Comparison of Clinical Outcomes and Postoperative Nutritional Status Between Early and Late Oral Feeding After Esophagectomy: An Open Labeled Randomized Controlled Trial.

OBJECTIVE: To compare nutritional and postoperative outcomes between early oral feeding and late oral feeding with jejunostomy feeding support after esophagectomy. SUMMARY BACKGROUND DATA: Esophagectomy is associated with substantial body weight loss and malnutrition, impacting the prognosis of esophageal cancer patients. Despite many studies on post-esophagectomy nutritional support, optimal strategies remain elusive. This study investigates the impact of jejunostomy feeding with late oral feeding compared to conventional oral feeding on nutritional and postoperative outcomes. METHODS: We performed a single-center prospective open-labelled randomized controlled trial between 2020 and 2022. Patients aged 18 to 75 years with resectable esophageal cancer were randomly assigned to undergo either early oral feeding (early group) or late oral feeding with jejunostomy feeding support (late group) after esophagectomy. The primary endpoint was body weight loss from preoperative body weight at postoperative 4-5 weeks and 4 months. Other perioperative and nutritional outcomes were also evaluated. RESULTS: We randomly assigned 29 patients to the early group and 29 patients to the late group. The late group exhibited significantly less body weight loss at both postoperative 4-5 weeks (8.3% vs. 5.6%; P =0.002) and 4 months (15.0% vs. 10.5%; P =0.003). The total calorie intake and protein intake were higher in the late group for both postoperative 4-5 weeks (1800 kcal/day vs. 1100 kcal/day; P <0.001) and 4 months (1565 kcal/day vs. 1200 kcal/day; P =0.010). Sixty percentage of early group changed to malnutrition state, while 40% of the late group changed to malnutrition. The complication rate and length of hospital stays were similar. CONCLUSIONS: The late group demonstrated prevention of significant body weight loss, enhanced nutritional intake, and reduces malnutrition without compromising short-term surgical outcomes.

Diagnostic performance and prognostic value of CT-defined visceral pleural invasion in early-stage lung adenocarcinomas.

OBJECTIVES: To analyze the diagnostic performance and prognostic value of CT-defined visceral pleural invasion (CT-VPI) in early-stage lung adenocarcinomas. METHODS: Among patients with clinical stage I lung adenocarcinomas, half of patients were randomly selected for a diagnostic study, in which five thoracic radiologists determined the presence of CT-VPI. Probabilities for CT-VPI were obtained using deep learning (DL). Areas under the receiver operating characteristic curve (AUCs) and binary diagnostic measures were calculated and compared. Inter-rater agreement was assessed. For all patients, the prognostic value of CT-VPI by two radiologists and DL (using high-sensitivity and high-specificity cutoffs) was investigated using Cox regression. RESULTS: In 681 patients (median age, 65 years [interquartile range, 58-71]; 382 women), pathologic VPI was positive in 130 patients. For the diagnostic study (n = 339), the pooled AUC of five radiologists was similar to that of DL (0.78 vs. 0.79; p = 0.76). The binary diagnostic performance of radiologists was variable (sensitivity, 45.3-71.9%; specificity, 71.6-88.7%). Inter-rater agreement was moderate (weighted Fleiss κ, 0.51; 95%CI: 0.43-0.55). For overall survival (n = 680), CT-VPI by radiologists (adjusted hazard ratio [HR], 1.27 and 0.99; 95%CI: 0.84-1.92 and 0.63-1.56; p = 0.26 and 0.97) or DL (HR, 1.44 and 1.06; 95%CI: 0.86-2.42 and 0.67-1.68; p = 0.17 and 0.80) was not prognostic. CT-VPI by an attending radiologist was prognostic only in radiologically solid tumors (HR, 1.82; 95%CI: 1.07-3.07; p = 0.03). CONCLUSION: The diagnostic performance and prognostic value of CT-VPI are limited in clinical stage I lung adenocarcinomas. This feature may be applied for radiologically solid tumors, but substantial reader variability should be overcome. CLINICAL RELEVANCE STATEMENT: Although the diagnostic performance and prognostic value of CT-VPI are limited in clinical stage I lung adenocarcinomas, this parameter may be applied for radiologically solid tumors with appropriate caution regarding inter-reader variability. KEY POINTS: • Use of CT-defined visceral pleural invasion in clinical staging should be cautious, because prognostic value of CT-defined visceral pleural invasion remains unexplored. • Diagnostic performance and prognostic value of CT-defined visceral pleural invasion varied among radiologists and deep learning. • Role of CT-defined visceral pleural invasion in clinical staging may be limited to radiologically solid tumors.

Long-term survival analysis of robotic esophagectomy for esophageal cancer.

Robotic esophagectomy has improved early outcomes and enhanced the quality of lymphadenectomy for esophageal cancer surgery. This study aimed to determine risk factors for long-term survival following robotic esophagectomy and the causes of long-term mortality. We included patients who underwent robotic esophagectomy at our institute between 2010 and 2022. Robotic esophagectomy was defined as a surgical procedure performed robotically in both the abdomen and thorax. Robotic esophagectomy was performed in patients at all stages, including advanced stages, even in patients with stage IV and supraclavicular lymph node metastasis. A total of 340 patients underwent robotic esophagectomy during the study period. Ivor-Lewis operation and McKeown operation were performed on 153 (45.0%) and 187 (55.0%) patients, respectively. The five-year survival rates based on clinical stages were as follows: 85.2% in stage I, 62.0% in stage II, 54.5% in stage III, and 40.3% in stage IV. Risk factors for long-term survival included body mass index, Charlson comorbidity index, clinical stages, and postoperative complications of grade 4 or higher. Among the cases of long-term mortality, recurrence accounted for 42 patients (61.7%), while non-cancer-related death occurred in 26 patients (38.2%). The most common cause of non-cancer-related death was malnutrition and poor general condition, observed in 11 patients (16.2%). Robotic esophagectomy has demonstrated the ability to achieve acceptable long-term survival rates, even in patients with cervical lymph node metastasis. However, addressing high-grade postoperative complications and long-term malnutrition remains crucial for further improving the long-term survival outcomes of patients with esophageal cancer.

Prognostication of lung adenocarcinomas using CT-based deep learning of morphological and histopathological features: a retrospective dual-institutional study.

OBJECTIVES: To develop and validate CT-based deep learning (DL) models that learn morphological and histopathological features for lung adenocarcinoma prognostication, and to compare them with a previously developed DL discrete-time survival model. METHODS: DL models were trained to simultaneously predict five morphological and histopathological features using preoperative chest CT scans from patients with resected lung adenocarcinomas. The DL score was validated in temporal and external test sets, with freedom from recurrence (FFR) and overall survival (OS) as outcomes. Discrimination was evaluated using the time-dependent area under the receiver operating characteristic curve (TD-AUC) and compared with the DL discrete-time survival model. Additionally, we performed multivariable Cox regression analysis. RESULTS: In the temporal test set (640 patients; median age, 64 years), the TD-AUC was 0.79 for 5-year FFR and 0.73 for 5-year OS. In the external test set (846 patients; median age, 65 years), the TD-AUC was 0.71 for 5-year OS, equivalent to the pathologic stage (0.71 vs. 0.71 [p = 0.74]). The prognostic value of the DL score was independent of clinical factors (adjusted per-percentage hazard ratio for FFR (temporal test), 1.02 [95% CI: 1.01-1.03; p < 0.001]; OS (temporal test), 1.01 [95% CI: 1.002-1.02; p = 0.01]; OS (external test), 1.01 [95% CI: 1.005-1.02; p < 0.001]). Our model showed a higher TD-AUC than the DL discrete-time survival model, but without statistical significance (2.5-year OS: 0.73 vs. 0.68; p = 0.13). CONCLUSION: The CT-based prognostic score from collective deep learning of morphological and histopathological features showed potential in predicting survival in lung adenocarcinomas. CLINICAL RELEVANCE STATEMENT: Collective CT-based deep learning of morphological and histopathological features presents potential for enhancing lung adenocarcinoma prognostication and optimizing pre-/postoperative management. KEY POINTS: • A CT-based prognostic model was developed using collective deep learning of morphological and histopathological features from preoperative CT scans of 3181 patients with resected lung adenocarcinoma. • The prognostic performance of the model was comparable-to-higher performance than the pathologic T category or stage. • Our approach yielded a higher discrimination performance than the direct survival prediction model, but without statistical significance (0.73 vs. 0.68; p=0.13).

The oncologic efficacy of extended resections for lung cancer.

Extended lung resections for T3-T4 non-small-cell lung cancer remain challenging. Multimodal management is mandatory in multidisciplinary tumor boards, and here the determination of resectability is key. Long-term oncologic efficacy depends mostly on complete resection (R0) and the extent of N2 disease. The development of novel innovative treatments (targeted therapy and immune checkpoint inhibitors) sets interesting perspectives to reinforce current therapeutic options in the induction and adjuvant setting.

Histopathologic Basis for a Chest CT Deep Learning Survival Prediction Model in Patients with Lung Adenocarcinoma.

Background A preoperative CT-based deep learning (DL) prediction model was proposed to estimate disease-free survival in patients with resected lung adenocarcinoma. However, the black-box nature of DL hinders interpretation of its results. Purpose To provide histopathologic evidence underpinning the DL survival prediction model and to demonstrate the feasibility of the model in identifying patients with histopathologic risk factors through unsupervised clustering and a series of regression analyses. Materials and Methods For this retrospective study, data from patients who underwent curative resection for lung adenocarcinoma without neoadjuvant therapy from January 2016 to September 2020 were collected from a tertiary care center. Seven histopathologic risk factors for the resected adenocarcinoma were documented: the aggressive adenocarcinoma subtype (cribriform, morular, solid, or micropapillary-predominant subtype); mediastinal nodal metastasis (pN2); presence of lymphatic, venous, and perineural invasion; visceral pleural invasion (VPI); and EGFR mutation status. Unsupervised clustering using 80 DL model-driven CT features was performed, and associations between the patient clusters and the histopathologic features were analyzed. Multivariable regression analyses were performed to investigate the added value of the DL model output to the semantic CT features (clinical T category and radiologic nodule type [ie, solid or subsolid]) for histopathologic associations. Results A total of 1667 patients (median age, 64 years [IQR, 57-71 years]; 975 women) were evaluated. Unsupervised patient clusters 3 and 4 were associated with all histopathologic risk factors (P < .01) except for EGFR mutation status (P = .30 for cluster 3). After multivariable adjustment, model output was associated with the aggressive adenocarcinoma subtype (odds ratio [OR], 1.03; 95% CI: 1.002, 1.05; P = .03), venous invasion (OR, 1.03; 95% CI: 1.004, 1.06; P = .02), and VPI (OR, 1.08; 95% CI: 1.06, 1.10; P < .001), independently of the semantic CT features. Conclusion The deep learning model extracted CT imaging surrogates for the histopathologic profiles of lung adenocarcinoma. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Yanagawa in this issue.

CT-defined visual emphysema in smokers with normal spirometry: association with prolonged air leak and other respiratory complications after lobectomy for lung cancer.

OBJECTIVES: To evaluate the association of visual emphysema on preoperative CT with respiratory complications and prolonged air leak (PAL) in smokers with normal spirometry who underwent lobectomy for lung cancer. METHODS: Among patients who underwent lobectomy for lung cancer between 2018 and 2019 at a single center, ever-smokers with normal spirometry were identified retrospectively. Visual emphysema was graded for centrilobular emphysema (CLE) and paraseptal emphysema (PSE), respectively, by two thoracic radiologists. The associations of visual emphysema with PAL and respiratory complications (except PAL) were investigated. RESULTS: In total, 282 patients were evaluated (257 men; mean age, 64.6 ± 9.8 years). Visual emphysema was present in 126 patients (44.7%) (CLE, 26; PSE, 40; combined CLE and PSE, 60). PAL and respiratory complications occurred in 34 (12.1%) and 26 patients (26.9%), respectively. Greater frequency of PAL and respiratory complications were observed in patients with higher grades of CLE (p = 0.002 for PAL; p = 0.039 for respiratory complications) and PSE (p < 0.001 for PAL; p < 0.001 for respiratory complications). For reader 1 evaluation, the presence of both CLE and PSE was associated with PAL (adjusted odds ratio [OR], 4.94; 95% confidence interval [CI], 1.75-13.95; p = 0.003). For reader 2 evaluation, PSE (adjusted OR, 4.26; 95% CI, 1.22-14.97; p = 0.024) and combined CLE and PSE (adjusted OR, 3.49; 95% CI, 12.1-10.06; p = 0.020) were associated with PAL. The presence of solely CLE was not associated with any adverse outcome (all p > 0.05) for both readers. CONCLUSIONS: Visual assessment of PSE in smokers with normal spirometry may help identify those who develop PAL after lobectomy. KEY POINTS: • Visual emphysema was highly prevalent (44.7%) in smokers with normal lung function who underwent lobectomy for lung cancer. • Increasing tendency of postoperative complications was observed as the grade of visual emphysema increased. • The presence of paraseptal emphysema was associated with prolonged air leak.

Association of Adipopenia at Preoperative PET/CT with Mortality in Stage I Non-Small Cell Lung Cancer.

Background Body mass index (BMI) and sarcopenia status are well-established prognostic factors in patients with lung cancer. However, the relationship between the amount of adipose tissue and survival remains unclear. Purpose To investigate the association between baseline adipopenia and outcomes in patients with early-stage non-small cell lung cancer (NSCLC). Materials and Methods Consecutive patients who underwent surgical resection for stage I NSCLC between 2011 and 2015 at a single tertiary care center were retrospectively identified. The primary outcome was the 5-year overall survival (OS) rate, and secondary outcomes were the 5-year disease-free survival (DFS) rate and the major postoperative complication rate. The abdominal total fat volume at the waist and the skeletal muscle area at the L3 level were obtained from preoperative PET/CT data and were normalized by the height squared to calculate the fat volume index (FVI) and skeletal muscle index. Adipopenia was defined as the sex-specific lowest quartile of the FVI for the study sample, and sarcopenia was determined using the skeletal muscle index reference value (men, <55 cm2/m2; women, <39 cm2/m2). The association between body composition and outcomes was evaluated using Cox regression analysis. Results A total of 440 patients (median age, 65 years [interquartile range, 58-72 years]; 243 men) were evaluated. Most underweight patients (<20 kg/m2) had adipopenia (97%, 36 of 37 patients), but overweight patients (25-30 kg/m2, n = 138) and obese patients (>30 kg/m2, n = 14) did not have adipopenia (3%, four of 152 patients). In the group with a normal BMI (20-25 kg/m2), 28% (70 of 251 patients) had adipopenia and 67% (168 of 251 patients) had sarcopenia. After adjusting for age, sex, smoking history, surgical procedure, stage, histologic type, BMI, and sarcopenia, adipopenia was associated with reduced 5-year OS (hazard ratio [HR] = 2.2; 95% CI: 1.1, 3.8; P = .02) and 5-year non-cancer-specific OS rates (HR = 3.2; 95% CI: 1.2, 8.7; P = .02). There was no association between adipopenia and postoperative complications (P = .45) or between adipopenia and the 5-year DFS rate (P = .18). Conclusion Baseline adipopenia was associated with a reduced 5-year overall survival rate in patients with early-stage non-small cell lung cancer and may indicate risk for non-cancer-related death. © RSNA, 2021 Online supplemental material is available for this article.

Combined lung and liver transplantation for noncirrhotic portal hypertension with severe hepatopulmonary syndrome in a patient with dyskeratosis congenita.

DC is caused by defects at the level of telomere maintenance, and cells from patients with this disease have abnormally short telomeres and show premature senescence. One consequence of DC is bone marrow failure. Thus, patients with DC often require HSCT. However, HSCT does not ameliorate other DC-related manifestations. In fact, HSCT can accelerate organ dysfunction due to treatment-related complications, and solid organ transplantation is required in some patients with DC. In this report, we describe the clinical course of a 5-year-old boy who was transferred to our hospital because of progressive dyspnea, 2 years after HSCT. At admission, he had tachypnea and hypoxemia. A liver biopsy was performed for suspected HPS caused by PH, and LT was considered. Eventually, his hypoxemia worsened, and he was transferred to a PICU and started on VA ECMO. He subsequently underwent a CLLT. ECMO was stopped on post-operative day 12, extubation was achieved on post-operative day 29, and the patient recovered well from the surgery. Our results show that CLLT could be a life-saving treatment option for DC patients with very severe HPS in whom a poor outcome is expected after LT.

Outcomes of adjunctive surgery for nontuberculous mycobacterial pulmonary disease.

BACKGROUND: Owing to the unsatisfactory results of antibiotic treatment alone, surgical resection is currently considered as adjunctive therapy in patients with nontuberculous mycobacterial pulmonary disease (NTM-PD). However, reports regarding the outcomes of surgery vary considerably by institution. Here, we investigated the surgical outcomes and risk factors associated with unfavorable outcomes after surgery. METHODS: We analyzed patients with NTM-PD who underwent pulmonary resection at Seoul National University Hospital between January 1, 2006, and December 31, 2020, and assessed the types of surgical procedures, complications, and long-term outcomes. Multivariate logistic regression analysis was used to identify the risk factors associated with treatment refractoriness or recurrence after surgery. RESULTS: Among 67 patients who underwent surgery during the study period, the most common indication for surgery was persistent culture positivity despite rigorous medical treatment (80.6%), followed by longstanding cavitary lesions or radiographic aggravation (10.4%) and massive hemoptysis (4.5%). Among 53 patients with positive mycobacterial cultures at the time of surgery, 38 (71.7%) achieved initial negative culture conversion, 9 (17.0%) of whom experienced recurrence. Nine (13.4%) patients experienced postoperative complications, which were managed without lasting morbidity and mortality. Female sex (adjusted odds ratio [aOR] 6.63; 95% confidence interval [CI] 1.04-42.4; P = .046), preoperative positive mycobacterial culture (aOR 5.87; 95 %CI 1.04-33.08; P = .045), and residual lesions (aOR 6.86; 95 %CI 1.49-31.56; P = .013) were associated with refractoriness or recurrence. CONCLUSIONS: Pulmonary resection is a reasonable treatment modality for patients with refractory NTM-PD or major complications such as massive hemoptysis. The potential risk factors associated with unfavorable outcomes included female sex, preoperative positive mycobacterial culture, and residual lesions after surgery.

Reduction of cycles of neoadjuvant chemotherapy for advanced epithelial ovarian, fallopian or primary peritoneal cancer (ROCOCO): study protocol for a phase III randomized controlled trial.

BACKGROUND: Primary debulking surgery (PDS) and adjuvant chemotherapy is the standard treatment for advanced ovarian, fallopian or primary peritoneal cancer. However, neoadjuvant chemotherapy (NAC) followed by interval debulking surgery (IDS) has been introduced as an alternative, showing similar efficacy and decreased postoperative complications compared with PDS. Although there is still no evidence for whether three or four cycles of NAC used clinically could be adequate, reducing one cycle of NAC is expected to remove more visible tumours and thereby improve prognosis. Thus, we proposed with this study to evaluate the efficacy and safety of reducing one cycle of NAC for advanced ovarian, fallopian or primary peritoneal cancer. METHODS: This study is a prospective, multi-centre, open-label, randomized phase III trial. A total of 298 patients with advanced ovarian, fallopian or primary peritoneal cancer will be recruited and randomly assigned to either three (control group) or two cycles of NAC (experimental group). After the NAC, we will conduct IDS with maximal cytoreduction and then administer the remaining three or four cycles for a total of six cycles of adjuvant chemotherapy. The primary end point is progression-free survival, and the secondary end points are time to tumour progression, overall survival, tumour response after NAC, IDS and adjuvant chemotherapy, radiologic investigation after IDS, tumour response by positron emission tomography-computed tomography after NAC, quality of life, adverse events, success rate of optimal cytoreduction, surgical complexity, postoperative complications and safety of IDS. We will assess these factors at screening, at every cycle of chemotherapy, at IDS, after the completion of chemotherapy, every 3 months for the first 2 years after the planned treatment and every 6 months thereafter for 3 years. DISCUSSION: We hypothesize that reducing one cycle of NAC will contribute to more resection of visible tumours despite 10% reduction of optimal cytoreduction, which could improve survival. Moreover, two cycles of NAC may increase postoperative complications by 5% compared with three cycles, which may be acceptable. TRIAL REGISTRATION: This study has been prospectively registered at ClinicalTrials.gov on Oct. 2nd, 2018 (NCT03693248, URL: https://clinicaltrials.gov/ct2/show/NCT03693248).

Cardiopulmonary resuscitation in pediatric pectus excavatum patients-Where is the heart?

BACKGROUND: In children with pectus excavatum, the posteriorly depressed sternum compresses and displaces the heart. However, the currently recommended compression site and depth for cardiopulmonary resuscitation have not been studied in this population. AIM: This retrospective study investigated the location of the center of ventricles with the largest cross-sectional area to determine the optimal site and depth for chest compressions in pediatric pectus excavatum patients. METHODS: Chest computed tomography images of 94 pediatric pectus excavatum patients before and after correction surgery were compared with normal patients. The caudal displacement of the ventricles was calculated by dividing the length of sternum by the length from the suprasternal notch to the transverse level of the largest cross-sectional area of the ventricles. The proportional leftward deviation of the center of the ventricles from the midline versus transverse diameter of the thorax was calculated. The remaining internal thickness was calculated at the midline assuming the recommended compression depth of one-third of the anterior to posterior diameter. RESULTS: Compared with the normal population (mean = 81% [SD = 10.3%]), pediatric pectus excavatum patients showed caudal displacement of ventricles before (98.2% [15.1%], 95% CI of mean difference; 13.7%-20.5%, P < .001) and after correction (100.4% [13.5%], 95% CI of mean difference; 16.2%-22.5%, P < .001). Compared with the normal population (6.9% [2.7%]), pediatric pectus excavatum patients showed leftward deviation of ventricles before (16.2% [5.5%], 95% CI of mean difference; 8.2%-10.4%, P < .001) and after correction (13.3% [4.8%], 95% CI of mean difference; 5.3%-7.3%, P < .001). The remaining internal thickness assuming the recommended chest compression was <10 mm in 54/94(57.4%) and 18/94 (19.1%) of pediatric pectus excavatum patients before and after correction, respectively. CONCLUSIONS: Pediatric pectus excavatum patients showed significant caudal displacement and leftward deviation of the ventricles compared with the normal population despite correction surgery and the currently recommended compression site and depth might injure intrathoracic structures without effective cardiac compression during cardiopulmonary resuscitation.

Efficacy and Cost-effectiveness of Surgical Biopsy for Histologic Diagnosis of Indeterminate Nodules Suspected for Early Stage Lung Cancer: Comparison with Percutaneous Needle Biopsy.

BACKGROUND: Indeterminate pulmonary nodules (IPN) suspected for early stage lung cancer mandate accurate diagnosis. Both percutaneous needle biopsy (PCNB) and surgical biopsy (SB) are valuable options. The present study aimed to compare the efficacy and cost-effectiveness between PCNB and SB for IPN suspected for early stage lung cancer. METHODS: During January-November 2018, patients who underwent operation for IPN suspected for early stage lung cancer (SB group, n = 245) or operation after PCNB (PCNB group, n = 113) were included. Patient-level cost data were extracted from medical bills from the institution. Propensity score matching was performed between the two groups from a retrospectively-collected database. RESULTS: Fifteen patients (11.5%) had complications after PCNB; thirteen (11.5%) were not confirmed to have lung cancer through PCNB but underwent operation for IPN. In SB group, 172 (70.2%) and 7 (2.9%) patients underwent wedge resection and segmentectomy for SB, respectively; 66 patients (26.9%) underwent direct lobectomy without SB. After propensity score matching, 58 paired samples were produced. Most patients in PCNB group were admitted twice (n = 55, 94.8%). The average hospital stay was longer in PCNB group (12.9 ± 5.3 vs. 7.3 ± 3.0, P < 0.001). Though the cost of the operation was comparable (USD 12,509 ± 2,909 vs. 12,669 ± 3,334; P = 0.782), the total cost was higher for PCNB group (USD 14,403 ± 3,085 vs. 12,669 ± 3,334; P = 0.006). The average subcategory cost, which increases proportional to hospital stay, was higher in PCNB group, whereas the cost of operation and surgical materials were comparable between the two groups. CONCLUSION: Lung cancer operation following SB for IPN was associated with lesser cost, shorter hospital stays, and lesser admission time than lung cancer operation after PCNB. The increased cost and longer hospital stay appear largely related to the admission for PCNB.

Sleeve Lobectomy for Non-Small Cell Lung Cancers: Predictive CT Features for Resectability and Outcome Analysis.

OBJECTIVE. The purpose of this study was to investigate the CT features predictive of resectability in sleeve lobectomy (SL) for patients with non-small cell lung cancers (NSCLCs) and the outcomes of this procedure. MATERIALS AND METHODS. The study included 45 patients with NSCLCs who planned to undergo SL as a first-line surgical option and underwent SL or pneumonectomy between February 2014 and July 2017. The patients were dichotomized according to whether SL was achieved without residual disease. ROC curve and logistic regression analyses were performed to identify CT features predictive of resectability in SL without residual disease. For outcome analysis, postoperative complications and survival were compared between the two patient groups. RESULTS. SL was successfully performed in 25 patients (55.6%), whereas eight patients underwent SL but had a positive resection margin and 12 required pneumonectomy. The AUC value of the tumor-involved length of the salvage bronchus for SL without residual disease was 0.802, with 5 mm considered the optimal cutoff for this tumor-involved length. A tumor-involved length of 5 mm or less for the salvage bronchus representing the distal anastomosis end in SL was the sole significant predictor for resectability in SL without residual disease in logistic regression analysis (odds ratio, 16.0; 95% CI, 3.7-69.6; p < 0.001). The group of patients who underwent SL without residual disease tended to have a more favorable survival outcome than patients who underwent SL but had residual disease or those who underwent pneumonectomy (p = 0.110), but postoperative complication rates were similar between the two patient groups (20.0% vs 25.0%, respectively). CONCLUSION. A tumor-involved salvage bronchus length of 5 mm or less was a CT feature predictive of resectability in SL without residual disease, which may improve the survival of patients with NSCLCs.

Pediatric Case Report on an Interstitial Lung Disease with a Novel Mutation of SFTPC Successfully Treated with Lung Transplantation.

Mutations of the surfactant protein (SP)-C gene (SFTPC) have been associated with neonatal respiratory distress syndrome (RDS) and childhood interstitial lung disease (ILD). If accurate diagnosis and proper management are delayed, irreversible respiratory failure demanding lung transplantation may ensue. A girl was born at term but was intubated and given exogenous surfactant due to RDS. Cough and tachypnea persisted, and symptoms rapidly progressed at 16 months of age despite treatment with antibiotics, oral prednisolone, methylprednisolone pulse therapy, and intravenous immunoglobulin. At 20 months, she visited our hospital for a second opinion. A computed tomography scan showed a diffuse mosaic pattern with ground-glass opacity and subpleural cysts compatible with ILD. A video-assisted thoracoscopic lung biopsy revealed ILD with eosinophilic proteinaceous material and macrophages in the alveolar space. Bilateral lung transplant from a 30-month-old child was done, and she was discharged in room air without acute complications. Genetic analysis revealed a novel c.203T>A, p.Val68Asp mutation of SP-C, based on the same exon as a known pathogenic mutation, p.Glu66Lys.

Serial improvement of quality metrics in pediatric thoracoscopic lobectomy for congenital lung malformation: an analysis of learning curve.

BACKGROUND: Video-assisted thoracic surgery (VATS) pulmonary resection in children is a technically demanding procedure that requires a relatively long learning period. This study aimed to evaluate the serial improvement of quality metrics according to case volume experience in pediatric VATS pulmonary resection of congenital lung malformation (CLM). Methods VATS anatomical resection in CLM was attempted in 200 consecutive patients. The learning curve for the operative time was modeled by cumulative sum analysis. Quality metrics were used to measure technical achievement and efficiency outcomes. Results The median operative time was 95 min. The median length of hospital stay and chest tube indwelling time was 4 and 2 days, respectively. The improvement of operation time was observed persistently until 200 cases. However, two cut-off points, the 50th case and 110th case, were identified in the learning curve for operative time, and the 110th case was the turning point for stable outcomes with short operation time. Significant reduction of length of hospital stay and chest tube indwelling time was observed after 50 cases (p = .002 and p = .021, respectively). The complication rate decreased but continued at a low rate for entire study period and the interval decrease was not statistically significant. Conversion rate decreased significantly (p = .001), and technically challenging procedures were performed more frequently in later cases. Conclusions Improvements of quality metrics in operation time, conversion rate, length of hospital stay, and chest tube indwelling time were observed in proportion to case volume. Minimum experience of 50 is necessary for stable outcomes of pediatric VATS pulmonary resection.

Gender representation among speaking and leader roles at European cardio-thoracic surgical annual meetings.

OBJECTIVES: Our goal was to evaluate gender representation among session leaders and abstract presenters at European cardio-thoracic surgical annual meetings. METHODS: We did a descriptive study of the gender distribution among session leaders and abstract presenters at 2 European cardio-thoracic international meetings from 2017 to 2022. Data from publicly available programmes were used to generate a list of session leaders and abstract presenters. The primary outcome was to evaluate the proportion of female sessions leaders at the annual meetings. Descriptive analyses were performed including the Cochran-Armitage trend test for linear trend of proportions. RESULTS: A total of 1025 sessions of 11 annual meetings of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Thoracic Surgeons were examined. A total of 397 (13.2%) out of 3007 total session leaders and 955 (15.2%) out of 6251 abstract presenters were female. From 2017 to 2022, the proportions of both female session leaders and abstract presenters trended significantly [10.4% to 21.9% (P < 0.001) and 13.7% to 18.3% (P < 0.001), respectively]. The EACTS female members and female meeting attendees significantly increased from 2017 to 2022 [11.1% to 15.9% (P < 0.001) and 23.7% to 26.9% (P < 0.001)], respectively. Most of the women attendees at the EACTS and the European Society of Thoracic Surgeons meetings who were session leaders and speakers came from Germany, Italy, the United Kingdom and the United States. CONCLUSIONS: Women are under-represented compared to men in leadership and speaking roles at European cardio-thoracic surgical annual meetings. In the past few years, an encouraging positive trend over time for female leadership roles has been noted; as a result, the proportion of female society members is represented at the annual meetings. However, a substantial gender gap still exists in leading roles of meeting attendees.

Safety of Perioperative Maintenance of Antiplatelet Agents in Elderly Patients Undergoing Lung Cancer Surgery.

Background: The maintenance of antiplatelet therapy increases the risk of bleeding during lung cancer surgery. Conversely, the perioperative interruption of antiplatelet therapy may result in serious thrombotic complications. This study aimed to investigate the safety of continuing antiplatelet therapy in the context of lung cancer surgery. Methods: We retrospectively reviewed a cohort of 498 elderly patients who underwent surgery for lung cancer. These patients were categorized into 2 groups: group N, which did not receive antiplatelet therapy, and group A, which did. Group A was subsequently subdivided into group Am, where antiplatelet therapy was maintained, and group Ai, where antiplatelet therapy was interrupted. We compared the incidence of bleeding-related and thrombotic complications across the 3 groups. Results: There were 387 patients in group N and 101 patients in group A (Ai: 70, Am: 31). No significant differences were found in intraoperative blood loss, thoracotomy conversion rates, transfusion requirements, volume of chest tube drainage, or reoperation rates for bleeding control between groups N and A or between groups Am and Ai. The duration of hospital stay was longer for group A compared to group N (7 days vs. 6 days, p=0.005), but there was no significant difference between groups Ai and Am. The incidence of cardiovascular or cerebrovascular complications did not differ significantly between groups Ai and Am. However, group Ai included a severe case of in-hospital ST-elevation myocardial infarction. Conclusion: The maintenance of antiplatelet therapy was found to be safe in terms of perioperative bleeding and thrombotic complications in elderly lung cancer surgery patients.

Thoracic cavity remodeling and pulmonary function change after chest wall resection.

Background: Chest wall resection (CWR) is an essential procedure for treating malignancies and infectious conditions of the chest wall. However, there are few studies on the pulmonary function and changes in thoracic cavity volume (TCV) related to CWR. This study aims to investigate the effects of CWR on long-term changes in TCV and pulmonary function. Methods: Data of patients who underwent CWR between 2001 and 2021 were retrospectively reviewed. Patients who underwent single rib or lung resection rather than wedge resection were excluded. TCV (liter) was defined as the sum of the right and left TCVs (RCV and LCV) and was measured using computed tomography image reconstruction software. Changes in pulmonary function and TCV 1 year postoperatively were analyzed. Results: A total of 45 patients were included. The number of resected ribs was 2 in 16 (35.6%) and ≥3 in 29 (64.4%) patients. Thirty patients underwent reconstruction. Long-term post-CWR decreased in forced vital capacity (FVC) (-7.9%, P=0.004) and forced expiratory volume in 1 second (FEV1) (-7.0%, P=0.002) were significant. There was no significant decrease in FEV1/FVC ratio (-3.0%, P=0.06), diffusing capacity of the lung for carbon monoxide (DLCO) (-5.9%, P=0.18) and TCV (-3.1%, P=0.10). There was no correlation between changes in TCV and decreases in FVC (r=0.12, P=0.56) or FEV1 (r=0.15, P=0.45). After right-side CWR (n=27), RCV (-7.8%, P=0.01) decreased significantly, whereas LCV (+2.1%, P=0.58) did not. The left-side CWR exhibited an identical pattern. (LCV: -8.5%, P=0.004; RCV: +1.3%, P=0.85). In the ≥3 rib-resection group, FVC (-9.5%, P=0.02), FEV1 (-7.9%, P=0.02) and TCV (-6.4%, P=0.04) decreased significantly. No significant changes were noted in the 2 rib-resection group. There were no significant differences in the changes in pulmonary function nor TCV between the reconstruction and no-reconstruction groups. Conclusions: The long-term decrease in pulmonary function after CWR was significant, especially after ≥3-rib resection.

Clinical Factors Affecting Discrepancy Between Predicted and Long-term Actual Lung Function Following Surgery.

PURPOSE: Lung cancer surgery outcomes depend heavily on preoperative pulmonary reserve, with forced expiratory volume in 1 second (FEV1) being a critical preoperative evaluation factor. Our study investigates the discrepancies between predicted and long-term actual postoperative lung function, focusing on clinical factors affecting these outcomes. METHODS: This retrospective observational study encompassed lung cancer patients who underwent preoperative lung perfusion SPECT/CT between 2015 and 2021. We evaluated preoperative and postoperative pulmonary function tests, considering factors such as surgery type, resected volume, and patient history including tuberculosis. Predicted postoperative lung function was calculated using SPECT/CT imaging. RESULTS: From 216 patients (men:women, 150:66; age, 67.9 ± 8.7 years), predicted postoperative FEV1% (ppoFEV1%) showed significant correlation with actual postoperative FEV1% (r = 0.667; P < 0.001). Paired t test revealed that ppoFEV1% was significantly lower compared with actual postoperative FEV1% (P < 0.001). The study identified video-assisted thoracic surgery (VATS) (odds ratio [OR], 3.90; 95% confidence interval [CI], 1.98-7.69; P < 0.001) and higher percentage of resected volume (OR per 1% increase, 1.05; 95% CI, 1.01-1.09; P = 0.014) as significant predictors of postsurgical lung function improvement. Conversely, for the decline in lung function postsurgery, significant predictors included lower percentage of resected lung volume (OR per 1% increase, 0.92; 95% CI, 0.86-0.98; P = 0.011), higher preoperative FEV1% (OR, 1.03; 95% CI, 1.01-1.07; P = 0.009), and the presence of tuberculosis (OR, 5.19; 95% CI, 1.48-18.15; P = 0.010). Additionally, in a subgroup of patients with borderline lung function, VATS was related with improvement. CONCLUSIONS: Our findings demonstrate that in more than half of the patients, actual postsurgical lung function exceeded predicted values, particularly following VATS and with higher volume of lung resection. It also identifies lower resected lung volume, higher preoperative FEV1%, and tuberculosis as factors associated with a postsurgical decline in lung function. The study underscores the need for precise preoperative lung function assessment and tailored postoperative management, with particular attention to patients with relevant clinical factors. Future research should focus on validation of clinical factors and exploring tailored approaches to lung cancer surgery and recovery.