Outcomes of minimally invasive surgery for pulmonary metastasis: who benefits the most?

Introduction: Metastatic disease is one of the main causes of death and factors affecting overall survival. It is known that selected patients with pulmonary oligometastases whose primary tumor is under control and who have adequate respiratory capacity may benefit from metastasectomy by resecting all detected lesions. Aim: To report our findings on the use of video-assisted thoracoscopic surgery (VATS) for pulmonary metastasectomy, with a focus on identifying suitable candidates. Material and methods: Between August 2010 and 2023 a total of 532 pulmonary metastasectomy procedures were performed in our institution. Metastasectomy was performed with VATS for 281 of those patients. Results: VATS metastasectomy was performed in 131 patients with a single lesion on preoperative imaging, while 110 patients underwent metastasectomy for multiple lesions. The rate was significantly (p < 0.05) lower in the group with multiple lesions removed during surgery (38 months) than in the group with only one lesion removed during surgery (60 months). The predicted survival time in the group with other tumor histology (79 months) was significantly (p < 0.05) higher than in the groups with tumor histology carcinoma (41.4 months) and sarcoma (55.5 months). Conclusions: The best prognosis after metastasectomy is provided in cases with a single nodule. Grade is also an important prognostic factor affecting survival, particularly for grade 1 tumor. The histopathological type of the primary tumor is also a significant prognostic factor affecting survival after pulmonary metastasectomy in secondary pulmonary neoplasms, particularly for sarcoma and carcinoma.

Post bar removal results of pectus deformity patients who underwent minimally invasive correction.

Introduction: The most common chest wall deformities are pectus excavatum and pectus carinatum. Surgical repair of these deformities via minimally invasive technique using pectus bars is commonly preferred by numerous thoracic surgeons. Despite this common choice for treatment, the duration of the bar stay, the bar removal process, the possible complications and ways to prevent them have been debated over the years and still there is no single decision. Aim: To determine the decision making, surgical outcomes and negative factors in the bar removal process. Material and methods: There were 1032 patients underwent bar removal between 2006-2020 and their data was recorded prospectively. We analyzed patients' demographics, family history, Haller index, bar count, body mass index, stabilizer and wire usage, length of hospital stay, time until bar removal, incision side and complications retrospectively. Results: There was no significant correlation between BMI and surgery time (p = 0.748). There was no statistically significant correlation between the age groups and the number of pectus bars removed. The other factors showed no significant difference. The surgery time was found to be significantly longer in those with callus tissue (p = 0.002). Conclusions: These findings suggest that pectus bars can be left in place for a shorter time than the standard 3-year interval without any additional recurrence risk and without compromising quality of life. As a result, patients with persistent pain after pectus repair should be well evaluated for the possibility of life-threatening complications during bar removal.

Mediastinal lymph node removal modulates natural killer cell exhaustion in patients with non-small cell lung cancer.

Non-small cell lung cancer (NSCLC) is the leading cause of cancer-related death globally. In this study, the effect of complete removal of mediastinal lymph nodes by video-assisted mediastinoscopic lymphadenectomy (VAMLA) on natural killer (NK) cell phenotype and functions in patients with NSCLC was evaluated. The study included 21 NSCLC patients (cIA-IVA) undergoing VAMLA staging and 33 healthy controls. Mononuclear cells were isolated from peripheral blood of all participants and mediastinal lymph nodes of the patients. NK cells were analyzed by flow cytometry to define NK subsets, expressions of PD-1, CTLA-4, activating/inhibitory receptors, granzyme A, and CD107a. The plasma levels of soluble PD-1, PDL-1, and CTLA-4 were measured by ELISA. Mediastinal lymph nodes of NSCLC patients had increased ratios of exhausted NK cells, increased expression of PD-1 and IL-10, and impaired cytotoxicity. Mediastinal lymph nodes removal increased CD56dimCD16bright cytotoxic effector phenotype and reduced exhausted NK cells. PD-1+ NK cells were significantly more abundant in patients' blood, and VAMLA significantly reduced their ratio as well. The ratio of IL-10 secreting regulatory NK cells was also reduced after VAMLA. Blood NK cells had increased cytotoxic functions and spontaneous IFN-γ secretion, and these NK cell functions were also recovered by VAMLA. Mediastinal lymph node removal reversed NK cell exhaustion, reduced regulatory NK cells, and improved antitumoral functions of NK cells. Tumor-draining lymph nodes may contribute to tumor evasion from antitumoral immune responses. The role of their removal needs to be further studied both to better understand this mechanism and as a potential immunotherapeutic approach.

Mediastinal lymph node removal ameliorates cytotoxic T-lymphocyte functions in patients with non-small cell lung cancer.

INTRODUCTION: Mediastinal lymph node (MLN) removal by video-assisted mediastinoscopic lymphadenectomy (VAMLA) for preoperative cancer staging was reported to be associated with increased survival. The aim of this study was to evaluate the immunologic effects of complete MLN removal by VAMLA on cytotoxic T lymphocyte (CTL) phenotype and function. METHODS: Seventeen patients with non-small cell lung cancer (NSCLC) (stage cT1-4N0-3M0-1A) and 20 healthy participants were included in this study. Blood samples were collected before and 4 weeks after the procedure. Lymphocytes were isolated from the removed MLNs. CTL phenotypes and functions were evaluated by flow cytometry. Plasma levels of soluble programmed cell death protein 1 (sPD-1), soluble programmed cell death protein 1 ligand, and soluble CTL antigen 4 (sCTLA-4) were measured with enzyme-linked immunosorbent assay. RESULTS: The ratio of the immunosenescent CTLs (CD3+CD8+CD28-) was increased in peripheral blood and MLNs of the patients with NSCLC compared to controls (p = 0.037), and MLN removal did not change this ratio. PD-1 and CTL antigen 4 expressions were significantly reduced in peripheral blood CTLs after MLN removal by VAMLA (p = 0.01 and p = 0.01, respectively). Granzyme A expression was significantly reduced in the peripheral blood CTLs of the patients compared to controls (p = 0.006) and MLN removal by VAMLA significantly improved Granzyme A expression in CTLs (p = 0.003). Plasma concentrations of sPD-1 and sCTLA-4 remained unchanged after VAMLA. CONCLUSION: CTLs in the MLNs and peripheral blood of the patients with NSCLC had an immunosenescent phenotype, increased immune checkpoint receptor expression, and impaired cytotoxicity. MLN removal by VAMLA improved these phenotypic and functional characteristics of CTLs. These changes may explain the potential contribution of VAMLA to improved survival.