Survival after radiation for stage I and II non-small cell lung cancer with positive margins.

BACKGROUND: There is limited data guiding treatment for positive margins following lobectomy for early-stage non-small cell lung cancer (NSCLC). Using data from the National Cancer Data Base, we sought to determine whether radiation therapy following lobectomy for stage I or II NSCLC was associated with improved overall survival in patients with positive margins. METHODS: Patients who underwent lobectomy without induction therapy for stage I or II NSCLC (1998-2006) with positive resection margins were selected. Patients were stratified by administration of radiation therapy following surgery, and overall survival was estimated using the Kaplan-Meier method. The association between radiation therapy and survival was adjusted for nonrandom treatment selection using Cox proportional hazards regression modeling. RESULTS: Positive margins were recorded in 1934 of 49,563 (3.9%) patients who underwent lobectomy for stage I or II NSCLC. Positive margin status was associated with significantly worse 5-year survival (34.5% versus 57.2%, P < 0.001). After selection of patients with positive margins and known radiation status and exclusion of patients who had upstaged disease or received radiation therapy for palliative indications, radiation therapy was used in 579 of 1579 patients (38.2%) but was not associated with a significant difference in the likelihood of death during subsequent follow-up (hazard ratio: 1.10, 95% confidence interval: 0.90, 1.35). CONCLUSIONS: Positive margins following lobectomy for stage I or II NSCLC are associated with reduced 5-year survival. Postsurgical radiation is not strongly associated with an improvement in overall survival among these patients.

Rapid and Effective Vitamin D Supplementation May Present Better Clinical Outcomes in COVID-19 (SARS-CoV-2) Patients by Altering Serum INOS1, IL1B, IFNg, Cathelicidin-LL37, and ICAM1.

BACKGROUND: We aimed to establish an acute treatment protocol to increase serum vitamin D, evaluate the effectiveness of vitamin D3 supplementation, and reveal the potential mechanisms in COVID-19. METHODS: We retrospectively analyzed the data of 867 COVID-19 cases. Then, a prospective study was conducted, including 23 healthy individuals and 210 cases. A total of 163 cases had vitamin D supplementation, and 95 were followed for 14 days. Clinical outcomes, routine blood biomarkers, serum levels of vitamin D metabolism, and action mechanism-related parameters were evaluated. RESULTS: Our treatment protocol increased the serum 25OHD levels significantly to above 30 ng/mL within two weeks. COVID-19 cases (no comorbidities, no vitamin D treatment, 25OHD <30 ng/mL) had 1.9-fold increased risk of having hospitalization longer than 8 days compared with the cases with comorbidities and vitamin D treatment. Having vitamin D treatment decreased the mortality rate by 2.14 times. The correlation analysis of specific serum biomarkers with 25OHD indicated that the vitamin D action in COVID-19 might involve regulation of INOS1, IL1B, IFNg, cathelicidin-LL37, and ICAM1. CONCLUSIONS: Vitamin D treatment shortened hospital stay and decreased mortality in COVID-19 cases, even in the existence of comorbidities. Vitamin D supplementation is effective on various target parameters; therefore, it is essential for COVID-19 treatment.

Unusual complication of endostapler use in video-assisted thoracoscopic surgery.

Video-assisted thoracoscopic surgery is becoming more popular in thoracic surgery practice. Use of endostaplers is mandatory for anatomical video-assisted thoracoscopic surgery resections. In this article, we present an unusual complication related to use of endostapler, which, to our knowledge, may be the first reported in the literature.

Validity of the updated European Society of Thoracic Surgeons staging guideline in lung cancer patients.

OBJECTIVE: The European Society of Thoracic Surgeons (ESTS) has proposed a revised preoperative lymph node staging guideline for patients with potentially resectable non-small cell lung cancer (NSCLC). We aimed to assess the validity of this revised ESTS guideline and survival results in our patient cohort. METHODS: A total of 571 patients with potentially resectable NSCLC seen between January 2004 and November 2013 were included in the study. The preoperative mediastinal staging was performed by video-assisted cervical mediastinoscopy or video-assisted mediastinoscopic lymphadenectomy in all patients except those with peripheral cT1N0 nonadenocarcinoma tumors. Resection via thoracotomy or video-assisted thoracoscopic surgery was done in patients with no mediastinal lymph node metastasis. Surgical pathological results were compared with the ESTS staging guideline, and the validity of the guideline was tested. RESULTS: In this series, mediastinal lymph node metastasis was revealed preoperatively in 266 patients (46.6%). A total of 305 patients underwent anatomic lung resection. The sensitivity, specificity, positive and negative predictive values, and accuracy of the guidelines were calculated as 95.0%, 100%, 100%, 94.6%, and 97.2%, respectively. CONCLUSIONS: The ESTS revised preoperative lymph node staging guidelines for patients with NSCLC seem to be effective and valid, and may provide high survival following resectional surgery.

Minimally invasive injection laryngoplasty in the management of unilateral vocal cord paralysis after video-assisted mediastinal lymph adenectomy.

INTRODUCTION: Video-assisted mediastinal lymphadenectomy (VAMLA) is a valuable tool for invasive staging of the mediastinum. Unilateral vocal cord paralysis (UVCP) may occur in patients following VAMLA and may result in secretion retention within the lungs, atelectasis and associated infectious situations such as pneumonia. Minimally invasive injection laryngoplasty (ILP) is the treatment of choice in UVCP. AIM: To evaluate the efficacy and success of acute minimally invasive injection laryngoplasty for patients with UVCP following VAMLA. MATERIAL AND METHODS: Patients with the symptom of dysphonia following VAMLA were reviewed. All of the patients had UVCP according to the video laryngoscopy examination and had symptoms of aspiration and ineffective coughing. The Voice Handicap Index (VHI) questionnaire and maximum phonation time (MPT) were measured. Minimally invasive ILP was performed under general anesthesia with 1 cm of hyaluronic acid. RESULTS: There were 525 consecutive non-small cell lung cancer (NSCLC) patients who underwent VAMLA. Five (0.95%) of the patients had UVCP and were suffering from aspiration during oral intake and ineffective coughing reflex. Maximum phonation time (MFT) was measured before and after ILP, and the results were 7.1 ±1.6 and 11.1 ±2.3 s, respectively (p < 001). The Voice Handicap Index-10 (VHI-10) score was 30.4 ±4.7 and 13.4 ±3.5 (p < 0.01), respectively. Patients underwent surgical lung resection. There was no morbidity or mortality. CONCLUSIONS: Unilateral vocal cord paralysis may occur as a complication of VAMLA. ILP may be an active tool for treating UVCP before anatomical lung resection to avoid potential morbidities. Successful management of this complication with multidisciplinary team work may encourage the use of VAMLA more frequently.

A prospective randomized trial comparing homologous and autologous fibrin sealants for the control of alveolar air leak.

BACKGROUND: Postoperative air leak is a common complication seen after pulmonary resection. It is a significant reason of morbidity and also leads to greater hospital cost owing to prolonged length of stay. The purpose of this study is to compare homologous sealant with autologous one to prevent air leak following pulmonary resection. METHODS: A total of 57 patients aged between 20 and 79 (mean age: 54.36) who underwent pulmonary resection other than pneumonectomy (lobar or sublobar resections) were analyzed. There were 47 males (83%) and 10 females (17%). Patients who intraoperatively had air leaks were randomized to receive homologous (Tisseel; n=28) or autologous (Vivostat; n=29) fibrin sealant. Differences among groups in terms of air leak, prolonged air leak, hospital stay, amount of air leak were analyzed. RESULTS: Indications for surgery were primary lung cancer in 42 patients (71.9%), secondary malignancy in 5 patients (8.8%), and benign disease in 10 patients (17.5%). Lobectomy was performed in 40 patients (70.2%), whereas 17 patients (29.8%) had wedge resection. Thirteen (46.4%) patients developed complications in patients receiving homologous sealant while 11 (38.0%) patients had complication in autologous sealant group (P=0.711). Median duration of air leak was 3 days in two groups. Time to intercostal drain removal was 3.39 and 3.38 days in homologous and autologous sealant group respectively (P=0.978). Mean hospital stay was 5.5 days in patients receiving homologous sealant whereas it was 5.0 days in patients who had autologous agent (P=0.140). There were no significant differences between groups in terms of measured maximum air leak (P=0.823) and mean air leak (P=0.186). There was no significant difference in the incidence of complications between two groups (P=0.711). CONCLUSIONS: Autologous and heterologous fibrin sealants are safe and acts similarly in terms of air leak and hospital stay in patients who had resectional surgery.

Modified uniportal video-assisted thoracoscopic surgery (VATS).

Video-assisted thoracoscopic surgery (VATS) for resectable lung cancer patients has been frequently used in the past decades. The potential beneficial advantages and safety of VATS has been shown in large patient series and meta-analyses. The strategy of limiting access to one incision in one intercostal space (uniportal VATS) has been adopted by some thoracic surgeons in recent years. We have described a modified uniportal VATS technique with its potential advantages. Modified uniportal VATS potentially offers better exposure, beneficial opportunities for education and improved comfort for the thoracic surgery team in clinical usage.

Multidisciplinary approach to treatment of radiation-induced chest wall sarcoma.

Radiation-induced sarcoma (RIS) is a rare complication following therapeutic external irradiation for lung cancer patients. Patients with RIS may develop recurrence or metastasis of the previous disease and also at high risk for early chest wall complications following operation, which requires close follow-up and multidisciplinary approach. We present a challenging case of RIS with a multidisciplinary teamwork in the decision-making and successful management.

Spontaneous herniation of the lung and diaphragm treated with surgical repair.

Lung herniation is rare and is usually caused by blunt trauma, congenital abnormalities of the ribs, or previous thoracic operations. We report a rare case of spontaneous lung herniation in a 72-year-old woman and describe the operative repair.

Challenging cases: thoracoscopic lobectomy with chest wall resection and sleeve lobectomy-Duke experience.

Video-assisted thoracoscopic surgery (VATS) had recent advances in both equipment and technique so has been applied to more complex conditions in some thoracic surgery centers. We have adopted our VATS lobectomy experience for patients with chest wall invasion and endobronchial localized tumor requiring bronchial sleeve resection. We are describing our decision-making and surgical methods for these patients which we believe will be decreasing the number of contraindications for VATS and offering this surgical method for more patients.

Modified uniportal video-assisted thoracoscopic lobectomy: Duke approach.

Traditional thoracoscopic strategies using two to four ports has been demonstrated to be oncologically successful for patients with resectable lung cancer, with numerous advantageous over thoracotomy. A single-incision approach has been described, but it is associated with potential disadvantages. The modified uniportal approach described may address those disadvantageous, with retention of the potential advantages of using a single incision.

Surgical excision for mediastinal synovial sarcoma with limited response to chemoradiotherapy.

Primary synovial sarcoma of the mediastinum is an exceedingly rare neoplasm. We describe a 31-year-old woman who had an incidental diagnosis of mediastinal mass. Histopathology and immunohistochemistry analysis confirmed the diagnosis of primary mediastinal synovial sarcoma. The patient underwent concurrent chemotherapy and radiotherapy, with minimal response radiologically. Resection was subsequently performed, with negative margins. The histopathologic examination revealed the diagnosis with a limited pathologic response. Because of the rarity of primary mediastinal synovial sarcoma, the optimal therapy is still unclear. We report this case of induction therapy followed by en bloc surgical resection.

Thoracoscopic pneumonectomy in management of histoplasmosis and fibrosing mediastinitis.

Pulmonary histoplasmosis is generally a self-limited respiratory illness in endemic areas. Fibrosing mediastinitis is a severe chronic complication of pulmonary histoplasmosis in which pulmonary vessels and airways can be compressed with the potential for life-threatening implications. We present a 50-year-old male patient who presented with a total occlusion of the left pulmonary artery due to fibrosing mediastinitis.

Enigmatic contralateral hemothorax after left thoracotomy.

Intrathoracic hemorrhage following surgical intervention that needs rethoracotomy has a low rate in the daily practice of thoracic surgery. Hemothorax in the contralateral site is definitely unexpected after thoracotomy. We present a case of contralateral hematoma after left posterolateral thoracotomy as a rare and enigmatic complication.

Thoracoscopic removal of a maternal mediastinal ectopic parathyroid adenoma causing neonatal hypocalcemia: a case report.

Most parathyroid glands in hyperparathyroidism can be resected through a cervical approach. In approximately 2% of cases, the ectopic gland is in the mediastinum in a location that requires a thoracic approach. Advancement in video-assisted thoracoscopic surgical (VATS) techniques has decreased the need for sternotomy to successfully remove these ectopic glands. We describe a case involving a 29-year-old woman with hyperparathyroidism resulting from an ectopic mediastinal parathyroid adenoma that caused neonatal hypocalcemia, which was removed through VATS.

Surgical treatment of pulmonary hydatid disease: a comparison of children and adults.

BACKGROUND: Hydatid cyst still remains an important health problem in our country as in many Mediterranean countries. The disease may affect children, and its treatment may be challenging in this age group. Surgery is the primary way of treatment. In the current study, the features unique to childhood pulmonary hydatid disease are emphasized. METHODS: Between 1992 and 2003, 301 patients were operated on because of pulmonary hydatid cyst in our hospital; 44 of them were 14 years or younger. They were categorized as pediatric patients. We retrospectively evaluated the clinical data of the patients. RESULTS: The mean age of the patients was 10.6 +/- 3.7 years (5-14 years) in children and 32.2 +/- 14 years (16-75 years) in adults. The rate of intact cyst was 71% in children and 57% in adults (P = .07). The mean diameter of the cyst was 8.5 +/- 3.1 cm (3-15 cm) and 6.6 +/- 3 cm (2-16 cm) in children and adults, respectively (P < .001). The rate of parenchyme-saving procedures was 84.1% in children, whereas 94.9% in adults. Lobectomy was performed in 16% of children, whereas it was performed in 1.5% of adults (P < .001). Morbidity rates were 13.6% in children and 11.6% in adults. No children but 1 adult died. Long-term follow-up revealed the recurrence rates as 4.5% in children and 4.3% in adults. CONCLUSIONS: Surgery, the primary method of treatment of hydatid cyst, is safe. Parenchyma-saving procedures such as cystotomy and capitonnage should be performed as much as possible. Nevertheless, hydatid cyst can reach relatively larger dimensions in children than in adults, which causes parenchyme destruction eventually leading to lung resection.