Invasiveness assessment by artificial intelligence against intraoperative frozen section for pulmonary nodules ≤ 3 cm.

PURPOSE: To investigate the performance of an artificial intelligence (AI) algorithm for assessing the malignancy and invasiveness of pulmonary nodules in a multicenter cohort. METHODS: A previously developed deep learning system based on a 3D convolutional neural network was used to predict tumor malignancy and invasiveness. Dataset of pulmonary nodules no more than 3 cm was integrated with CT images and pathologic information. Receiver operating characteristic curve analysis was used to evaluate the performance of the system. RESULTS: A total of 466 resected pulmonary nodules were included in this study. The areas under the curves (AUCs) of the deep learning system in the prediction of malignancy as compared with pathological reports were 0.80, 0.80, and 0.75 for all, subcentimeter, and solid nodules, respectively. Additionally, the AUC in the AI-assisted prediction of invasive adenocarcinoma (IA) among subsolid lesions (n = 184) was 0.88. Most malignancies that were misdiagnosed by the AI system as benign diseases with a diameter measuring greater than 1 cm (26/250, 10.4%) presented as solid nodules (19/26, 73.1%) on CT. In an exploratory analysis involving nodules underwent intraoperative pathologic examination, the concordance rate in identifying IA between the AI model and frozen section examination was 0.69, with a sensitivity of 0.50 and specificity of 0.97. CONCLUSION: The deep learning system can discriminate malignant diseases for pulmonary nodules measuring no more than 3 cm. The AI model has a high positive predictive value for invasive adenocarcinoma with respect to intraoperative frozen section examination, which might help determine the individualized surgical strategy.

[Neoadjuvant chemoradiotherapy followed by combined thoracoscopic and laparoscopic esophagectomy in the treatment of locally advanced esophageal carcinoma].

OBJECTIVE: To investigate the feasibility and efficacy of neoadjuvant chemoradiotherapy followed by combined thoracoscopic and laparoscopic esophagectomy (CTLE) in the treatment of advanced esophageal carcinoma. METHODS: From June 2011 to February 2012, 11 patients with locally advanced esophageal carcinoma underwent neoadjuvant chemoradiotherapy followed by CTLE (clinical stage IIB-IIIA). NP (vinorelbine pin and cisplatin) or TP (program paclitaxel-pin and cisplatin) were applied as preoperative chemotherapy. During the same period, conventional fractionated radiotherapy was used with the radiation dose of 40 Gy/20 F. At four to six weeks after CRT, 11 patients received three-incision CTLE. RESULTS: During chemoradiation, 9 patients developed bone marrow suppression. The interval between completion of chemoradiation and surgery was (49.6±15.4) d. Intraoperative findings revealed local fibrosis in one patient (75 days after chemoradiation) while operative difficulty was not increased in the remaining 10 patients. Compared to 15 patients who received surgery alone, operative time was shorter [(242.3±27.0) min vs.(280.5±27.2) min, P=0.002] and intraoperative blood loss was less [(168.2±95.6) ml vs. (244.5±84.8) ml, P=0.042], the number of removal lymph nodes was similar [(19.5±5.8) vs. (20.5±7.1), P=0.683], postoperative hospital stay was prolonged [(18.9±10.3) d vs. (12.5±4.6) d, P=0.020]. The postoperative complication rate was 36.4% including cervical anastomotic leak with pulmonary infection (n=1), cervical anastomotic fistula and hoarseness (n=1), pulmonary infection with pleural effusion (n=2). Follow up ranged from 1 to 9 months, and no recurrence was found. CONCLUSION: The neoadjuvant chemoradiotherapy followed by combined thoracoscopic and laparoscopic esophagectomy in the treatment of locally advanced esophageal carcinoma is safe, feasible, and the short-term outcomes are favorable.

[Angiogenesis in chronic ischemic porcine myocardium after transfer of VEGF165 and angiopoietin-1 mediated by recombinant adeno-associated viral vector].

OBJECTIVE: To study the effects of combination of angiopoietin-1 (ANG-1) and vascular endothelial growth factor165 (VEGF165) gene transfer mediated by recombinant adeno-associated viral vector on the neovascularization in chronic ischemic porcine myocardium. METHODS: An ameroid constrictor was implanted around the left circumflex coronary artery (LCX) via endoscopy. Six weeks later, coronary angiography revealed that the myocardial ischemia was established by gradual occlusion of the left circumflex coronary artery (LCX). Sixteen swine with the total occlusion or partial stenosis (> 85 %) of the LCX were divided into 4 groups (4 in each group): group I, group II and group IV (control) received direct myocardium injection of rAAV2 VEGF165, rAAV2 ANG-1 or PBS alone, respectively; group III received rAAV2 VEGF165 and rAAV2 ANG-1. Selective coronary angiography and ultrasonography were performed perioperatively to evaluate the cardiac function and the formation of collateral circulation. The expression of VEGF165 and ANG-1 proteins were assessed using ELISA or Western blot. The degree of angiogenesis was assessed by use of immunohistochemical analysis. RESULT: Angiography showed that the occlusion of all LCX was completed or exceeded 95% 6 weeks after ameroid constrictor implantation, indicating the successful establishment of animal model. The expression levels of VEGF165 in group I and III and ANG-1 in groups II and III began to increase at d7 after transfection and reached the peak at d14; then decreased gradually to the normal level after 3 months. The expression levels of VEGF165 in group II and group IV or that of ANG-1 protein in group I and group IV had no markedly changes at different time after transfection. There were significant increase in capillary density and arteriole density and more side branch vessels formed in group III compared with other groups. Echocardiographic measurements showed that the left ventricular systolic function of animals in groups I, II and III increased significantly after gene transfection, especially in group III; but there was no changes in group IV. CONCLUSION: Myocardial perfusion and the left ventricular systolic function are improved after rAAV2 VEGF165 or rAAV2 ANG-1 transfection, which is associated with the angiogenesis in porcine model of chronic myocardial ischemia.

[Clinical comparative study of minimally invasive esophagectomy versus open esophagectomy for esophageal carcinoma].

OBJECTIVE: To explore and evaluate the feasibility, safety, radicality and the short-term outcome of minimally invasive esophagectomy versus open esophagectomy for esophageal cancer. METHODS: From July 2007 to October 2009, 67 patients with esophageal cancer received minimally invasive esophagectomy (MIE group), while 38 patients underwent conventional open esophagectomy (OE group: via right thorax, abdomen, left neck). The operative procedures, clinicopathological data and short-term outcome were collected and compared between the two groups. RESULTS: The clinical data of the two groups were comparable. No significant differences was found in demographics between the two groups. Median blood loss in MIE group was less than that in OE group (chest: 112.3 ml vs. 175.3 ml, P = 0.035, abdominal: 31.4 ml vs. 100.5 ml, P = 0.026). More patients in OE group were transferred to ICU (P = 0.042) and more obvious pain (P = 0.005). The rate of pulmonary infection and intestinal obstruction in OE group were higher than MIE group (P = 0.046 and 0.045). There were no differences in the number of lymph node dissection for two groups, the average was 20.9 and lymph node metastasis rate was 26.9% in MIE group. Mean follow up was (14.0 ± 2.2) months (range, 2 to 29 months). Recurrence rate and survival rate were no differences. CONCLUSION: The Minimally invasive esophagectomy for esophageal cancer is feasible, safe, and reliable short-term effect, and can achieve radical tumor resection, which may lead to better future of surgical treatment for esophageal carcinoma.

[Create a standard mini-swine model of chronic ischemic myocardium by thoracoscopy].

OBJECTIVE: To create a standard mini-swine model of chronic ischemic myocardium by endoscopy for the research of gene transfer and stem cell. METHODS: Twenty-three male China experimental minipigs were used, aged from 8 to 11 months with a mean of (9.3 +/- 1.8) months and weighed from 20 to 30 kg with a mean of (29.3 +/- 4.3) kg. The myocardial ischemia was established by gradual occlusion of the left circumflex coronary artery (LCX) with an Ameroid constrictor. The Ameroid constrictor was implanted around LCX by endoscopy. Selective coronary angiography, electrocardiogram and Echo-Doppler study were performed perioperatively to evaluate the degree of stenosis. RESULTS: Chronic ischemic myocardial models were successfully generated in 20 of 23 swine by full-endoscopy. Ameroid constrictors were placed at the LCX accurately. Three swine died of anesthetic accident, cardiac arrhythmia at secondary coronary angiography, and pulmonary infection within 6 weeks after operation respectively. Operation time was 25 to 65 min with a mean of (46 +/- 9) min. The blood loss was 30 to 60 ml with a mean of (55 +/- 12) ml. Six weeks later, coronary angiography revealed the total occlusion and partial stenosis (> 85%) of the LCX occurred in 7 and 13 swine respectively. Cardiac systolic and diastolic dysfunction were found in all swine. The ejection fraction value was (65.0 +/- 6.3)% before operation and (41.0 +/- 9.3)% after operation (P = 0.008). The fractional shortening value was (36.2 +/- 4.3)% before operation and (34.2 +/- 2.3)% after operation (P = 0.027). CONCLUSION: The endoscopic surgery is a less invasive way to create a standard mini-swine model of chronic ischemic myocardium with effective results.