[Predictive model for additional intraoperative placement of chest drainage after thoracoscopic lobectomy]. / Prognosticheskaya model' dlya dopolnitel'noi intraoperatsionnoi ustanovki plevral'nogo drenazha pri torakoskopicheskoi lobektomii.

OBJECTIVE: To create a prognostic model determining the risk of tension pneumothorax and the need for intraoperative installation of additional drainage after thoracoscopic lobectomy. MATERIAL AND METHODS: A retrospective multiple-center study included patients who underwent thoracoscopic lobectomy for lung cancer between 2016 and 2022. One drainage tube was used after surgery in all cases. We synthesized data to expand patient selection using the Riley method and machine learning algorithm. In total, treatment outcomes in 1458 patients were analyzed. After identifying significant factors, we performed binary logistic regression analysis using backward stepwise inclusion of variables in accordance with the Akaike information criterion. After validating the model using the Bootstrap method (400 iterations) and original data set, we created a nomogram determining scoring characteristics, linear predictors and risk of postoperative tension pneumothorax. RESULTS: The incidence of tension pneumothorax was 4.53% (n=66). The most significant variables associated with pneumothorax and the need for additional pleural drainage were adhesions, intraoperative lung suturing, unclear interlobar groove, enlarged intrapulmonary lymph nodes and chronic obstructive pulmonary disease (p<0.001). The model's C-index was 0.957, mean absolute calibration error - 0.6%, calibration curve slope - 0.959. A score of 26 indicated a 95% risk of postoperative pneumothorax. CONCLUSION: We developed a prognostic model for tension pneumothorax after thoracoscopic lobectomy. Nomogram makes it possible to make a decision on intraoperative installation of additional pleural drainage tube and prevent complications associated with postoperative lung collapse.

[Intraoperative and early surgical complications after VATS lobectomy]. / Intraoperatsionnye i rannie khirurgicheskie oslozhneniya pri torakoskopicheskikh lobektomiyakh.

OBJECTIVE: To improve the results of thoracoscopic anatomic lung resections (lobectomy) via reducing the incidence of intraoperative and early surgical complications. MATERIAL AND METHODS: The study enrolled 479 patients who underwent thoracoscopic lobectomy. We determined the main criteria of complications: injury of vascular structures with severe bleeding, damage of the bronchi and adjacent organs. RESULTS: Potentially life-threatening conditions requiring additional surgical manipulations (bleeding in 35 patients, bronchial trauma in 3 patients) were diagnosed in 7.9% (38/479) of cases. Vascular injury with severe bleeding occurred in 7.3% of patients (n=35). Three patients had bronchial trauma (7.9%). We stopped bleeding without thoracotomy in 48.5% (17/35) of patients. In 51.5% (18/35) of cases, emergency thoracotomy was performed. CONCLUSION: The problem of safety is still urgent despite widespread thoracoscopy in lung resections. Knowledge of the factors contributing to complications and working out appropriate algorithm of actions are of great importance.

[Surgical treatment of lung cancer in patients over 75 years old]. / Khirurgicheskoe lechenie raka legkogo u bol'nykh starshe 75 let.

OBJECTIVE: To analyze surgical treatment of lung cancer in patients over 75 years old. MATERIAL AND METHODS: The study enrolled 73 patients. Lobectomy was performed in 50 (68.5%) patients, segmentectomy - 14 (19.2%), pneumonectomy - 4 (5.5%), bilobectomy - 3 (4.1%), wedge resection - 2 (2.7%) patients. The most common clinical scenario was lobectomy for lung adenocarcinoma stage I. Metastases in lymph nodes were noted in 32.9% of cases. Among 9 patients with pN2 (12.9%), lesion of mediastinal lymph nodes was preoperatively diagnosed in 4 (44%) cases. Mean tumor size was 3 (1-14) cm. RESULTS: Overall morbidity was 16.4%, mortality 5.5%. Multivariate analysis revealed the most significant risk factors such as stage IIIb (OR 9.3, 95% CI 1.365-63.816, p=0.023), pN1 (OR 3.889, 95% CI 1.008-14.999, p=0.049), pN2 (OR 5.300, 95% CI 1.170-23.999, p=0.030), central cancer (OR 7.572, 95% CI 1.742-32.884, p=0.007). CONCLUSION: Surgical treatment of lung cancer patients over 75 years old may be completed safely and effectively in careful preoperative selection of patients. The most important risk factors of postoperative complications are cancer stage IIIb stage, lymph node lesion and central cancer.

[Diagnostic clinical algorithm for mediastinal tumors]. / Klinicheskii algoritm diagnostikii i lecheniya opukholei sredosteniya.

OBJECTIVE: To optimize therapeutic and tactical algorithm in patients with mediastinal tumors. MATERIAL AND METHODS: The study included 300 patients with mediastinal tumors examined and treated in the Thoracic Surgery Department of the Hertzen Moscow Cancer Research Center between 2008 and 2019. Patients were stratified into 2 groups. The diagnostic group consisted of 160 patients including 80 ones after 89 ultrasound-assisted transthoracic biopsies and 80 patients after open biopsy through parasternal mediastinotomy. The treatment group consisted of 140 patients who underwent 145 resections of mediastinal tumors. We analyzed the results of diagnosis and treatment in both groups, mistakes, risk factors of non-informative biopsies and complicated course of the postoperative period. Subsequently, a clinical algorithm was developed. Its effectiveness in 50 patients was compared with 90 patients who constituted the historical control group. RESULTS: The final histological diagnosis after transthoracic ultrasound-assisted biopsy of the mediastinum was established in 71 out of 89 cases (80%). Informative value of ultrasound-assisted biopsy for thymic tumors was 100%, for metastatic mediastinal lesions - 92%. Repeated ultrasound-assisted biopsies were performed in 7 (9%) patients that made it possible to establish the final diagnosis in 5 (71%) cases. In the parasternal mediastinotomy group, the final correct histological diagnosis was made in 79 out of 80 (99%) patients. Analyzing thoracoscopic approach and traditional sternotomy or thoracotomy, we found surgery time decrease from 187 (150-215) to 140 (122-165) min (p<0.01), blood loss from 300 (200-350) to 50 (35-150) ml (p<0.01), postoperative hospital-day from 12 (9-14.5) to 7 (6-8) days (p<0.01). Mean dimension of tumor was 5 (4-6) cm in the thoracoscopy group and 7.5 (6-10) cm in the open surgery group (p<0.01). Postoperative complications occurred in 19 (13%) patients, mortality rate was 2.8%. Multivariate analysis revealed superior vena cava syndrome (OR=5.1, 95% CI=1.246-21.343; p=0.024) and invasion of the right pleural cavity (OR 4.2, 95% CI 1.12-7.69; p=0.006) as the most significant predictors of postoperative complications. The proposed algorithms made it possible to reduce the incidence of non-informative biopsy from 12% to 0% (p<0.05), misdiagnosis from 9% to 1% (p<0.05), exploratory surgeries from 23% to 0% (p<0.05). CONCLUSION: The developed algorithm is valuable to avoid the errors and improve the results of diagnosis and treatment of patients with mediastinal tumors.

[Hemangioendothelioma of the right innominate vein]. / Gemangioendotelioma pravoi plechegolovnoi veny.

The authors report a rare case of hemangioendothelioma of the right innominate vein complicated by superior vena cava syndrome. Considering development of enlarged venous collaterals, we performed circular resection of superior vena cava together with the right and left innominate veins without replacement. There were no postoperative complications. The use of vascular prosthesis in patients with long-standing superior vena cava compression and enlarged collaterals is associated with high risk of thrombosis and subsequent pulmonary embolism. Safe circular resection of superior vena cava without replacement is possible after intraoperative test clamping.

[Rethymectomy in patients with myasthenia gravis and recurrent thymoma]. / Retimektomiya u bol'nykh miasteniei i retsidivom opukholi vilochkovoi zhelezy.

OBJECTIVE: To analyze efficacy and safety of rethymectomy in patients with pathology of thymus. MATERIAL AND METHODS: Nine patients (2 males and 7 females) underwent rethymectomy in the thoracic surgery department of the Hertzen Research Institute of Oncology for the period from March 2009 to December 2019. Initial thymectomy for myasthenia gravis was performed in 6 patients, for thymoma without myasthenia - in 3 patients. Age of patients varied from 27 to 75 years (median 42.8 years). Myasthenia manifested at the age of 25-61 years (median 29.2 years). Period between manifestation and thymectomy varied from 6 to 24 months (median 12.6 months). MGFA grade IIIa was in 1 patient, grade IIIb - in 1, grade IVa - in 1, grade IVb - in 2, grade V - in 1 patient. Rethymectomy was performed via sternotomy in 4 cases, through thoracoscopy - in 5 patients. RESULTS: Postoperative complications occurred in 2 (22.2%) patients. Biopsy revealed residual thymic tissue in all patients. Median follow-up after rethymectomy was 30.2 months (range 12-132 months). Complete stable remission was achieved in 3 (50.0%) patients, remission - in 2 cases, partial remission - in 1 patient. Median dose of steroids before rethymectomy was 40 mg (range 16-96 mg), median dose after rethymectomy - 8 mg (range 0-24 mg). Differences were significant (p=0.04). All patients operated on for thymoma or recurrence are alive within 12-124 months after rethymectomy. CONCLUSION: Rethymectomy is a safe and effective treatment option for patients with refractory myasthenia gravis (especially in case of detected residual thymic tissue) or recurrent thymoma. Radical surgery for recurrent thymoma ensures favorable survival.

[Solitary fibrous tumor of pleura (symptoms, diagnosis, treatment)]. / Solitarnaya fibroznaya opukhol' plevry (klinika, diagnostika, lechenie).

OBJECTIVE: Optimization of diagnosis and treatment of patients with solitary fibrous tumor of pleura, analysis of overall survival and disease-free survival, predictors of recurrence. MATERIAL AND METHODS: There were 66 patients with solitary fibrous tumor of pleura (26 men and 40 women) aged 57.6 years (range 26-80 years). Asymptomatic course was found in 29 (44%) patients, various symptoms - in 37 (56%) patients. Thoracotomy was applied in 36 patients, thoracoscopy - in 30 patients. Immunohistochemical examination included analysis of definition of Stat6 expression. RESULTS: Benign variant of SFT was diagnosed in 50 (75.7%) patients, malignant variant - in 16 (24.3%) patients. STAT6 expression was observed in all cases. Postoperative morbidity was 9%, mortality - 1.6%. Recurrence was diagnosed in 2 (4%) patients with benign variant of disease and in 5 (31.2%) patients with malignant variant (2 of them died from progression of disease). Progression-free survival was 89.4%, overall survival - 95.4%. Predictors of recurrence are tumor dimension over 10 cm, necrosis and/or hemorrhagic component of tumor, mitotic count of at least four per 10 high-power fields. CONCLUSION. S: Olitary fibrous tumor of pleura is a rare mesenchymal fibroblastic neoplasm growing from submesothelial layer. Differential and preoperative morphological diagnosis of SFT is difficult and demands a special immunohistochemical examination with analysis of Stat 6 expression. Surgery is preferred for tumor de novo and recurrent neoplasm.

[Segmentectomy in patients with primary pulmonary malignancies]. / Segmentéktomiia pri pervichnykh zlokachestvennykh opukholiakh legkikh.

OBJECTIVE: To analyze immediate and long-term results of anatomical resections for lung cancer with subsequent comparison of the results of segmentectomy and lobectomy in patients with peripheral NSCLC stage IA1-2. MATERIAL AND METHODS: There were 52 sublobular anatomical resections of the lung for peripheral non-small cell carcinoma and carcinoid T1a-bN0M0, IA1-2 stage. 3D-CT reconstruction with separation of bronchial and vascular structures was used to schedule complex segmentectomy. We retrospectively analyzed 200 patients with cT1a-bN0M0 peripheral non-small cell lung cancer (NSCLC) and tumor dimension ≤2 cm who underwent lobectomy (n=148) and segmentectomy (n=52). Mortality, morbidity and overall 5-year survival were compared in two propensity score matched groups (46 pairs, segmentectomy vs. lobectomy). RESULTS: There was no mortality in both groups. Morbidity was similar after segmentectomy and lobectomy (8.69 and 6.52%; p=0.32). 3D-CT with separation of bronchial and vascular structures enabled surgeons to perform atypical segmentectomies and VATS procedures more often (from 13.5 to 31.3%; p>0.05 and from 11.5 to 50.0%; p<0.05). Five-year survival was 82 and 86% (p=0.652) after segmentectomy and lobectomy, respectively. CONCLUSION: Postoperative results and long-term outcome after segmentectomy and lobectomy are comparable in patients with NSCLC cT1a-bN0M0, stage IA1-2. Segmentectomy is advisable surgery in patients with low pulmonary capacity and severe comorbidities.

[Lymphatic malformation of cervical-supraclavicular area with large mediastinal component]. / Limfaticheskaia mal'formatsiia sheino-nadkliuchichnoi oblasti s mediastinal'nym komponentom bol'shikh razmerov.

Lymphatic malformation (LM) is a benign neoplasm that consists of abnormally formed lymphatic vessels and cavities. The incidence of LM is 6% among all benign tumors. Mediastinal localization is extremely rare, only case reports in adults are described. Clinical observation of 42-year-old patient with LM of cervical-supraclavicular area and large mediastinal component communicating with thoracic lymphatic duct is presented. The first stage was thoracoscopic clipping of thoracic lymphatic duct, the second one - radical surgery through combined cervico-sterno-thoracotomy.

[Pulmonary metastases: classification and the need for staging?] / Legochnye metastazy: klassifikatsiia i neobkhodimost' stadirovaniia?

AIM: To analyze pulmonary metastases classifications which are used in Russian and foreign literature at present time. MATERIAL AND METHODS: It is proposed the variant of pulmonary metastases staging depending on quantitative and regional prevalence of the process. RESULTS: The development of pulmonary metastases classification is advisable to determine homogeneous subgroups of patients with metastatic lesion for prospective randomized trials in order to obtain objective results about the results of surgical or other local treatment of patients with intrapulmonary metastases.

[Regional and peripheral blockades for prevention of chronic post-thoracotomy pain syndrome in oncosurgical practice]. / Primenenie regionarnykh i perifericheskikh blokad dlia profilaktiki khronicheskogo posttorakotomicheskogo bolevogo sindroma v onkokhirurgicheskoi praktike.

AIM: To compare an effectiveness of thoracic epidural anesthesia/analgesia, paravertebral and intercostal blockades in prevention of chronic post-thoracotomy pain syndrome (CPTPS) in oncosurgery. MATERIAL AND METHODS: There were 300 patients who underwent open surgery including lobectomy or pneumonectomy. Patients were randomized into 3 groups depending on type of anesthesia: TEA (n=100) - combined general and epidural anesthesia; PVB (n=50) - combined general and paravertebral anesthesia; ICB (n=50) - general anesthesia was supplemented by intercostal blockade after removal of the drug. RESULTS: CPTPS incidence was 34 and 40% in 6 months postoperatively after PVB and ICB, respectively (p>0.05). In TEA group this value was significantly lower compared with ICB group (23%, p<0.05). CONCLUSION: TEA contributes to significant reduction of CPTPS incidence, while paravertebral blockade does not affect the frequency of this complication.

[Surgery for non-small cell lung carcinoma after previous chemoradiotherapy alone]. / Operatsii u bol'nykh nemelkokletochnym rakom legkogo posle samostoyatel'noi khimioluchevoi terapii.

AIM: To investigate early and remote results of surgery in patients with recurrent non-small cell lung carcinoma (NSCLC) after previous chemoradiotherapy alone. MATERIAL AND METHODS: The retrospective study included 14 NSCLC patients (10 men and 4 women, mean age 52.6 years) who were operated in thoracic department for the period June 2008 - December 2013. Histologically squamous cell carcinoma prevailed (64.3%). Prior to surgery stage IIB was diagnosed in 2 patients, IIIA in 11 and IIIB in 1 patient. The dose of radiotherapy ranged from 45 to 70 Gr (median 58Gr). The average number of chemotherapy cycles was 3.8 per patient. Pneumonectomy was performed in all patients except one who underwent left-sided lower lobectomy. In all cases bronchial stump was covered by vascularized muscle flap (intercostal, latissimus dorsi). Postoperative complications were classified by TMM system (Thoracic Morbidity and Mortality System). RESULTS: Postoperative complications were observed in 7 (50.0%) patients including level II in 2 cases, IIIA in 1 case, IVA in 3 patients and V (death) in 1 (7.1%) patient. Postoperative stages of lung cancer were IB in 2 cases, IIA in 1, IIB in 5, IIIA in 4 and IIIB in 2 patients. Overall 1, 2 and 3-year survival rate was 89.1%, 82.0% and 48.0% respectively (median 35.0 months). Recurrence-free survival was 84.2%, 72.0% and 24.8%, respectively (median 28.0 months). Overall and recurrence-free 5-year survival rate was 10.8%. CONCLUSION: «Salvage¼ surgery may be recommended as individual approach in patients with reccurent lung cancer after previous chemoradiotherapy.

[Analysis of postoperative complications after pneumo-n-ectomy using thoracic morbidity and mortality (tmm) system in nsclc patients for a 5-year period]. / Analiz posleoperatsionnykh oslozhnenii po sisteme TMM u bol'nykh nemelkokletochnym rakom legkogo posle pnevmonektomii za 5-letnii period.

AIM: Postoperative complications after pneumonectomy for NSCLC depend on the extension of surgery, comorbidities and accurate registration of any adverse event. The aim of the study was to evaluate the short-term results after standard and extended pneumonectomy in NSCLC patients according to the TMM grading system. MATERIAL AND METHODS: We included 216 NSCLC patients consecutively submitted to pneumonectomy at our institution from January 2009 to December 2013 in the retrospective study performed on data prospectively collected in an electronic clinical database. All patients were divided into two different groups: standard (n=142) and extended (n=74) pneumonectomy, where resection of adjacent organs was indicated. The patients undergone extended pneumonectomy were subdivided into single (n=49) and multi-organ resection (n=25) groups. Morbidity and mortality rate was analyzed according to the standard criteria and TMM classification system. RESULTS: Postoperative morbidity and mortality rate after standard pneumonectomy (23,9% and 3,5%) was significantly lower than extended procedure (43,2% and 10,8%) (p=0.02). Multi-organ resection was an independent prognostic factor of unfavourable outcome: morbidity and mortality was significantly higher in the multi-organ group (48,0% and 16,0%), while in the single-organ group it was 40,8% and 8,2% respectively (p=0.01). Major complications rate (grade IIIA and higher according to the TMM) was significantly higher in the multi-organ group (40,0%) than in the single-organ (28,6%) and standard (14,8%) group (p=0.01). CONCLUSION: TMM classification system is more accurate in grading and further analysis of postoperative complications after pneumonectomy in NSCLC patients in compare with standard criteria. Multi-organ resection should be carried out with caution due to unacceptable high morbidity and mortality rate.

[Lung-preserving surgical treatment of patients with bronchial carcinoid].

Isolated bronchus resection for central cancer was performed in 25 patients including preoperative bronchoscopic removal of exophytic tumor in 20 (80%) observations in thoracic department of P. Gertsen Moscow Research Cancer Institute. According to morphological study typical carcinoid was diagnosed in 23 (92%) patients, atypical - in 2 (8%) cases. All patients underwent conventional mediastinal lymphadenectomy. Postoperative complications after bronchus resection developed in 6 (33.3%) patients. There were no deaths. Overall 5- and 10-year survival was 100% and 96% respectively. The authors consider that by strict indications combination of endoscopic removal with isolated bronchus resection preserves all pulmonary parenchyma without prejudice for surgical radicalism.

[The mechanoreceptor tactile diagnostics of thoracic diseases].

The novel system of tactile analysis was used in the mechanoreceptor device. The local pressure measurement is carried out in in cameras, divided by the elastic membrane from the analyzed organ. The devise allows fast and adequate real-time measurement of tissue density and elasticity. The results, acquired with the use of the mechanoreceptor device were checked microscopically. The study showed high compatibility and adequacy of the novel mechanoreceptor.

[Endobronchial surgery and photodynamic therapy for the treatment of multiple primary lung cancer].

Endoluminal endoscopic surgery and fotodynamic therapy were used in treatment of 104 patients with multiple primary lung cancer (MPLC), or more exactly, of trachea and lobar and segmental bronchi. Diagnostic division included videobronchoscopy of high resolution in with light and NBI-regimen; autoflourescent and 5-ALA-induced fluorescent videobronchoscopy, endosonography, computed tompgraphy or magnetic resonance imaging of the thorax and epithelial mucine (MUC-1) immunohistochemical analysis of scarificates. Result of treatment strongly depended on the size of primary tumor. Complete regression of cancer was observed for all tumors less then 1 sm in diameter. Endoscopic treatment, including fotodynamic therapy and argon coagulation, proved to be a method of choice in treatment early synchronous or metachronous multiple primary lung cancer in incurable patients.

[Surgical treatment of metastatic lung lesions: state of art].

454 patients, aged 17-79 years, were operated on metastatic lung lesions during the period from 1970 to 2007 years. Overall 538 operations were performed, of them 40 bilateral lung resections, 33 patients were reoperated on the subject of recurrent lung metastases. Postoperative complications were registered in 44 (9,6%) patients. Lethality rate was 1,1%. Overall 5-year survival after solitary metastasis removal was 34,9+/-3,1%, after removal of several lesions the survival rate was 21,7+/-4,8%, and after operation on the subject of multiple lung metastasis the survival rate was 14,7+/-4,5%. The level of intrathoracic lymph nodes involvement and type of the performed surgery showed to be independent prognostic factors.