Morphologically intact airways in lung fibrosis have an abnormal proteome.

Honeycombing is a histological pattern consistent with Usual Interstitial Pneumonia (UIP). Honeycombing refers to cystic airways located at sites of dense fibrosis with marked mucus accumulation. Utilizing laser capture microdissection coupled mass spectrometry (LCM-MS), we interrogated the fibrotic honeycomb airway cells and fibrotic uninvolved airway cells (distant from honeycomb airways and morphologically intact) in specimens from 10 patients with UIP. Non-fibrotic airway cell specimens from 6 patients served as controls. Furthermore, we performed LCM-MS on the mucus plugs found in 6 patients with UIP and 6 patients with mucinous adenocarcinoma. The mass spectrometry data were subject to both qualitative and quantitative analysis and validated by immunohistochemistry. Surprisingly, fibrotic uninvolved airway cells share a similar protein profile to honeycomb airway cells, showing deregulation of the slit and roundabout receptor (Slit and Robo) pathway as the strongest category. We find that (BPI) fold-containing family B member 1 (BPIFB1) is the most significantly increased secretome-associated protein in UIP, whereas Mucin-5AC (MUC5AC) is the most significantly increased in mucinous adenocarcinoma. We conclude that fibrotic uninvolved airway cells share pathological features with fibrotic honeycomb airway cells. In addition, fibrotic honeycomb airway cells are enriched in mucin biogenesis proteins with a marked derangement in proteins essential for ciliogenesis. This unbiased spatial proteomic approach generates novel and testable hypotheses to decipher fibrosis progression.

Outcomes after Conversion from Video-Assisted Thoracoscopic Lobectomy to Thoracotomy.

BACKGROUND: Lung cancer resections are increasingly being performed via video-assisted thoracoscopic surgery (VATS). Conversion to thoracotomy can occur for many reasons and may affect outcomes. The objective of this study was to investigate the impact of VATS conversion on short- and mid-term outcomes and identify reasons for conversion. METHODS: Consecutive patients undergoing lobectomy for primary non-small cell lung cancer between 2012 and 2019 in a single UK center were included. Primary outcomes were 90-day mortality, intraoperative conversion, and overall survival. Reasons for conversion were defined as bleeding or nonbleeding. Outcomes were compared between groups using univariable analysis. Multivariable logistic regression analysis was performed to identify risk factors for conversion. RESULTS: A total of 2,622 patients were included with 20.6% (n = 541) completing surgery via VATS and 79.4% (n = 2,081) via thoracotomy. The rate of completed VATS surgery increased significantly over time (2012: 6.9%, 2019: 55.1%, p < 0.001). Overall conversion rate was 14.3% (n = 90/631) and has reduced significantly over time (p < 0.001). The rate of conversion due to intraoperative bleeding was 31.1% (n = 28/90). Obesity, male sex, and stage III disease were independent risk factors for conversion. The 90-day mortality rate after conversion was not significantly different from the rate for planned thoracotomy (3.3 vs. 3.4%, p = 0.987). There was no significant difference in overall survival between patients experiencing intraoperative conversion and those undergoing planned thoracotomy (p = 0.135). CONCLUSION: This study demonstrates comparable outcomes for patients undergoing conversion from VATS to those undergoing planned surgery via thoracotomy. It remains unclear if reason for conversion is associated with outcomes.

Adequacy of Mediastinal Lymph Node Sampling in Patients With Lung Cancer Undergoing Lung Resection.

BACKGROUND: Intraoperative mediastinal lymph node sampling (MLNS) is a crucial component of lung cancer surgery. Whilst several sampling strategies have been clearly defined in guidelines from international organizations, reports of adherence to these guidelines are lacking. We aimed to assess our center's adherence to guidelines and determine whether adequacy of sampling is associated with survival. MATERIALS AND METHODS: A single-center retrospective review of consecutive patients undergoing lung resection for primary lung cancer between January 2013 and December 2018 was undertaken. Sampling adequacy was assessed against standards outlined in the International Association for the Study of Lung Cancer 2009 guidelines. Multivariable logistic and Cox proportional hazards regression analyses were used to assess the impact of specific variables on adequacy and of specific variables on overall survival, respectively. RESULTS: A total of 2380 patients were included in the study. Overall adequacy was 72.1% (n= 1717). Adherence improved from 44.8% in 2013 to 85.0% in 2018 (P< 0.001). Undergoing a right-sided resection increased the odds of adequate MLNS on multivariable logistic regression (odds ratio 1.666, 95% confidence interval [CI]: 1.385-2.003, P< 0.001). Inadequate MLNS was not significantly associated with reduced overall survival on log rank analysis (P= 0.340) or after adjustment with multivariable Cox proportional hazards (hazard ratio 0.839, 95% CI 0.643-1.093). CONCLUSIONS: Adherence to standards improved significantly over time and was significantly higher for right-sided resections. We found no evidence of an association between adequate MLNS and overall survival in this cohort. A pressing need remains for the introduction of national guidelines defining acceptable performance.

The Impact of Initial Postoperative Destination on Unplanned Critical Care Admissions After Lung Resection.

OBJECTIVES: Despite an increasing proportion of patients undergoing lung resection being managed postoperatively in a ward-based environment, studies analyzing the impact of initial postoperative destination (IPD) on perioperative outcomes and unplanned critical care admission (UCCA) are lacking. DESIGN: A single-center retrospective review. SETTING: A cardiothoracic surgery center in the Northwest of England. PARTICIPANTS: A total of 3,841 patients between 2012 and 2018. INTERVENTIONS: All patients underwent lung resection. Patients were classified as either IPD ward or IPD critical care. MEASUREMENTS AND MAIN RESULTS: Outcomes assessed included in-hospital and 90-day mortality and UCCA. Differences in mortality rates between groups were assessed using the chi-square test. Multivariate logistic regression analyses were performed to identify variables independently associated with 90-day mortality and UCCA. In total, 23.8% (n = 913) of patients went to critical care as their IPD. Overall in-hospital mortality was 1.6% (n = 62), and 90-day mortality was 2.9% (n = 112). The rate of UCCA was 10.5% (n = 404) and was significantly higher for IPD ward patients compared to IPD critical care patients (11.9% v 6.2%, p < 0.001). The 90-day mortality rates after UCCA were 5.2% (IPD ward) and 19.3% (IPD critical care) (p < 0.001). Advanced age, worse pulmonary function, IPD ward, and timing of surgery were all independently associated with UCCA. CONCLUSIONS: Most patients undergoing lung resection can be managed safely postoperatively in a ward-based environment. Short-term mortality is higher after UCCA, with patients who experience readmission to critical care at the highest risk of death. Patients should receive additional monitoring immediately following discharge from critical care.

Preoperative Anemia is Associated With Worse Long-Term Survival After Lung Cancer Resection: A Multicenter Cohort Study of 5,029 Patients.

OBJECTIVES: Although some evidence to suggest an association between preoperative anemia and reduced overall survival exists, contemporary studies investigating the impact of preoperative anemia on outcomes after resection for primary lung cancer are lacking. DESIGN: A multicenter retrospective review. SETTING: Two tertiary cardiothoracic surgery centers in the Northwest of England. PARTICIPANTS: A total of 5,029 patients between 2012 and 2018. INTERVENTIONS: All patients underwent lung resection for primary lung cancer. Patients were classified as anemic based on the World Health Organization definition. Men with hemoglobin <130 g/L and women with hemoglobin <120 g/L were considered to be anemic. MEASUREMENTS AND MAIN RESULTS: Outcomes assessed included perioperative mortality, 90-day mortality, and overall survival. Multivariate logistic and Cox regression analyses were used to assess the impact of preoperative anemia on 90-day mortality and overall survival, respectively. Overall, preoperatively, 24.0% (n = 1207) of patients were anemic. The 90-day mortality for anemic and nonanemic patients was 5.6% and 3.1%, respectively (p < 0.001). After multivariate adjustment, preoperative anemia was not associated with increased 90-day mortality. However, a log-rank analysis demonstrated reduced overall survival for anemic patients (p < 0.001). After multivariate adjustment, preoperative anemia was found to be independently associated with reduced overall survival (hazard ratio 1.287, 95% confidence interval 1.141-1.451, p < 0.001). CONCLUSIONS: Although anemia was not an independent predictor of short-term outcomes, it was independently associated with significantly reduced survival for patients undergoing resection for lung cancer. Further work is required to understand why anemia reduces long-term survival and whether pathways for anemic patients can be adapted to improve long-term outcomes.

Test performance of PET-CT for mediastinal lymph node staging of pulmonary carcinoid tumours.

Positron emission tomography-CT (PET-CT) is one of the initial mediastinal staging modality for non-small cell lung cancer; however, the clinical utility in carcinoid tumours is uncertain. We sought to determine the test performance of PET-CT for mediastinal lymph node staging of pulmonary carcinoid tumours. We collated data from seven institutions, performing a retrospective search on pathological databases for a consecutive series of patients who underwent thoracic surgery (with lymph nodal dissection) for carcinoid tumours with preoperative PET-CT staging. PET-CT results were compared with the reference standard of pathologic results obtained from lymph node dissection and test performance reported using sensitivity and specificity. From November 1999 to January 2013, 247 patients from seven institutions underwent surgery for carcinoid tumours with a corresponding preoperative PET-CT scan. The mean age of the patients was 61 (SD 15, range 73) and 84 were male patients (34%). The pathologic subtype was typical carcinoid in 217 patients (88%) and atypical carcinoid in 30 patients (12%). Results from lymph node dissection were obtained in 207 patients. The calculated sensitivity and specificity of PET-CT to identify mediastinal lymph node disease was 33% (95% CI 4% to 78%) and 94% (95% CI 89% to 97%), respectively. Our results indicate that PET-CT has a poor sensitivity but good specificity to detect the presence of mediastinal lymph node metastases in pulmonary carcinoid tumours. Mediastinal lymph node metastases cannot be ruled out with negative PET-CT uptake, and if the absence of mediastinal lymph node disease is a prerequisite for directing management, tissue sampling should be undertaken.

Chronic Pulmonary Aspergillosis after Surgical Treatment for Non-Small Cell Lung Cancer-An Analysis of Risk Factors and Clinical Outcomes.

Chronic pulmonary aspergillosis (CPA) is a rare but significant complication of lung cancer surgery. Its effect on survival remains unclear. Our aim was to describe the outcomes of the patients who developed CPA following the surgery for non-small cell lung cancer (NSCLC), identify the risk factors associated with its development following lung resection, and evaluate its impact on survival. All the patients with a diagnosis of CPA and operated NSCLC were identified in the National Aspergillosis Centre (NAC) database (2009-2020). Additional patients were identified in the Northwest Clinical Outcomes Research Registry (2012-2019) database. A regression analysis was performed to examine potential links between CPA and long-term outcomes and also to identify the factors associated with the development of CPA. The primary outcomes were the development of CPA, 1-year and 5-year mortality, and overall survival. Thirty-two patients diagnosed with CPA after lung resection were identified in the NAC database, of which 11 were also contained within the NCORR database, with a prevalence of 0.2% (n = 11/4425). Post-operative CPA was associated with significantly lower survival on log-rank analysis (p = 0.020). Mortality at one year was 25.0% (n = 8) and 59.4% (n = 19) at five years after the CPA diagnosis. On univariable analysis, a lower mean percentage-predicted forced expiratory volume in 1 s, ischaemic heart disease, and chronic obstructive pulmonary disease were all significantly associated with CPA development. CPA is a rare complication following lung cancer surgery which has a significant impact on long-term survival. Its development may be associated with pre-existing cardiopulmonary comorbidities. Further research in larger cohorts is required to substantiate these findings.

Pre-Operative Measures of Systemic Inflammation Predict Survival After Surgery for Primary Lung Cancer.

BACKGROUND: Measures of systemic inflammation (MSIs) have been developed and shown to help predict prognosis in patients with lung cancer. However, studies investigating the impact of MSIs on outcomes solely in cohorts of patients undergoing curative-intent resection of NSCLC are lacking. In the era of individualized therapies, targeting inflammatory pathways could represent a novel addition to the armamentarium of lung cancer treatment. METHODS: A multicentre retrospective review of patients who underwent primary lung cancer resection between 2012 and 2018 was undertaken. MSIs assessed were neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), systemic immune inflammation index (SII), advanced lung cancer inflammation index (ALI), prognostic nutritional index (PNI) and haemoglobin albumin lymphocyte platelet (HALP) score. Cox regression analysis was performed to assess the impact of MSIs on overall survival. RESULTS: A total of 5029 patients were included in the study. Overall 90-day mortality was 3.7% (n = 185). All MSIs were significantly associated with overall survival on univariable analysis. After multivariable Cox regression analyses, lower ALI (expressed as a continuous variable) (HR 1.000, 95% CI 1.000-1.000, P = .049) and ALI <366.43 (expressed as a dichotomous variable) (HR 1.362, 95% CI 1.137-1.631, P < .001) remained independently associated with reduced overall survival. CONCLUSIONS: MSIs have emerged in this study as potentially important factors associated with survival following lung resection for NSCLC with curative intent. In particular, ALI has emerged as independently associated with long-term outcomes. The role of MSIs in the clinical management of patients with primary lung cancer requires further investigation.

Multicentre Validation of the RESECT-90 Prediction Model for 90-Day Mortality After Lung Resection.

BACKGROUND: The RESECT-90 model was developed to predict 90-day mortality for patients undergoing lung resection but hasn't been externally validated. The aim of this study was to validate the RESECT-90 clinical prediction model using multicentre patient data from across the United Kingdom (UK). MATERIALS AND METHODS: Data from 12 UK thoracic surgery centers for patients undergoing lung resection between 2016 and 2020 with available 90-day mortality status were used to externally validate the RESECT-90 model. Measures of discrimination (area under the receiving operator characteristic curve [AUC]) and calibration (calibration slope, calibration intercept and flexible calibration plot) were assessed as measures of model performance. Model recalibration was also performed by updating the original model intercept and coefficients. RESULTS: A total of 12,241 patients were included. Overall 90-day mortality was 2.9% (n = 360). Acceptable model discrimination was demonstrated (AUC 0.74 [0.73, 0.75]). Calibration varied between centers with some evidence of overall model miscalibration (calibration slope 0.80 [0.66, 0.95] and calibration intercept 0.40 [0.29, 0.52]) despite acceptable appearances of the flexible calibration plot. The model was subsequently recalibrated, after which all measures of calibration indicated excellent performance. CONCLUSIONS: After external validation and recalibration using a large contemporary cohort of patients undergoing surgery in multiple geographical locations across the UK, the RESECT-90 model demonstrated satisfactory statistical performance for the prediction of 90-day mortality after lung resection. Whilst the recalibrated model will require ongoing validation, the results of this study suggest that routine use of the RESECT-90 model in UK thoracic surgery practice should be considered.

Current Status of Simulation in Thoracic Surgical Training.

BACKGROUND: Simulation is playing an increasingly important role in surgical training but is not yet a mandatory part of most surgical curricula. A simulator must undergo rigorous validation to verify it as a reliable tool. The aim of this study was to review the literature to identify simulators that are currently available to augment thoracic surgical training and to analyze any evidence supporting or validating them. METHODS: A literature search of the MEDLINE (1946 to November 2022) and Embase (1947 to November 2022) databases was performed to identify simulators for basic skills and procedures in thoracic surgery. A selection of keywords were used to perform the literature search. After identification of appropriate articles, data were extracted and analyzed. RESULTS: Thirty-three simulators were found in 31 articles. Simulators for basic skills (n = 13) and thoracic lobectomy (n = 13) were most commonly described, followed by miscellaneous (n = 7). Most models were of a hybrid modality (n = 18). Evidence of validity was established in 48.5% (n = 16) of simulators. In total, 15.2% (n = 5) of simulators had 3 or more elements of validity demonstrated, and only 3.0% (n = 1) accomplished full validation. CONCLUSIONS: Numerous simulators of varying modality and fidelity exist for a variety of thoracic surgical skills and procedures, although validation evidence is frequently inadequate. Simulation models may be able to provide training in basic surgical and procedural skills; however, further assessment of validity needs to be undertaken before consideration of their integration into training programs.

Impact of skip mediastinal lymph node metastasis on outcomes after resection for primary lung cancer.

OBJECTIVES: Patients with non-small cell lung cancer and nodal disease are a heterogeneous group with varied patterns of disease. The aim of this study was to assess long-term outcomes of patients with skip N2 disease in comparison to those with N1 or non-skip N2 disease. MATERIALS AND METHODS: A retrospective review of 445 patients undergoing anatomical lung resection for primary lung cancer between 2012 and 2019 with post-operative histological confirmation of nodal disease was undertaken. Log rank analysis was used to assess differences in estimated median overall survival according to nodal status. Multivariable Cox regression analysis was performed to determine whether skip N2 disease was independently associated with overall survival. RESULTS: Mean patient age was 67.0 years (standard deviation ± 9.2 years) and 48.1% (n = 214) were male. In total, 20.7% (n = 92) of patients had N1 disease, 32.1% (n = 143) had skip N2 disease and 47.2% (n = 210) had non-skip N2 disease. Post-operative upstaging took place in 33.0% (n = 147) of patients. Median follow-up time was 35 months (interquartile range 14-68 months). Skip N2 patients had significantly longer estimated median overall survival in comparison to their non-skip N2 counterparts (47 months vs 28 months, log rank analysis p = 0.029) and non-skip N2 disease remained independently associated with reduced overall survival after multivariable analysis (hazard ratio 1.421, 95% confidence interval 1.060-1.907, p = 0.019). CONCLUSION: Skip N2 disease is a positive prognostic factor for patients with N2 lung cancer, suggesting that lung cancer staging guidelines should consider separating N2 disease into additional subgroups in order to improve prognostic accuracy.

Comparative phenotype of circulating versus tissue immune cells in human lung and blood compartments during health and disease.

The lung is a dynamic mucosal surface constantly exposed to a variety of immunological challenges including harmless environmental antigens, pollutants, and potentially invasive microorganisms. Dysregulation of the immune system at this crucial site is associated with a range of chronic inflammatory conditions including asthma and Chronic Pulmonary Obstructive Disease (COPD). However, due to its relative inaccessibility, our fundamental understanding of the human lung immune compartment is limited. To address this, we performed flow cytometric immune phenotyping of human lung tissue and matched blood samples that were isolated from 115 donors undergoing lung tissue resection. We provide detailed characterization of the lung mononuclear phagocyte and T cell compartments, demonstrating clear phenotypic differences between lung tissue cells and those in peripheral circulation. Additionally, we show that CD103 expression demarcates pulmonary T cells that have undergone recent TCR and IL-7R signalling. Unexpectedly, we discovered that the immune landscape from asthmatic or COPD donors was broadly comparable to controls. Our data provide a much-needed expansion of our understanding of the pulmonary immune compartment in both health and disease.

Patients with thymomas have an increased risk of developing additional malignancies: lack of immunological surveillance?

AIMS: To assess the risk, for patients with thymoma, of developing an additional malignancy (AM). METHODS AND RESULTS: We studied 68 patients with thymomas. Based on the World Health Organization classification, the tumours were categorised as A, AB or B (B1, B2, B3) thymomas. Control populations comprised 114 patients with colorectal cancer, 108 patients with lymphoma and 123 patients with thyroid carcinoma. Patients with thymomas showed a higher risk of developing an AM (22 of 68 patients versus 11 of 114, eight of 108, and eight of 123 patients, respectively; P = 0.0002). The association between thymomas and AMs was related to the thymoma histotype, with B1, B2, B3 and AB tumours showing a higher risk of developing an AM than A thymomas (P = 0.0474). CONCLUSIONS: Patients affected by thymomas showed a significantly higher risk of developing additional malignancies than those in the control groups, and cases that exhibited a predominantly cortical component were more likely to develop other neoplasms. This may be related to the functions of cortical thymic epithelial cells in providing for T lymphocyte maturation through interaction with major histocompatibility complexes.

Veno-venous extracorporeal membrane oxygenation used as an adjunct in the surgical management of acquired and iatrogenic tracheobronchial pathology.

BACKGROUND: Surgical repair of tracheobronchial tree injuries is challenging due to the difficulties associated with providing perioperative ventilatory support. Veno-venous extracorporeal membrane oxygenation (V-V ECMO) is a recognized treatment modality for managing respiratory failure. Its use has expanded to include offering respiratory support for patients requiring surgery on the tracheobronchial tree. This study presents our experience with V-V ECMO support for elective and emergency surgery for acquired and iatrogenic tracheobronchial pathology. METHODS: A retrospective review of our single-center experience of surgical tracheobronchial repairs where V-V ECMO was employed between 2017 and 2020 was undertaken. Preoperative patient characteristics, intraoperative findings, details of ECMO support and postoperative outcomes were collected and analyzed. RESULTS: Five patients underwent surgery with V-V ECMO support during the study period. Indications for surgery included repair of iatrogenic tracheal tear (N.=2), repair of iatrogenic gastro-bronchial fistula (N.=1), elective tracheoplasty (N.=1) and elective resection of tracheal tumor (N.=1). The median duration of V-V ECMO was 17 hours (range: 4-543 hours), and the median postoperative length of stay was 9 days (range: 7-19 days). In-hospital and 90-day mortality were both 0% (N.=0). Postoperative complications included reoperation for bleeding (N.=1) and thrombotic complications (N.=2). CONCLUSIONS: We have shown how V-V ECMO can be safely utilized to manage patients with a range of tracheobronchial injuries with low rates of postoperative morbidity. Acceptable postoperative outcomes can be achieved for this cohort of clinically complex patients when treatment is provided with a multidisciplinary team approach in high-volume specialist centers.

Pre-existing pulmonary fibrosis is associated with adverse outcomes after lung resection.

INTRODUCTION: Pulmonary fibrosis is a risk factor for the development of lung cancer. However, the low incidence of the pathology means that it is not well represented in thoracic surgery risk scoring systems. We aimed to assess whether short and long-term outcomes after lung resection for primary lung cancer were worse in patients with pre-existing pulmonary fibrosis. METHODS: A total of 5029 consecutive patients undergoing lung resection for primary lung cancer between 2012 and 2018 in two UK centres were included. Primary outcomes were 90-day & 1-year mortality, post-operative complications and overall survival. Univariable analyses were used to compare outcomes between patients with and without pre-existing pulmonary fibrosis. RESULTS: In total, 0.7% (n = 33) of patients had a pre-existing diagnosis of pulmonary fibrosis (idiopathic pulmonary fibrosis 48.5%, non-specific interstitial pneumonia 6.1%, unknown 45.5%). Overall, 90-day and 1-year mortality were all significantly higher amongst patients with fibrosis (90-day: 18.2% vs 3.6%, p < 0.001; 1-year: 36.4% vs 10.7%, p < 0.001). The rate of reintubation was significantly higher for patients with fibrosis (9.1% vs 2.9%, p = 0.038) yet there was no difference in post-operative length of stay between groups (fibrosis: 6 days [IQR 4-9 days] vs non-fibrosis: 5 days [IQR 4-8 days], p = 0.675). Overall survival was also significantly reduced for patients with pulmonary fibrosis (log-rank analysis, p < 0.001). CONCLUSIONS: Despite its small size, this study suggests that short and long-term outcomes after lung resection are worse for patients with pre-existing pulmonary fibrosis. Segmental resections could be considered in these patients where oncologically appropriate to minimise peri-operative risk.

Pneumonectomy for primary lung cancer: contemporary outcomes, risk factors and model validation.

OBJECTIVES: Despite the increased rate of adverse outcomes compared to lobectomy, for selected patients with lung cancer, pneumonectomy is considered the optimal treatment option. The objective of this study was to identify risk factors for mortality in patients undergoing pneumonectomy for primary lung cancer. METHODS: Data from all patients undergoing pneumonectomy for primary lung cancer at 2 large thoracic surgical centres between 2012 and 2018 were analysed. Multivariable logistic and Cox regression analyses were used to identify risk factors associated with 90-day and 1-year mortality and reduced long-term survival, respectively. RESULTS: The study included 256 patients. The mean age was 65.2 (standard deviation 9.4) years. In-hospital, 90-day and 1-year mortality were 6.3% (n = 16), 9.8% (n = 25) and 28.1% (n = 72), respectively. The median follow-up time was 31.5 months (interquartile range 9-58 months). Patients who underwent neoadjuvant therapy had a significantly increased risk of 90-day [odds ratio 6.451, 95% confidence interval (CI) 1.867-22.291, P = 0.003] and 1-year mortality (odds ratio 2.454, 95% CI 1.079-7.185, P = 0.044). Higher Performance Status score was associated with higher 1-year mortality (odds ratio 2.055, 95% CI 1.248-3.386, P = 0.005) and reduced overall survival (hazard ratio 1.449, 95% CI 1.086-1.934, P = 0.012). Advanced (stage III/IV) disease was associated with reduced overall survival (hazard ratio 1.433, 95% CI 1.019-2.016, P = 0.039). Validation of a pneumonectomy-specific risk model demonstrated inadequate model performance (area under the curve 0.54). CONCLUSIONS: Pneumonectomy remains associated with a high rate of perioperative mortality. Neoadjuvant chemoradiotherapy, Performance Status score and advanced disease emerged as the key variables associated with adverse outcomes after pneumonectomy in our cohort.

Case Report: Spontaneous lung intercostal hernia series and literature review.

Spontaneous lung intercostal hernia (SLIH) is a rare condition potentially carrying severe morbidity. About 120 cases have been described so far, with an apparently increasing number of reports in recent years. The main presenting findings are chest pain and bulging, with ecchymosis in the affected area, hemoptysis, respiratory distress, and signs of infection or incarceration being described as well. The gold standard treatment has not been established, and conservative management has been advocated as first-line treatment for asymptomatic patients. Here, we report a case series of five patients, and surgical repair was deemed necessary for four of them either at first evaluation or after failure of conservative management. One patient remains under surveillance and conservative management. We believe that SLIH surgical repair should be considered as first-line treatment for fit patients, due to the uncertainty of its mid- and long-term impact and described pejorative trend/defect enlargement. A proposed algorithm for SLIH management is also presented.

External validation of six existing multivariable clinical prediction models for short-term mortality in patients undergoing lung resection.

OBJECTIVES: National guidelines advocate the use of clinical prediction models to estimate perioperative mortality for patients undergoing lung resection. Several models have been developed that may potentially be useful but contemporary external validation studies are lacking. The aim of this study was to validate existing models in a multicentre patient cohort. METHODS: The Thoracoscore, Modified Thoracoscore, Eurolung, Modified Eurolung, European Society Objective Score and Brunelli models were validated using a database of 6600 patients who underwent lung resection between 2012 and 2018. Models were validated for in-hospital or 30-day mortality (depending on intended outcome of each model) and also for 90-day mortality. Model calibration (calibration intercept, calibration slope, observed to expected ratio and calibration plots) and discrimination (area under receiver operating characteristic curve) were assessed as measures of model performance. RESULTS: Mean age was 66.8 years (±10.9 years) and 49.7% (n = 3281) of patients were male. In-hospital, 30-day, perioperative (in-hospital or 30-day) and 90-day mortality were 1.5% (n = 99), 1.4% (n = 93), 1.8% (n = 121) and 3.1% (n = 204), respectively. Model area under the receiver operating characteristic curves ranged from 0.67 to 0.73. Calibration was inadequate in five models and mortality was significantly overestimated in five models. No model was able to adequately predict 90-day mortality. CONCLUSIONS: Five of the validated models were poorly calibrated and had inadequate discriminatory ability. The modified Eurolung model demonstrated adequate statistical performance but lacked clinical validity. Development of accurate models that can be used to estimate the contemporary risk of lung resection is required.

A diagnostic cohort study on the accuracy of 18-fluorodeoxyglucose (18FDG) positron emission tomography (PET)-CT for evaluation of malignancy in anterior mediastinal lesions: the DECiMaL study.

OBJECTIVES: The aim of this study is to collate multi-institutional data to determine the value by defining the diagnostic performance of fluorodeoxyglucose positron emission tomography (FDG PET)/CT for malignancy in patients undergoing surgery with an anterior mediastinal mass in order to ascertain the clinical utility of PET/CT to differentiate malignant from benign aetiologies in patients presenting with an anterior mediastinal mass SETTING: DECiMaL Study is a multicentre, retrospective, collaborative cohort study in seven UK surgical sites. PARTICIPANTS: Between January 2002 and June 2015, a total of 134 patients were submitted with a mean age (SD) of 55 years (16) of which 69 (51%) were men. We included all patients undergoing surgery who presented with an anterior mediastinal mass and underwent PET/CT. PET/CT was considered positive for any reported avidity as stated in the official report and the reference was the resected specimen reported by histopathology using WHO criteria. PRIMARY AND SECONDARY OUTCOME MEASURES: Sensitivity, specificity, positive and negative predicted values of [18F]-FDG PET in determining malignant aetiology for an anterior mediastinal mass. RESULTS: The sensitivity and specificity of PET/CT to correctly classify malignant disease were 83% (95% CI 74 to 89) and 58% (95% CI 37 to 78). The positive and negative predictive values were 90% (95% CI 83% to 95%) and 42% (95% CI 26% to 61%). CONCLUSIONS: The results of our study suggest reasonable sensitivity but no specificity implying that a negative PET/CT is useful to rule out the diagnosis of malignant disease whereas a positive result has no value in the discrimination between malignant and benign diseases of the anterior mediastinum.

Dynamic suture less repair of incisional hernia.

BACKGROUND AND AIM OF THE STUDY: An incisional hernia is represented by the escape of organs from their physiologic position through an area of weakness on the surgical scar. An original technique, based on a Rives intervention, which is the golden standard in the treatment of incisional hernias, is presented in this study. METHODS: From January 1995 to December 2003, 93 patients underwent surgery for incisional hernia in our Division. The intervention was performed in 52 cases (Group A) with a classic Rives technique, with apposition of a prolene mesh in the subaponeurotic space, and fixation of the mesh with transcutaneous stitches. In 41 cases (Group B) the intervention was performed with a personal technique, with apposition of an "Hertra 0", a rigid and memory controlled mesh between the rectum abdomini muscle and its posterior fascia, tension free without fixation with stitches. RESULTS: The mean follow-up was of 23 months. In Group A we observed immediately 3 postoperative cases (5%) of intraparietal haematoma, 2 (4%) of subcutaneous haematoma, 4 (7%) of retrofascial haematoma, 4 (7%) of wound infection (in 1 it was necessary to remove the prosthesis), 3 (6%) of respiratory complications, and 1 case (2%) of cardiovascular complication. In Group B we observed only 3 cases (7%) of subcutaneous seroma. The mean postoperative stay was 6 days in both groups. There was no postoperative mortality or relapses. CONCLUSIONS: The presented technique seems to offer advantages in the management of incisional hernia; the use of "Hertra 0" mesh simplifies Rives technique, improving its resistance to infections.