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.

Detection of type III effector-induced transcription factors that regulate phytohormone content during symbiosis establishment in soybean.

Soybean is a pivotal protein and oil crop that utilizes atmospheric nitrogen via symbiosis with rhizobium soil bacteria. Rhizobial type III effectors (T3Es) are essential regulators during symbiosis establishment. However, how the transcription factors involved in the interaction between phytohormone synthesis and type III effectors are connected is unclear. To detect the responses of phytohormone and transcription factor genes to rhizobial type III effector NopAA and type III secretion system, the candidate genes underlying soybean symbiosis were identified using RNA sequencing (RNA-seq) and phytohormone content analysis of soybean roots infected with wild-type Rhizobium and its derived T3E mutant. Via RNA-seq analysis the WRKY and ERF transcription factor families were identified as the most differentially expressed factors in the T3E mutant compared with the wild-type. Next, qRT-PCR was used to confirm the candidate genes Glyma.09g282900, Glyma.08g018300, Glyma.18g238200, Glyma.03g116300, Glyma.07g246600, Glyma.16g172400 induced by S. fredii HH103, S. fredii HH103ΩNopAA, and S. fredii HH103ΩRhcN. Since the WRKY and ERF families may regulate abscisic acid (ABA) content and underlying nodule formation, we performed phytohormone content analysis at 0.5 and 24 h post-inoculation (hpi). A significant change in ABA content was found between wild Rhizobium and type III effector mutant. Our results support that NopAA can promote the establishment of symbiosis by affecting the ABA signaling pathways by regulating WRKY and ERF which regulate the phytohormone signaling pathway. Specifically, our work provides insights into a signaling interaction of prokaryotic effector-induced phytohormone response involved in host signaling that regulates the establishment of symbiosis and increases nitrogen utilization efficiency in soybean plants.

The efficacy of high-frequency jet ventilation on intraoperative oxygen saturation compared to cross-field ventilation in patients undergoing carinal resection and reconstruction.

Background: Cross-field ventilation is used as a conventional choice during carinal resection and anastomosis, but may interfere with surgical procedures. High-frequency jet ventilation (HFJV) allows for control of oxygenation in the open airways; nevertheless, there is a paucity of data to support its benefits versus cross-field ventilation. Herein, we aimed to investigate the efficacy of HFJV on intraoperative oxygen saturation compared with cross-field ventilation in patients undergoing carinal surgeries. Methods: We conducted a retrospective analysis of 82 adults who underwent carinal resection and reconstruction (CRR) for benign or malignant diseases and received cross-field ventilation or HFJV at Shanghai Chest Hospital between January 2018 and September 2021. Patients were excluded when they had emergency surgeries or critical airway stenosis requiring extracorporeal life support, or limited resection without the need for cross-field ventilation or HFJV. Patients were classified into two groups based on the airway approach: cross-field ventilation group and HFJV group. The primary outcome was the area under the curve (AUC) of intraoperative hypoxemia defined as peripheral oxygen saturation (SpO2) below 90% lasting at least 1 minute. The secondary outcomes included cumulative time of SpO2 below 90%, AUC and cumulative time of severe intraoperative hypoxemia (defined as SpO2 below 80% lasting at least 1 minute), and AUC and cumulative time of suboptimal SpO2 (defined as SpO2 below 95% lasting at least 1 minute). Results: Thirty-two patients were included in the final analysis, with 22 patients in cross-field ventilation group and 10 patients in HFJV group. The two groups did not differ in the severity and duration of intraoperative hypoxemia (P=0.366). The median (IQR) AUC of SpO2 below 90% was 21.92 (4.28, 54.48) min in cross-field ventilation group and 28.93 (10.78, 199.89) min in HFJV group. The cumulative time of SpO2 <90% was 16.67 (4.46, 37.11) min in cross-field ventilation group and 19.32 (7.50, 121.24) min in HFJV group, without statistical difference between groups (P>0.05). Severe intraoperative hypoxemia did not occur in either group. Conclusions: This retrospective case series demonstrates that HFJV can be adopted to maintain oxygenation in CRR, without the interruption of surgical procedure.

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.