Fibrin sealant for esophageal anastomosis: A phase II study.

BACKGROUND: Esophagectomy is a pivotal curative modality for localized esophageal or esophagogastric junction cancer (EC or EJC). Postoperative anastomotic leakage (AL) remains problematic. The use of fibrin sealant (FS) may improve the strength of esophageal anastomosis and reduce the incidence of AL. AIM: To assess the efficacy and safety of applying FS to prevent AL in patients with EC or EJC. METHODS: In this single-arm, phase II trial (Clinicaltrial.gov identifier: NCT03529266), we recruited patients aged 18-80 years with resectable EC or EJC clinically staged as T1-4aN0-3M0. An open or minimally invasive McKeown esophagectomy was performed with a circular stapled anastomosis. After performing the anastomosis, 2.5 mL of porcine FS was applied circumferentially. The primary endpoint was the proportion of patients with AL within 3 mo. RESULTS: From June 4, 2018, to December 29, 2018, 57 patients were enrolled. At the data cutoff date (June 30, 2019), three (5.3%) of the 57 patients had developed AL, including two (3.5%) with esophagogastric AL and one (1.8%) with gastric fistula. The incidence of anastomotic stricture and other major postoperative complications was 1.8% and 17.5%, respectively. The median time needed to resume oral feeding after operation was 8 d (Interquartile range: 7.0-9.0 d). No adverse events related to FS were recorded. No deaths occurred within 90 d after surgery. CONCLUSION: Perioperative sealing with porcine FS appears safe and may prevent AL after esophagectomy in patients with resectable EC or EJC. Further phase III studies are warranted.

Comparison of Segmentectomy and Lobectomy in Stage IA Adenocarcinomas.

INTRODUCTION: Recent studies have suggested that segmentectomy may be an acceptable alternative treatment to lobectomy for surgical management of smaller lung adenocarcinomas. The objective of this study was to compare survival after lobectomy and segmentectomy among patients with pathological stage IA adenocarcinoma categorized as stage T1b (>0 to ≤20 mm) according to the new eighth edition of the TNM system. METHODS: In total, 7989 patients were identified from the Surveillance, Epidemiology, and End Results registry. Propensity scores generated from logistic regression on preoperative characteristics were used to balance the selection bias of undergoing segmentectomy. Overall and lung cancer-specific survival rates of patients undergoing segmentectomy and lobectomy were compared in propensity score-matched groups. RESULTS: Overall, 564 patients (7.1%) underwent segmentectomy. Lobectomy led to better overall and lung cancer-specific survival than segmentectomy for the entire cohort (log-rank p < 0.01). After 1:2 propensity score matching, segmentectomy (n = 552) was no longer associated with significantly worse overall survival (5-year survival = 74.45% versus 76.67%, hazard ratio = 1.09, 95% confidence interval: 0.90-1.33) or lung cancer-specific survival (5-year survival = 83.89% versus 86.11%, hazard ratio = 1.12, 95% confidence interval: 0.86-1.46) compared with lobectomy (n = 1085) after adjustment for age, sex, lymph node quantity, and histological subtype. Similar negative findings were identified when patients were stratified according to sex, age, histological subtype, and number of evaluated lymph nodes. CONCLUSIONS: Patients who underwent segmentectomy may have survival outcomes no different than those of some patients who received lobectomy for pathological stage IA adenocarcinomas at least 10 but no larger than 20 mm in size. These results should be further confirmed through prospective randomized trials.

Recent clinical innovations in thoracic surgery in Hong Kong.

The concept of personalized medicine, which aims to provide patients with targeted therapies while greatly reducing surgical trauma, is gaining popularity among Asian clinicians. Single port video-assisted thoracic surgery (VATS) has rapidly gained popularity in Hong Kong for major lung resections, despite bringing new challenges such as interference between surgical instruments and insertion of the optical source through a single incision. Novel types of endocutters and thoracoscopes can help reduce the difficulties commonly encountered during single-port VATS. Our region has been the testing ground and has led the development of many of these innovations. Performing VATS, in particular single-port VATS in hybrid operating theatre helps to localise small pulmonary lesions with real-time images, thus increasing surgical accuracy and pushes the boundaries in treating subcentimeter diseases. Such approach may be assisted by use of electromagnetic navigational bronchoscopy in the same setting. In addition, sublobar resection can also be more individualised according to pathologic tumour subtype that require rapid intraoperative diagnostic test to guide appropriate surgical therapy. A focus on technology and innovation for large tumours that require chest wall resection and reconstructions have also been on going, with new materials and prostheses that may be tailored to each individual needs. The current paper reviews the literature pertaining to the above topics and discusses recent related innovations in Hong Kong, highlighting the study results and future perspectives.

Prognostic impact of pattern-based grading system by the new IASLC/ATS/ERS classification in Asian patients with stage I lung adenocarcinoma.

OBJECTIVES: We examined the prognostic effect of the grading system based on the new IASLC/ATS/ERS classification in an Asian cohort of patients with early-stage lung adenocarcinoma. MATERIALS AND METHODS: Patients with a lung adenocarcinoma less than 3cm in diameter that had undergone complete anatomic resection, diagnosed with pT1a-2aN0M0 consecutively from 2004 to 2013, were enrolled. All specimens were reviewed according to the new IASLC/ATS/ERS classification. The growth patterns were divided into three major categories: grade 1 for lepidic growth, grade 2 for acinar and papillary patterns, and grade 3 for solid and micropapillary patterns. Each tumor was then graded according to the modified grading system, the final score being the sum of the two most predominant grades. The correlations of clinical and pathological factors with disease-free survival (DFS) and overall survival (OS) were evaluated. RESULTS: In total, 201 adenocarcinomas were eligible for score grading. Only 37 (18.4%) patients had a pure pathological growth pattern. Higher stage, greater tumor diameter, positive lymphovascular invasion, and a higher score were associated with shorter DFS. In contrast, stage no longer had a significant impact on OS in a multivariable analysis. Acinar/papillary-predominant tumors with a score of 3 or 4 were associated with better survival than those with a score of 5 (5-year DFS rate: 64.68 vs. 44.18%, HR=2.19, 95% CI: 1.24-3.87; 5-year OS rate: 85.61 vs. 68.59%, HR=3.03, 95% CI: 1.25-7.32). CONCLUSION: The architectural scores may help to stratify survival differences among certain predominant growth subtypes of adenocarcinoma.

Three-field vs two-field lymph node dissection for esophageal cancer: a meta-analysis.

AIM: To assess the effects of 3-field lymphadenectomy for esophageal carcinoma. METHODS: We conducted a computerized literature search of the PubMed, Cochrane Controlled Trials Register, and EMBASE databases from their inception to present. Randomized controlled trials (RCTs) or observational epidemiological studies (cohort studies) that compared the survival rates and/or postoperative complications between 2-field lymphadenectomy (2FL) and 3-field lymphadenectomy (3FL) for esophageal carcinoma with R0 resection were included. Meta-analysis was conducted using published data on 3FL vs 2FL in esophageal carcinoma patients. End points were 1-, 3-, and 5-year overall survival rates and postoperative complications, including recurrent nerve palsy, anastomosis leak, pulmonary complications, and chylothorax. Subgroup analysis was performed on the involvement of recurrent laryngeal lymph nodes. RESULTS: Two RCTs and 18 observational studies with over 7000 patients were included. There was a clear benefit for 3FL in the 1- (RR = 1.16; 95%CI: 1.09-1.24; P < 0.01), 3- (RR = 1.44; 95%CI: 1.19-1.75; P < 0.01), and 5-year overall survival rates (RR = 1.37; 95%CI: 1.18-1.59; P < 0.01). For postoperative complications, 3FL was associated with significantly more recurrent nerve palsy (RR = 1.43; 95%CI: 1.28-1.60; P = 0.02) and anastomosis leak (RR = 1.26; 95%CI: 1.05-1.52; P = 0.09). In contrast, there was no significant difference for pulmonary complications (RR = 0.93; 95%CI: 0.75-1.16, random-effects model; P = 0.27) or chylothorax (RR = 0.77; 95%CI: 0.32-1.85; P = 0.69). CONCLUSION: This meta-analysis shows that 3FL improves overall survival rate but has more complications. Because of the high heterogeneity among outcomes, definite conclusions are difficult to draw.

The Sino-French 2012 Conference in Thoracic Oncology: an international academic platform for in-depth exchange on comprehensive research.

The Sino-French 2012 Conference in Thoracic Oncology, held November 17-18, 2012, was hosted by the Department of Thoracic Surgery at Sun Yat-sen University Cancer Center and organized in collaboration with two prestigious French hospitals: Institute Gustave Roussy and Marie Lannelongue Hospital. The conference was established by leading experts from China and France to serve as an international academic platform for sharing novel findings in basic research and valuable clinical practice experiences. Hot topics including innovation in surgical techniques, diagnosis and staging of early-stage lung cancer, minimally invasive surgery, multidisciplinary treatment of lung cancer, and progress in radiotherapy for lung cancer were explored. Highlights of the conference presentations are summarized in this report.

Thoracoscopic internal mammary lymph node dissection: a video demonstration.

BACKGROUND: Internal mammary lymph node (IMN) metastasis in breast cancer is a well-established prognostic factor of similar importance to axillary lymph node status. Although randomized controlled trials in the 1970s failed to show a survival benefit of IMN dissection during extended radical mastectomy, they did demonstrate diminished survival of patients with IMN metastasis.1,2 The 2011 National Comprehensive Cancer Network Clinical Practice Guidelines recommend radiotherapy to the IMN chain that is clinically or pathologically positive. However, the direct contribution of IMN irradiation to improved survival is still controversial, while it may contribute to the increased risk of relevant cardiac mortality.3-5 METHODS: Thoracoscopic internal mammary node dissection is a novel minimally invasive technique to assess and treat IMN metastasis. It ensures that the whole IMN chain is excised for histological evaluation, and therefore, no further irradiation of these regional nodes is needed. RESULTS: This procedure is indicated in the following instances: operable invasive breast cancer; all medial or central tumors; lateral tumors with involved axillary lymph nodes; primary internal mammary lymphatic drainage detected by lymphoscintigraphy; and no contraindications to thoracoscopic surgery, including the inability to tolerate single-lung ventilation and extensive pleural adhesion. CONCLUSIONS: Thoracoscopic internal mammary node dissection is a feasible procedure designed to provide simultaneous assessment and management of IMN metastasis. However, a larger study cohort with long-term follow-up is required to verify its safety and clinical significance.

Expression and prognostic relevance of tumor carcinoembryonic antigen in stage IB non-small cell lung cancer.

BACKGROUND: High serum carcinoembryonic antigen (CEA) levels have been reported to be associated with poor prognosis in non-small cell lung cancer (NSCLC), while the prognostic role of tumor CEA expression remains to be defined. The present study investigated the expression of tumor CEA in stage IB NSCLC, and correlated it with clinicopathological features and prognosis. PATIENTS AND METHODS: Immunohistochemistry for tumor CEA was assessed in the specimens of 183 patients with stage IB NSCLC. Receiver-operating characteristic (ROC) curve analysis was used to determine the cut-off score for tumor positivity. RESULTS: High CEA expression was detected more frequently in adenocarcinomas (72.2%) and other NSCLCs (69.0%) than in squamous cell carcinomas (25.4%, P<0.001). Both univariate and multivariate analysis indicated that tumor CEA was an independent prognostic factor for overall and disease-free survival (P<0.05). CONCLUSIONS: Elevated expression of tumor CEA may be an adverse prognostic indicator in stages IB NSCLC.

Prognostic relevance of ß-catenin expression in T2-3N0M0 esophageal squamous cell carcinoma.

AIM: To study the expression of ß-catenin in esophageal squamous cell carcinoma (ESCC) at stage T2-3N0M0 and its relation with the prognosis of ESCC patients. METHODS: Expression of ß-catenin in 227 ESCC specimens was detected by immunohistochemistry (IHC). A reproducible semi-quantitative method which takes both staining percentage and intensity into account was applied in IHC scoring, and receiver operating characteristic curve analysis was used to select the cut-off score for high or low IHC reactivity. Then, correlation of ß-catenin expression with clinicopathological features and prognosis of ESCC patients was determined. RESULTS: No significant correlation was observed between ß-catenin expression and clinicopathological parameters in terms of gender, age, tumor size, tumor grade, tumor location, depth of invasion and pathological stage. The Kaplan-Meier survival curve showed that the up-regulated expression of ß-catenin indicated a poorer post-operative survival rate of ESCC patients at stage T2-3N0M0 (P = 0.004), especially of those with T3 lesions (P = 0.014) or with stage IIB diseases (P = 0.007). Multivariate analysis also confirmed that ß-catenin was an independent prognostic factor for the overall survival rate of ESCC patients at stage T2-3N0M0 (relative risk = 1.642, 95% CI: 1.159-2.327, P = 0.005). CONCLUSION: Elevated ß-catenin expression level may be an adverse indicator for the prognosis of ESCC patients at stage T2-3N0M0, especially for those with T3 lesions or stage IIB diseases.

[Effect of different ways of insulin infusion in parenteral nutrition patients on activation and concentration of insulin and blood glucose control:a prospective randomized comparison study].

OBJECTIVE: To compare activation and concentration of insulin, and blood glucose control in patients between insulin added into "all in one" bags and syringes at parenteral nutrition (PN). METHODS: From April 2006 to August 2006, 20 consecutive patients after gastrointestinal operations were recruited and randomized to instillation group and pump group. In instillation group, the insulin was directly added into PN and transfused. In pump group, the insulin was added into syringes and transfused by infusion pump. Activation and concentration of insulin, and blood glucose in patients were measured at beginning infusion, infused 1000 ml, infused 2000 ml, and remained 100 ml daily for the first 3 days after operation. RESULTS: There was a tendency of decrease for the activation and concentration of insulin in both groups with the time. There was no significant difference of activation of insulin between the two groups (P = 0.347). There were no significant differences of blood glucoses between the two groups, and between the four time points in each groups (P > 0.05). There were no complications association with blood glucoses in the two groups. CONCLUSIONS: Both of activation and concentration of insulin at PN decreased gradually and slightly with the time no matter the ways of insulin infusion. Activation of insulin and blood glucoses in patients are no significant differences between the two groups. Insulin can be safely added into "all in one" bags at PN.

[Injuries after lobectomy: a prospective randomized comparison of video-assisted thoracoscopic surgery and mini-thoracotomy].

OBJECTIVE: To compare the differences of injuries and recovery between video-assisted thoracoscopic surgery (VATS) and mini-thoracotomy (MT) in patients with clinical early stage non-small cell lung cancer (NSCLC) after lobectomy. METHODS: From March 2004 to December 2006, 47 consecutive patients with early stage NSCLC with a diameter of tumor less than 6 cm were recruited and randomized to VATS group and MT group. Incision length, duration of operation and intraoperative blood loss were recorded. Postoperative pain was assessed using a visual analogue scale before operation and daily for the first 7 days after operation. The serum levels of interleukin-6 (IL-6) and interleukin-10 (IL-10) were measured by cytometric bead array before operation and at 4, 24, and 48 h after operation. Karnofsky performance status (KPS) was assessed before operation and daily for the first 7 days after operation. RESULTS: Incision length was (6.0 +/- 0. 9) cm in the VATS group and (12.5 +/- 1.5) cm in the MT group. There was no significant difference in duration of operation and intraoperative blood loss between the VATS group and the MT group. Postoperative pain was significantly less in the VATS group in the 5th to 7th day postoperatively (P < 0.05). There was no significant difference of serum concentrations of IL-6 and IL-10 between the VATS group and the MT group at 4, 24, and 48 h after operation. KPS score was significantly higher in the VATS group on 2nd to 7th day postoperatively (P < 0.05). CONCLUSION: Compared with MT, VATS for lobectomy has less postoperative pain, faster recovery, but can't reduce postoperative release of cytokines.

[Diagnosis and therapeutics of 24 cases of pulmonary sclerosing hemangioma].

BACKGROUND & OBJECTIVE: Pulmonary sclerosing hemangioma (PSH) is an uncommon benign lung tumor. The study was to investigate the clinical features, diagnosis, treatment, and prognosis of PSH in order to promote the recognition of this disease. METHODS: Data of 24 pathologically confirmed PSH patients treated in Sun Yat-sen University Cancer Center from Jan. 1999 to Jul. 2007 were reviewed. The clinical features, diagnosis, treatment, and prognosis were summarized. RESULTS: Of the 24 patients, two (8.3%) were males, and 22 (91.7%) were females. The median age of the patients was 54.5 years old, ranging from 21 to 76 years old. Ten (41.7%) patients were detected upon routine medical examination, while 14 (58.3%) patients presented clinical symptoms, including cough, hemoptysis, chest pain, chest distress and tachypnea. The imaging examination revealed isolated round or similar round nodules with distinct margins and homogeneous density. No calcification and aerial semilunar sign appeared. All the patients received surgical resection without complications and mortality. Eight patients underwent lobectomy, 13 underwent wedge resection, two underwent tumor resection and one underwent segmentectomy. There was no recurrence or metastasis during follow-ups. CONCLUSIONS: Clinical and radiological characteristics of PSH are nonspecific. Thus, accurate diagnosis of PSH before operation is difficult. Confirmation of PSH depends on pathological examination. Surgical resection is an effective treatment for PSH, among which lobectomy or limited resection is advisable, while systematic lymph node dissection is not recommended.

[Influence of unexpected simultaneous splenectomy on postoperative complications and prognosis of patients undergoing radical esophagectomy for esophageal carcinoma].

BACKGROUND & OBJECTIVE: Unexpected splenectomy is sometimes performed simultaneously with radical esophagectomy for esophageal carcinoma because of spleen injury or anatomical abnormity. This study was to investigate the influence of unexpected simultaneous splenectomy on postoperative complications and prognosis of patients undergoing radical esophagectomy for esophageal carcinoma. METHODS: Clinical data of 843 esophageal carcinoma patients, underwent esophagectomy (R0 resection) at Cancer Center of Sun Yat-sen University from Aug. 1999 to Jul. 2002, were analyzed. Of these patients, 39 (4.6%) underwent splenectomy. The clinicopathologic parameters and prognosis of the patients in splenectomy group and non-splenectomy group were compared. RESULTS: The amount of intraoperative blood loss was significantly higher in splenectomy group than in non-splenectomy group [(380+/-113) ml vs. (305+/-85) ml, P<0.001]. However, there were no significant differences in clinicopathologic characteristics, intraoperative or postoperative complications between the 2 groups (P>0.05). The occurrence rate of pulmonary complications was higher in splenectomy group than in non-splenectomy group (17.9% vs. 8.5%, P>0.05). The median survival time was shorter in splenectomy group than in non-splenectomy group (18.4 months vs. 21 months, P>0.05). CONCLUSION: Unexpected simultaneous splenectomy had no effect on the long-term survival of patients who underwent radical esophagectomy for esophageal carcinoma, but it may result in more intraoperative blood loss and pulmonary complications.

[Cytokine responses after lobectomy: a prospective randomized comparison of video-assisted thoracoscopic surgery and minimal incision thoracotomy].

BACKGROUND & OBJECTIVE: The cytokine network plays a pivotal role in inducing acute-phase inflammatory and immunologic responses to surgical trauma. Whether lesser release of cytokines by mini-invasive operation can reduce acute-phase responses and better preserve immune functions needs to be explored. This prospective randomized study was to compare the effects of video-assisted thoracoscopic surgery (VATS) and minimal incision thoracotomy (MIT) on serum levels of cytokines after lobectomy for clinical early stage non-small cell lung cancer (NSCLC). METHODS: From Mar. 2004 to Dec. 2006, 47 consecutive patients with early stage NSCLC (tumor size was

[Quality of life after lobectomy for early stage non-small cell lung cancer--video-assisted thoracoscopic surgery versus minimal incision thoracotomy].

BACKGROUND & OBJECTIVE: Quality of life (QOL) after video-assisted thoracoscopic surgery (VATS) lobectomy for clinical early stage non-small cell lung cancer (NSCLC) has seldom been systematically studied. This study was to compare the QOL in patients with clinical early stage NSCLC after VATS or minimal incision thoracotomy (MIT) lobectomy, and to explore the characteristic of QOL after VATS lobectomy. METHODS: A prospective randomized controlled trial was conducted. From Mar. 2004 to Mar. 2005, 32 consecutive patients with early stage NSCLC and tumor size of < or =6 cm diagnosed by CT scan were recruited and randomized to VATS group (17 patients) and MIT group(15 patients). Two patients in VAYS group were excluded for conversion to posterolateral thoracotomy because of uncontrolled bleeding and dense pleural adhesion. QOL was assessed using Lung Cancer Symptom Scale (LCSS) before operation and at 1, 3 and 6 months after operation. RESULTS: There were no significant differences between the 2 groups in age, sex, tumor pathologic stage, tumor size, and postoperative complications. One month after operation, the scores of dyspnea and pain were significantly lower in VATS group than in MIT group (10.9+/-7.4 vs. 17.4+/-9.6, P=0.047; 13.7+/-9.5 vs. 23.0+/-12.2, P=0.028). The score of overall symptom was slightly lower in VATS group than in MIT group (9.7+/-7.2 vs. 16.2+/-10.9, P=0.066). Five major symptoms (appetite, fatigue, cough, dyspnea, and pain) at the VATS group were deteriorated after operation. Appetite, fatigue and cough were deteriorated significantly at 1 month after operation (P<0.05), but returned to nearly preoperative levels at 3 months after operation (P>0.05) except appetite, and all returned to baseline levels at 6 months after operation (P>0.05). CONCLUSIONS: Compared with MIT lobectomy, VATS will lead to better QOL for the patients with early stage NSCLC. It takes 6 months for the patients to return to preoperative QOL levels after VATS lobectomy.