A Re-Examination of Neoadjuvant Therapy for Thymic Tumors: A Long and Winding Road.

For most patients with advanced thymic epithelial tumors (TETs), a complete resection is a strong indicator of a better prognosis. But sometimes, primary surgery is unsatisfactory, and preoperative therapy is needed to facilitate complete resection. Neoadjuvant chemotherapy is the most used form of preoperative therapy. But studies on neoadjuvant chemotherapy have included mainly patients with thymoma; its efficacy in patients with thymic carcinoma is less known. Neoadjuvant chemoradiation has also been explored in a few studies. Novel therapies such as immunotherapy and targeted therapy have shown efficacy in patients with recurrent/metastatic TETs as a second-line option; their role as preoperative therapy is still under investigation. In this review, we discuss the existing evidence on preoperative therapy and the insight it provides for current clinical practice and future studies.

Internal jugular vein pressure monitoring guided venous reconstruction could improve perioperative safety after superior vena cava resection for mediastinal tumors: a cohort study.

INTRODUCTION: After superior vena cava (SVC) resection, the decision on unilateral or bilateral reconstruction was mostly based on the expertise of surgeons without objective measurements. This study explored the use of internal jugular vein pressure (IJVP) monitoring to guide the SVC reconstruction strategy. METHODS: In a retrospective cohort, perioperative outcomes of unilateral and bilateral reconstruction based on surgeons' experience were compared. Then, IJVP threshold was measured when temporarily clamping the left innominate vein in a testing cohort. Venous reconstruction according to IJVP monitoring was performed in a prospective validation cohort afterward. Perioperative outcomes were compared between the prospective and the retrospective cohorts. For some interested variables, intuitive explanations would be given using Bayesian methods. Potential risk factors for postoperative complications were investigated by multivariable analysis. RESULTS: From March 2009 to September 2022, 57 patients underwent SVC reconstruction based on surgeons' experience. Bayesian analysis indicated a posterior probability of 80.49% that unilateral reconstruction had less blood loss than bilateral reconstruction (median 550 ml vs. 1200 ml). Cerebral edema occurred in two patients after unilateral reconstruction. In the testing cohort, median IJVP was 22.7 (18-27) cmH 2 O after temporary left innominate vein clamping in 10 patients. In the prospective cohort, unilateral reconstruction only was performed if the contralateral IJVP was <30 cmH 2 O in 16 patients. Bilateral reconstruction was performed if IJVP was ≥30 cmH 2 O after unilateral bypass in nine patients. No cerebral edema occurred in the prospective cohort. Less postoperative complications occurred in the prospective cohort than the retrospective cohort (12.0 vs. 38.6%, P =0.016). Upon multivariable analysis, IJVP-monitoring guided SVC reconstruction was associated with significantly less postoperative complications ( P =0.033). CONCLUSIONS: Intraoperative IJVP-monitoring is a useful strategy for selection of unilateral or bilateral SVC reconstruction and improving perioperative safety in patients with mediastinal tumors.

Evaluation of changes of cardiac morphology and function in fetuses with ductus arteriosus constriction by Speckle-tracking echocardiography.

Background: Premature ductus arteriosus constriction (DA Con) can result in right ventricular enlargement, right ventricular hypertrophy, and tricuspid regurgitation. Method: This study retrospectively analyzed 34 singleton fetuses that underwent fetal echocardiography with a diagnosis of DA Con (16 cases with mild to moderate, and 18 cases with moderate to severe) and 45 healthy fetuses. The morphology and function parameters of cardiac, as well as the 24-Segment of ventricles, were compared between the DA Con group and controls, and between the mild to moderate and moderate to severe groups, using the fetal heart quantification (FHQ) technology. Results: There were no significant difference in left ventricular parameters in DA Con group when compared to controls. Moreover, fetal 4CV-GSI was significantly reduced, as well as the sphericity index (SI), fractional shortening (FS), global longitudinal strain (GS) and fractional area change (FAC) of right ventricle, especially in the basal-middle segments. Compared with the mild to moderate group, LV-FS increased and RV-FS decreased in moderate to severe group. Conclusion: The results showed that the fetal heart in the DA Con group was different from the controls in morphology and function. FHQ technology provides a comprehensive assessment for the evaluation of cardiac morphological and functional changes in DA Con fetuses.

Minimally Invasive Thymectomy Could Be Attempted for Locally Advanced Thymic Malignancies: A Real-World Study With Propensity Score-Matched Analysis.

INTRODUCTION: Increasing evidence supports minimally invasive thymectomy (MIT) for early stage thymic malignancies than open median sternotomy thymectomy (MST). Nevertheless, whether MIT could be attempted for locally advanced disease remains unclear. METHODS: The clinical data of consecutive patients with stage T2-3NxM0 (eighth edition TNM staging) thymic malignancies who underwent MIT or MST were identified from a prospectively maintained database. The co-resected structures were rated with a resection index to evaluate surgical difficulty. The impact of surgical approach on treatment outcomes was investigated through propensity score-matched analysis and multivariable analysis. RESULTS: From January 2008 to December 2019, a total of 128 patients were included; MIT was initially attempted in 58 (45.3%) cases, and eight (13.8%) were converted to MST during surgery. The conversion group had similar perioperative outcomes to the MST group, except for a longer operation time. After propensity score matching, the resection index scores were similar between the MIT and MST groups (3.5 versus 3.7, p = 0.773). The MIT group had considerably less blood loss (p < 0.001), fewer postoperative complications (p = 0.048), a shorter duration of chest drainage (p < 0.001), and a shorter hospitalization duration (p < 0.001) than the MST group. The 5-year freedom from recurrence rate was not different between the two groups (78.2% versus 78.5%, p = 0.942). In multivariable analysis, surgical approach was not associated with freedom from recurrence (p = 0.727). CONCLUSIONS: MIT could be safely attempted in carefully selected patients with locally advanced thymic tumors. Conversion did not compromise the surgical outcomes. Patients may benefit from the less traumatic procedure and thus better recovery, with comparable long-term oncologic outcomes.

PLGA-Au-PFH-NPs-based Ultrasound Imaging in Detecting Fetal Spinal Deformities.

The study focused on the performance of ultrasound imaging in detecting fetal spinal deformities. First, the double emulsification method and the carbodiimide method were used to prepare the target Au-loaded nanorod phase-change nano-level contrast agent-PLGA-Au-PFH-NPs. After being characterized for physical and chemical properties, it was used in ultrasound imaging diagnosis. The results showed that the prepared PLGA-Au-PFH-NPs solution was a milky white suspension, the particle size detected by the laser particle sizer was (376.17±20.74) nm, and the Zeta potential was (-4.82±2.88) mV. Under the light microscope, it showed a spherical shape, uniform size distribution, and a very smooth surface. The encapsulation rate measured by the UV spectrophotometer was (80.63±4.82) %, and there was no significant difference in cell survival rate between different concentrations (P>0.05). Prenatal ultrasound in the observation group accurately diagnosed 10 cases with spinal deformities, and the diagnostic accuracy rate was 50%, including 5 cases of meningocele, 3 cases of invisible spina bifida, 1 case of myelomeningocele, and 1 case of hemivertebrae. In the control group, 7 cases were diagnosed correctly by conventional ultrasound, and the diagnosis accuracy rate was 35%, including 3 cases of meningocele, 3 cases of invisible spina bifida, and 1 case of hemivertebra. The diagnostic accuracy of the observation group was higher than that of the control group, and the difference was statistically significant (P<0.05). In conclusion, the prepared PLGA-Au-PFH-NPs had good physical and chemical properties. Ultrasound imaging based on the PLGA-Au-PFH-NPs had high accuracy in diagnosing fetal spinal deformities. To a certain extent, it provides a basis for clinical diagnosis of fetal spinal abnormality and some new ideas for ultrasound imaging diagnosis.

Electromagnetic bronchoscopy guided microwave ablation for early stage lung cancer presenting as ground glass nodule.

BACKGROUND: Patients with early-stage lung cancer are sometimes medically inoperable, and for patients with multiple primary lung cancers, surgical resection alone sometimes proves to be impractical. Local treatments like microwave ablation (MWA) are investigational alternatives for these patients. Most reported MWA procedures for lung cancers are performed percutaneously under CT guidance. MWA navigated by electromagnetic bronchoscopy (ENB) has been limitedly studied. In this study, we aimed to evaluate the safety and feasibility of MWA under ENB guidance in patients with inoperable early-stage lung cancers or multiple primary lung cancers which cannot be completely resected. METHODS: From June 2019 to December 2020, preliminary attempts of ENB-guided MWA were made in five medically inoperable patients with a single early-stage lung cancer and ten patients with multiple primary lung cancers which were difficult to resect at the same time. For patients with concomitant pulmonary nodules which needed surgical resection, thoracoscopic resections were performed following ENB-guided MWA. The safety, feasibility, and technique effectiveness of treatments were evaluated. RESULTS: ENB-guided MWA for 15 ground glass nodules (GGNs) in 15 patients was completed in accordance with the planned protocol. Biopsy of 13 GGNs showed malignancy. Five patients received simple ENB-guided MWA without simultaneous surgical resection and ten patients received simultaneous surgical resection for 13 concomitant pulmonary nodules. CT scan by the first postoperative week showed technique effectiveness of ablation for 11 nodules indicated for MWA. Four patients had mild complications after the procedure and recovered shortly after treatment. CONCLUSIONS: For medically inoperable patients with a single GGN manifesting early-stage lung cancer and patients with multiple primary early-stage lung cancers which cannot be resected at the same time, ENB-guided MWA might be a safe and feasible alternative local treatment, whether combined with surgical resection or not. However, large, prospective, randomized, multicenter studies are needed to confirm its role in the treatment of early-stage lung cancer.

Surgical resection of superior pulmonary sulcus tumor after neoadjuvant chemoradiation via the anterior transmanubrial approach: a case report.

Superior pulmonary sulcus tumor is a cancer arising in the apex of the lung that with potential invasion of the brachial plexus, upper ribs, vertebrae, subclavian vessels, and stellate ganglion. Induction concurrent chemoradiotherapy followed by radical surgical resection with lobectomy combined with any structures in the thoracic inlet invaded by tumor and thorough mediastinal lymph node dissection is the preferred treatment. Both anterior and posterior approaches are applied for resection. Here, we report a 61-year-old man with an 8.6 cm × 5.1 cm mass arising from the right upper lobe invading the apex of the chest wall. Brachial plexus magnetic resonance imaging suggested tumor invasion of the inferior trunk of the brachial plexus, anterior portion of the first 2 ribs, and suspicious involvement of the subclavian artery. Biopsy of the mass showed stage cT4N2M0, IIIB, poorly differentiated adenocarcinoma. The patient was treated by induction concurrent chemoradiotherapy, which was followed by surgical resection of the right upper lobe and the affected chest wall via the transmanubrial approach. The patient suffered prolonged postoperative air leak and empyema. After continuous chest tube drainage and intrapleural fibrinolytic therapy, he recovered well and was discharged safely. Final pathology showed no viable residue tumor, pathologic complete response of the tumor to induction treatment, a tumor size of 4.1 cm, and no lymph nodes; therefore, the final stage was ypT0N0M0. The transmanubrial approach is feasible for resection of tumor invading the branches of the subclavian artery; however, postoperative empyema which might have resulted from prolonged air leak should be carefully treated by meticulous air leak management.

The Feasibility and Safety of Routine Thoracic Surgeries in the Low-Risk Areas During the Coronavirus Disease 2019 Pandemic.

Coronavirus disease 2019 (COVID-19) has been under good control, and work resumption has been gradually carried out in most parts of the People's Republic of China including Shanghai after March 2020. However, intense focus and resources have been diverted to patients with COVID-19, leaving patients with diseases other than COVID-19 somehow neglected owing to limited access to routine health care. Furthermore, whether routine thoracic surgery service is safe in low-risk areas of COVID-19 infection is still unknown. We hereby retrospectively analyzed the quantity and quality of thoracic surgeries performed by a single team from the Shanghai Chest Hospital between January and May 2020, compared with the corresponding period in the past year. Results suggested that comparable qualities of diagnosis, surgical treatment, and perioperative outcomes were safely and successfully achieved. The total number of surgical procedures gradually increased and surpassed with that of the corresponding period in the past year when the situation of COVID-19 has been in good control in Shanghai by April. Importantly, neither medical staffs nor patients were diagnosed of having COVID-19 infection. In conclusion, although COVID-19 has made considerable impact on elective surgery for thoracic diseases, it is safe and feasible to carry out routine thoracic surgery services in low-risk areas, provided that careful screening of COVID-19 and thorough protection of medical staffs and patients are taken. It is hoped that these findings would serve as a useful reference for thoracic departments all over the world during the COVID-19 pandemic, especially after work resumption.

Comparison of fetal echocardiogram with fetal cardiac autopsy findings in fetuses with congenital heart disease.

OBJECTIVE: Although studies have compared fetal echo results with autopsy findings, investigations that compared multiple categories of congenital heart disease (CHD) are lacking. This study, therefore, aimed to compare fetal echocardiographic diagnoses with cardiac autopsy findings and evaluate the diagnostic accuracy of fetal echocardiography (FE). METHODS: One hundred seventy-one specimens from fetuses diagnosed with CHD were collected after termination of pregnancy, and fetal autopsies were performed. FE and autopsy diagnoses were compared and the degree of their correspondence was categorized as "complete agreement" (FE results were in accordance with autopsy findings), "minor discrepancies" (autopsies verified the main FE diagnoses but added and/or revised some minor information), or "discordance" (autopsy findings were different from the primary diagnoses of FE). RESULTS: The "complete agreement" group accounted for 87.1% (149/171) of the total specimens. In 11.7% (20/171) of cases, autopsies disclosed new deformities and/or revised some echo results (minor discrepancies group). Minor abnormalities were frequently embodied in small septal defects and vascular malformations. A rare malformation of common pulmonary vein atresia was confirmed by autopsy in two fetuses, but both were misdiagnosed by FE (discordance group). CONCLUSIONS: Fetal echocardiographic diagnoses were mostly consistent with autopsy findings. The diagnostic discrepancies mainly consisted of rare cases and minor abnormalities missed or misdiagnosed by FE. Autopsies may help confirm, modify, or add information to prenatal echo results. They may also help sonographers have a better understanding of the anatomic structures of CHD, especially for rare lesions, which could further improve the diagnostic accuracy and integrity of FE.

Laparoscopic bowel resection combined with infliximab treatment (LaRIC) versus infliximab for terminal ileitis in Crohn's disease: a randomised, controlled, open-label trial.

INTRODUCTION: Crohn's disease is a chronic inflammatory disease of the gastrointestinal tract with an increasing incidence and prevalence worldwide. The early use of anti--tumour necrosis factor agents, such as infliximab, in patients with an aggressive form of Crohn's disease has become part of routine practice. However, infliximab has limitations, and early surgery might benefit patients more. The objective of this study was to compare laparoscopic bowel resection with infliximab treatment in patients with moderately or severely active Crohn's disease with respect to endoscopic remission. The laparoscopic bowel resection combined with infliximab treatment trial is the first randomised controlled trial to demonstrate if early surgery can improve the outcome of patients with Crohn's disease with limited non-stricturing disease treated with infliximab. METHODS AND ANALYSIS: This is a randomised, open-label, controlled trial at Renji Hospital. In this study, a total of 106 adult patients aged 18-80 years with moderately or severely active and steroid-dependent or steroid-resistant Crohn's disease of the distal ileum will be randomly assigned in a 1:1 ratio to the control and surgery groups. The primary outcome is 12-month endoscopic remission measured by the Simple Endoscopic Score for Crohn's Disease in the control group and the Rutgeerts score in the surgery group. The secondary outcomes are clinical remission, surgery rate, quality of life, Crohn's disease-related medical costs and Crohn's disease-related morbidity. The patients will be followed up every 6 months after randomisation through intestinal magnetic resonance enterography and colonoscopy for either 3 years or until clinical remission. ETHICS AND DISSEMINATION: All participants will provide informed consent. The protocol has been approved by the Medical Ethical Committee of the Academic Medical Center in Shanghai (No KY2019-180). Results will be disseminated through peer-reviewed journals and scientific conference presentations. TRIAL REGISTRATION NUMBER: ChiCTR2000029323.

Prenatal diagnosis of left-sided aortic arch, right descending aorta and right-sided ductus arteriosus associated with anomalous origin of left pulmonary artery from ascending aorta.

Left-sided aortic arch (LAA), right descending aorta (rDAo), and right-sided ductus arteriosus (RDA) constitute a rare aortic arch anomaly. Moreover, anomalous origin of the pulmonary artery from the ascending aorta, especially that of the left pulmonary artery, is also a rare anomaly of the pulmonary artery branches. Because of the presence of the ductus arteriosus, prenatal ultrasound is an optimal diagnostic tool for the LAA with rDAo. Four-dimensional color Doppler can clearly demonstrate the spatial relationship between the LAA, rDAo, and RDA and the anomalous origin of the left pulmonary artery from the ascending aorta.

Diagnosis of double-chambered left ventricle by echocardiogram and cardiac magnetic resonance imaging: A rare case in an adult.

Double-chambered left ventricle (DCLV) is a very rare malformation which is congenital. In most cases, the left ventricle (LV) is divided into two parallel chambers by a septum or aberrant muscular structure, with fewer superior-inferior arrangement. Here, we present the case of an asymptomatic 25-year-old man who was diagnosed with superior-inferior arrangement DCLV on transthoracic echocardiography and cardiac magnetic resonance (CMR). DCLV generally does not cause serious outcomes. Owing to absence of any symptoms, no treatment was provided, and the patient was regularly followed up.

Prenatal diagnosis of tetralogy of Fallot associated with pulmonary artery sling: Two case reports.

Tetralogy of Fallot (TOF) is a common condition accounting for 10%-20% of all fetal cyanotic congenital heart disease cases. Pulmonary artery sling (PAS), or aberrant left pulmonary artery, is a rare congenital cardiovascular malformation. Approximately 58%-83% of PAS is associated with other cardiovascular malformations, TOF being rarest. The diagnosis of PAS is generally incidental or made at autopsy. Cases of prenatal diagnoses of TOF associated with PAS have not yet been reported. Here, we report two cases of TOF associated with PAS diagnosed prenatally in our hospital.