as severity of pain assessed using NRS (numeric rating scale) during the first 3 days after the surgery, number of days of hospitalization, and the need to use additional pain relievers were taken into account in both groups. Evaluation of postoperative pain management quality was performed applying Clinical Quality Indicators in Postoperative Pain Management. RESULTS: No statistical significance was demonstrated between the groups in respect of hemodynamic and respiratory parameters values, the need to use additional pain relievers and the number of days of hospitalization. There was no statistically significant difference between the groups in respect of general assessment of pain management quality, except for the assessment of the lowest level of pain within the last 24 h of measurement. This result in TEA group was statistically significantly lower than the one in PVB group (p = 0.019). CONCLUSIONS: In the assessment of postoperative pain management quality both analyzed methods are statistically significantly different only in the category of "lowest level of pain within the last 24 hours of measurement", to the benefit of TEA group. No statistically significant difference has been observed between the two study groups with respect to the remaining parameters. TRIAL REGISTRATION: KB-0012/71/15. Date of registration 22 June 2015.