A Case Report of Resection of a Mediastinal Paraganglioma: Why All the Fuss?

Mediastinal paragangliomas are rare tumors that have only been reported in individual cases or limited case series. Surgical resection of these tumors can be challenging, as they are highly vascular and intimately related to the great vessels. Surgery is usually performed via median sternotomy with or without cardiopulmonary bypass. We present the case of a mediastinal paraganglioma that was resected via a left-sided posterolateral thoracotomy. Histopathology revealed a completely resected 38-mm paraganglioma with a positive station 5 lymph node, indicative of locally aggressive disease. Hereditary paragangliomas are associated with malignant transformation; therefore, genetic testing is important. These tumors do not respond well to chemoradiotherapy, and consequently lifelong surveillance for early detection of recurrence is recommended.

USO1 expression is dysregulated in non-small cell lung cancer.

Background: USO1 vesicle transport factor (USO1) is a vesicular transport factor crucial for endoplasmic reticulum (ER) to Golgi transport and is required for transcytotic fusion and subsequent binding of the vesicles to the target membrane. USO1 has been studied in multiple cancers revealing high levels of expression and exerting its oncogenic role by increasing cell proliferation and evasion of apoptosis. Furthermore, multiple studies have implicated dysregulation of the Erk signalling pathway in the involvement of USO1 in multiple cancers. Overall survival (OS) in non-small cell lung cancer (NSCLC) remains low despite recent advances in treatments which are mainly due to the late stage of diagnosis and a significant cohort of patients lacking an available targeted therapy. The aim of this study was to investigate USO1 expression in NSCLC. Methods: An in-house NSCLC tissue microarray (TMA) comprising (n=204 patients) was stained for USO1. Scoring intensity (H score) was used to interrogate for correlations between USO1 expression and established prognostic factors, and OS. Further evaluation of the expression of USO1 in NSCLC was done using multiple online datasets including Lung Cancer Explorer (LCE), UALCAN, GEPIA, KM plotter, TIMER2 and MuTarget. Results: USO1, when highly expressed in lung adenocarcinomas (LUADs) leads to a significantly increased OS (P=0.028). There was no significant correlation between age, smoking status, lymph node status, tumour subgroup and stage. USO1 was significantly higher in patients with tumour size <5 cm compared to those ≥5 cm (P=0.016). Overexpression in LUAD occurred at an early stage being significantly upregulated in Stage 1 and N0 tumours. USO1's first neighbours, also involved in ER-Golgi transport have altered expression in LUAD and significantly impact overall survival. Overexpression occurred independently of commonly mutated genes in NSCLC and had no correlation with changes in the TME. Conclusions: This study highlights the importance of USO1 and ER-Golgi vesicular transport system in LUAD. USO1 overexpression occurs as an early event in LUAD and independently of commonly mutated genes in NSCLC and therefore may represent an attractive diagnostic biomarker as well as a potential target for treatment.

Thoracic Surgical Oncology: Maintaining a High-Volume Surgical Program During the COVID-19 Pandemic.

Thoracic surgical oncology is a time-sensitive, high-resource, complex surgical speciality to which coronavirus has posed a unique challenge. In response to the evolving situation in mainland Europe, our department rapidly established a coronavirus disease 2019-free site to maintain elective cancer surgery. This necessitated a strict admission pathway and perioperative patient management. It resulted in the maintenance of a high-volume, high-quality thoracic surgical oncology program with no coronavirus disease 2019-positive cases to date. Maintaining satisfactory training levels among surgical and anesthetic trainees has also been achieved. We suggest that this model could be adapted to local resource capabilities.

A pulmonary mass with invasion into the heart.

We describe the case of a 58 year old woman who presented with bronchial atypical carcinoid found at surgery to invade the left atrium along the pulmonary veins. A right pneumonectomy and removal of a portion of the left atrium was performed. The patient made an excellent post operative recovery. Three years later she presented in acute respiratory failure secondary to local recurrence. This is first case described in which recurrence after resection of bronchial carcinoid metastatic to the heart is described.

Traumatic aortic transection: evidence for the osseous pinch mechanism.

Acute traumatic transection of the thoracic aorta is most commonly seen in vehicular trauma and is generally accepted to be due to differential deceleration. A second mechanism is proposed for this injury and that is the osseous pinch mechanism. We report a case where aortic transection occurred due to a crush injury and supports the latter mechanism.

Prognostic impact of vascular and lymphovascular invasion in early lung cancer.

BACKGROUND: The prognostic significance of vascular and lymphatic invasion in non-small-cell lung cancer is under continuous debate. We analyzed the effect of tumor aggressiveness (lymphatic and/or vessel invasion) on survival and relapse in stage I and II non-small-cell lung cancer. METHODS: We retrospectively analyzed prospectively collected data of 457 patients with stage I and II non-small-cell lung cancer from 1998 to 2008. Specimens were analyzed for intratumoral vascular invasion and lymphovascular space invasion. Overall survival and disease-free survival were estimated using the Kaplan-Meier method, and differences were determined by the logrank test. Cox regression analysis was performed to identify independent risk factors. RESULTS: The incidence of intratumoral vascular invasion was 23.4%, and this correlated significantly with grade of differentiation, visceral pleural involvement, lymphovascular space invasion, and N status. The incidence of lymphovascular space invasion was 5.5%, and this correlated significantly with grade of differentiation, lymph nodes involved, and intratumoral vascular invasion. On multivariate analyses, intratumoral vascular invasion proved to be an significant independent risk factor for overall survival but not for disease-free survival. Lymphovascular space invasion was associated significantly with early tumor recurrence but not with overall survival. CONCLUSIONS: Vascular and lymphatic invasion can serve as independent prognostic factors in completely resected non-small-cell lung cancer. Intratumoral vascular invasion and lymphovascular space invasion in early stage non-small-cell lung cancer are important factors in overall survival and early tumor recurrence. Further large scale studies with more recent patient cohorts and refined histological techniques are warranted.

Case report and literature review: surgical treatment of a right atrial metastatic melanoma from a previously resected "advanced" primary site with regional lymph nodes involvement.

Although melanoma of the right atrium is a rare cardiac tumor, melanoma in general has a high propensity to involve the heart. Unfortunately, however, when the tumor is involving the heart, widespread metastasis ensues and hence surgery becomes a questionable option. We report a case of a young female who presented with an advanced skin primary melanoma and regional lymph node involvement and a metastasis into the right atrium. Postoperatively tumor dissemination was controlled with adjuvant chemotherapy. A vigorous attempt aiming at tumor clearance followed by adjuvant multimodality therapy along with a tumor surveillance program may improve survival even in advanced cases.

Gender influence in isolated coronary artery bypass graft surgery: a propensity match score analysis of early outcomes.

INTRODUCTION: The female gender has been shown as high-risk factor for mortality and morbidity. We sought to assess the influence of female gender on coronary artery bypass graft (CABG) surgery from our own experience. METHODS: This is a retrospective analysis of prospectively collected database from a single centre. Patients were grouped according to gender and potential differences in pre-operative, intra-operative and post-operative factors were explored. Significant high-risk factors were then fitted in a multivariate model to account for differences in predicting gender influence on surgical outcomes. RESULTS: Two thousand eight hundred and four consecutive patients underwent isolated first-time CABG between February 2000 and December 2008; 562 (20%) patients were females. Pre-operatively, females were more likely to have significant comorbidities (age, congestive cardiac failure, hypercholesterolemia, hypertension, ischemic heart disease, peripheral vascular disease, pre-op arrhythmias, small body surface area and poor ejection fraction (p < 0.001)) consistent with higher Euroscore (p > 0.0001) and more urgent surgery (p < 0.002). Intra-operatively, they showed less extent pattern of disease requiring less bypass and cross-clamp time (p < 0.001). Observed surgical mortality was significantly higher in females (3.6 vs. 2.1%, p < 0.042); however, after adjusting for propensity score and significant factors identified in multivariate models, females only independently predicted a higher wound infection, lower neurological complications, lower rate of re-sternotomy, longer hospital stay and post-surgery stay (p < 0.01). CONCLUSIONS: Despite higher risk profile and higher observed surgical mortality, early outcomes in females were similar to their matched males' counterpart in isolated CABG surgery. Females were associated with higher incidence of wound infections but lower rate of neurological complications.

Propensity analysis of outcome in coronary artery bypass graft surgery patients >75 years old.

PURPOSE: We looked at the complications and hospital resources of an elderly population undergoing first-time isolated coronary artery bypass graft surgery (CABG) in comparison to a younger counterpart for a propensity matched cohort. METHODS: A retrospective analysis of prospectively collected data was conducted on 2804 CABG patients. Two age groups, >75 years and ≤75 years, were generated. Potential differences in demographic, baseline, preoperative, and intraoperative characteristics were investigated. A propensity score based on these differences was calculated and used to create a matched set of patients. Major postoperative complications were recorded, and data on indicators of resource utilization were collected. RESULTS: In all, 311 (11.1%) patients were identified as >75 years of age. The observed complication rate was significantly higher in overall, pulmonary, cardiac, renal, gastrointestinal (GI), neurological, infective, and mortality categories (P < 0.0001). Observed hospital resource utilization was significant in the elderly group in terms of initial stay in the intensive care unit (ICU) and ICU readmission (P < 0.05) and in all preoperative, postoperative, cardiac surgery, and total hospital stays (P < 0.001). However, after propensity matching to 311 patients ≤75 years, the overall postoperative complication rate maintained its significance (P < 0.0001), in addition to atrial fibrillation and neurological, renal, and GI complications (P < 0.05). Elderly patients required longer duration of ventilation postoperatively and longer postoperative stay, cardiac surgery stay, and total hospital stay; and they maintained a higher surgical mortality rate (6.1% vs. 2.6%) (P < 0.05). CONCLUSION: Elderly patients undergoing CABG had significantly higher rates of postoperative complications. Their prolonged hospital stay and consequently higher resources utilization need to be adequately highlighted to heath care officials and appropriately addressed.

Should cardiac surgery be delayed among carriers of methicillin-resistant Staphylococcus aureus to reduce methicillin-resistant Staphylococcus aureus-related morbidity by preoperative decolonisation?

OBJECTIVES: Preoperative methicillin-resistant Staphylococcus aureus (MRSA) carriage is associated with higher rates of postoperative MRSA infection. Carriage can be eradicated but this requires delaying surgery, which presents a dilemma when the surgery is urgent. We analysed the incidence of preoperative MRSA carriage and the impact on postoperative outcomes in a cardiac surgery population. PATIENTS AND METHODS: Patient data were collected prospectively from 2000 to 2007 (n=3789). MRSA screening is performed at a preadmission clinic for elective patients and on admission to the hospital for all patients. Three groups of MRSA carriers were identified: patients who were identified as carriers at a preadmission clinic (n=22, group 1), patients whose admission screening was positive but where the result was received postoperatively (n=103, group 2) and patients who acquired an MRSA infection or colonisation more than 48 h after admission (n=60, group 3). RESULTS: MRSA eradication measures prior to admission were successful in 21 of 22 in group 1 (95.4%). There were no MRSA infections in group 1. However, in group 2 there were 11 patients with an MRSA infection (10%) even though eradication measures were started on confirmation of carriage. In group 3, 19 of the 60 patients had an MRSA infection. The intensive care stay and mortality were significantly greater in groups 2 and 3 than in group 1 or compared with the overall patient population. However, groups 2 and 3 also had a significantly higher risk profile (European System for Cardiac Operative Risk Evaluation (EuroSCORE)). When matched with similar risk patients, patients in groups 2 and 3 had mortality outcomes that were consistent with matched risk patients. CONCLUSION: Patients who were MRSA carriers were older, more likely to have been on haemodialysis and to have been admitted from another hospital and underwent more complex surgical procedures. Carriage of MRSA was associated with a very high rate of MRSA infection, particularly among patients with diabetes. This suggests that delaying surgery may be warranted in patients expected to require implantation of prosthetic material such as valves, especially with diabetes. However, the survival outcomes for MRSA carriers are determined by their EuroSCORE rather than their MRSA status. This suggests that urgent cardiac surgery should not be delayed in patients with MRSA carriage.