Prognostic impact of limited resection vs. inadequate adjuvant therapy in patients with pathologic stage II or III non-small cell lung cancer: results from the Korean Association of Lung Cancer Registry.

BACKGROUND: For patients with stage II and III non-small cell lung cancer (NSCLC), various multi-modality treatments are required. However, depending on the individual conditions of patients, there will be a significant difference in prognosis. Therefore, this study investigated the clinical impact of inadequate treatment (limited surgery and inadequate adjuvant therapy) in patients with NSCLC stage II or III using data from the Korean Association of Lung Cancer Registry (KALC-R) between 2014 and 2016. METHODS: Of the 8,110 new lung cancer cases registered at the Korea Central Cancer Registry in 2014-2016, 721 patients with stage II or III NSCLC were selected and divided into three groups according to differences in cancer treatment methods. In group A, patients underwent standard surgery and completed adjuvant therapy. In group B, patients underwent standard surgery without completing adjuvant therapy. In group C, patients received adjuvant therapy after limited surgery. After performing propensity score matching (PSM) for selected patients, overall survival (OS) and disease-free survival (DFS) rates of the three groups of patients with stage II and III NSCLC patients were then compared. RESULTS: Of the 721 patients with NSCLC, 239, 437, and 45 belonged to groups A, B, and C, respectively. After 1:3 PS matching for groups B and C, the 5-year survival rate of patients with stage II or III NSCLC were 68.0% and 26.7% for groups B and C, respectively and the DFS rate was 59.1% and 16.2% for groups B and C, respectively. CONCLUSIONS: The therapeutic effect of the standard surgery was the best. Although patients received adjuvant therapy, limited resection resulted in a poorer prognosis in compromised patients compared with omitting adjuvant therapy followed by standard surgery. Thus, surgical treatment should be considered in patients who are unable to complete surgical and adjuvant therapy.

BRAF V600E Mutation of Non-Small Cell Lung Cancer in Korean Patients.

Background and Objectives: BRAF mutational status in resected non-small cell lung cancer (NSCLC) in the Korean population is poorly understood. We explored BRAF (particularly BRAF V600E) mutational status among Korean patients with NSCLC. Materials and Methods: This study included 378 patients with resected primary NSCLC who were enrolled from January 2015 to December 2017. The authors obtained formalin-fixed paraffin-embedded (FFPE) tissue blocks and performed peptide nucleic acid (PNA)-clamping polymerase chain reaction (PCR) for detecting BRAF V600, real-time PCR for detecting BRAF V600E, and immunohistochemical analyses using the mutation-specific Ventana VE1 monoclonal antibody. For positive cases in any methods mentioned above, direct Sanger sequencing was additionally performed. Results: The PNA-clamping method revealed the BRAF V600 mutation in 5 (1.3%) of the 378 patients. Among these five patients, real-time PCR, direct Sanger sequencing detected BRAF V600E mutations in three (0.8%) patients. Thus, two cases showed differences in their PNA-clamping and the others. Direct Sanger sequencing of PNA-clamping PCR product was performed for two cases showing negative results on direct Sanger sequencing; both contained BRAF mutations other than V600E. All patients harboring BRAF mutations had adenocarcinomas, and all patients with V600E mutation exhibited minor micropapillary components. Conclusions: Despite the low incidence of the BRAF mutation among Korean patients with NSCLC, lung adenocarcinoma patients with micropapillary components should be prioritized in terms of BRAF mutation testing. Immunohistochemical staining using Ventana VE1 antibody may serve as a screening examination for BRAF V600E.

Localization Technique Using Mixture of Indigo Carmine and Lipiodol of Pulmonary Nodule via Bronchoscopic Navigation.

Background and Objectives: As the number of minimally invasive surgeries, including video-assisted thoracoscopic surgery, increases, small, deeply located lung nodules are difficult to visualize or palpate; therefore, localization is important. We studied the use of a mixture of indigo-carmine and lipiodol, coupled with a transbronchial approach-to achieve accurate localization and minimize patient discomfort and complications. Materials and Methods: A total of 60 patients were enrolled from May 2019 to April 2022, and surgery was performed after the bronchoscopy procedure. Wedge resection or segmentectomy was performed, depending on the location and size of the lesion. Results: In 58/60 (96.7%) patients, the localization of the nodules was successful after localization, and 2/60 required c-arm assistance. None of the patients complained of discomfort during the procedure; in all cases, margins were found to be free from carcinoma, as determined by the final pathology results. Conclusions: We recommend this localization technique using mixture of indigo carmine and lipiodol, in concert with the transbronchial approach, because the procedure time is short, patient's discomfort is low, and success rate is high.

Nerve Cable Graft Interposition in Patients with Brachial Plexus Schwannoma: Case Reports.

Schwannomas are rare benign tumors that develop in Schwann cells lining peripheral nerves. Schwannomas of the brachial plexus are especially rare, accounting for 5% of all cases. Although several treatments can be considered, the exact method of treatment is unclear owing to the scarcity and sporadic occurrence of schwannomas. Tumor resection is performed in most cases, and nerve damage is inevitable in cases of neuroinvasive schwannoma. In this case series, we present our successful use of transposition of cable-grafted nerves for the treatment of schwannomas. We performed cable-grafted nerve interposition in addition to tumor resection, leading to increased recovery of nerve damage. To relieve postoperative symptoms and minimize sequelae, precise surgical tumor resection followed by nerve interposition using a cable-grafted nerve may be recommended.

Cancer Testis Antigen, NOL4, Is an Immunogenic Antigen Specifically Expressed in Small-Cell Lung Cancer.

To identify cancer/testis (CT) antigens and immunogenic proteins, immunoscreening of testicular and small-cell lung cancer cell line NCI-H889 cDNA libraries was performed using serum obtained from a small-cell lung cancer (SCLC) patient. We obtained 113 positive cDNA clones comprised of 74 different genes, designated KP-SCLC-1 through KP-SCLC-74. Of these genes, 59 genes were found to be related to cancers by EMBASE analysis. Three of these antigens, including KP-SCLC-29 (NOL4), KP-SCLC-59 (CCDC83), and KP-SCLC-69 (KIF20B), were CT antigens. RT-PCR and western blot analysis showed that NOL4 was frequently present in small-cell lung cancer cell lines (8/9, 8/9). In addition, NOL4 mRNA was weakly, or at a low frequency, or not detected in various cancer cell lines. Our results reveal that NOL4 was expressed at protein levels in small-cell lung cancer tissues (10/10) but not detected in lung adenocarcinoma and squamous cell carcinoma by immunohistochemical analysis. Serological response to NOL4 was also evaluated by western blot assay using NOL4 recombinant protein. A humoral response against NOL4 proteins was detected in 75% (33/44) of small-cell lung cancer patients and in 65% (13/20) of healthy donors by a serological western blot assay. These data suggest that NOL4 is a specific target that may be useful for diagnosis and immunotherapy in SCLC.

Extralobar Supradiaphragmatic Pulmonary Sequestration Arising from the Retroperitoneum Through a Congenital Diaphragmatic Defect

Here, we report the rare case of a 13-year-old girl with a congenital diaphragmatic hernia (also known as Bochdalek hernia), which was revealed to be an extralobar pulmonary sequestration that was treated using laparoscopic and video-assisted thoracic surgery sequestrectomy and repair of the diaphragm defect after detection of a supradiaphragmatic mass connected with the retroperitoneum. The patient showed no postoperative complications at a 1-month follow-up examination.

Applying Fibrin Glue under Pleurography for Intractable Secondary Spontaneous Pneumothorax.

BACKGROUND: Prolonged air leakage is a problem that can frequently develop in patients with a secondary spontaneous pneumothorax (SSP) or in those who undergo thoracic surgery. However, the management of an air leak is difficult and reoperation might be avoided due to several reasons including adhesions. Herein, we introduce a fibrin glue application under pleurography (FGAP) and short-term outcomes in patients who underwent this procedure. METHODS: FGAP was performed in 20 patients with an intractable persistent air leakage who had poor lung function, comorbidities to undergo general anesthesia and were expected severe adhesions due to previous surgery. All medical records were retrospectively reviewed. RESULTS: Eighteen cases sealed soon after dropping the glue. One patient had a prolonged air leak for 12 days and another patient required an operation to control air leakage 16 days after the procedure. The mean duration of postoperative drainage was 4.17 ± 2.11 days (range: 3-14 days). No postprocedural complications were recorded. The mean duration of follow-up was 12.01 ± 5.02 months (range: 4-22 months). CONCLUSION: FGAP could be a treatment option to seal air leaks, especially in cases with intractable air leakage.

Evaluation of factors affecting the visualization of dye after transbronchial dye injection: an animal experiment.

BACKGROUND: Since peripheral lung lesions can be frequently visualized on computed tomography (CT), various methods of localization for thoracoscopic surgery have been developed. In the case of transbronchial dye injection (TDI), there can be difficulties with dye visualization through the thoracoscope depending on early disappearance of the dye due to diffusion before field exposure. Herein, we performed an animal experiment to determine the appropriate dye amount and the duration of visualization. METHODS: Twelve pigs were experimented as following four groups (n=3): group 1 received 0.6 mL of dye; group 2 as 0.8 mL; and group 3 as 1.0 mL, all followed by 2.0 mL of air injection and group 4, with 1.0 mL of dye followed no air injection to evaluate the utility of air injection. The detection, the peak time, the wash-out time were measured. RESULTS: The mean detection times, the peak time, and the mean wash-out times for 0.6, 0.8, and 1.0 mL of dye were not significantly different (P=0.195, 0.092, 0.06). However, regardless of the injected amount, it usually lasts in 2 hours. Comparing with non-air injection group, the peak time and wash-out time were statistically significantly different in injected group; P=0.07 and 0.001. CONCLUSIONS: The marking could be identified clearly at about 2 hours after TDI regardless of the amount of indigo carmine injected. However, in cases with longer duration to exposure, especially in cases with severe adhesions, it might be necessary to discover the mixture of dye which will last longer for visualization of lung nodules.

Corrigendum: Lymphangiographic Interventions to Manage Postoperative Chylothorax.

[This corrects the article on p. 409 in vol. 52, PMID: 31832377.].

[Applying Extended Theory of Planned Behavior for Lung Cancer Patients Undergone Pulmonary Resection: Effects on Self-Efficacy for Exercise, Physical Activities, Physical Function, and Quality of Life].

PURPOSE: This study aims to examine the effects of nursing interventions based on the Extended Theory of Planned Behavior (ETPB) regarding self-efficacy for exercise (SEE), physical activity (PA), physical function (PF), and quality of life (QOL) in patients with lung cancer who have undergone pulmonary resection. METHODS: This quasi-experimental study was conducted between July 2015 and June 2018 in two university-affiliated hospitals. The intervention included pre-operative patient education, goal setting (action and coping planning), and feedback (behavior intention and perceived behavioral control). The intervention group (IG) (n=51) received nursing interventions from the day before surgery to 12 months after lung resection, while the comparison group (CG) (n=36) received usual care. SEE, PA, PF (dyspnea, functional status, and 6-minute walking distance [6MWD]), and QOL were measured before surgery and at one, three, six, and 12 months after surgery. Data were analyzed using the χ² test, Fisher's exact test, Mann-Whitney U test, t-test, and generalized estimation equations (GEE). RESULTS: There were significant differences between the two groups regarding SEE (χ²=13.53, p=.009), PA (χ²=9.51, p=.049), functional status (χ²=10.55, p=.032), and 6MWD (χ²=15.62, p=.004). Although there were no time or group effects, the QOL mental component (Z=-2.78, p=.005) of the IG was higher than that of the CG one month after surgery. Interventions did not affect dyspnea or the QOL physical component. CONCLUSION: The intervention of this study was effective in improving SEE, PA, functional status, and 6MWD of lung cancer patients after lung resection. Further extended investigations that utilize ETPB are warranted to confirm these results.

Lymphangiographic Interventions to Manage Postoperative Chylothorax.

BACKGROUND: Postoperative chylothorax may be caused by iatrogenic injury of the collateral lymphatic ducts after thoracic surgery. Although traditional treatment could be considered in most cases, resolution may be slow. Radiological interventions have recently been developed to manage postoperative chylothorax. This study aimed to compare radiological interventions and conservative management in patients with postoperative chylothorax. METHODS: We retrospectively reviewed periprocedural drainage time, length of hospital stay, and nil per os (NPO) duration in 7 patients who received radiological interventions (intervention group [IG]) and in 9 patients who received conservative management (non-intervention group [NG]). RESULTS: The baseline characteristics of the patients in the IG and NG were comparable; however, the median drainage time and median length of hospital stay after detection of chylothorax were significantly shorter in the IG than in the NG (6 vs. 10 days, p=0.036 and 10 vs. 20 days, p=0.025, respectively). NPO duration after chylothorax detection and total drainage duration were somewhat shorter in the IG than in the NG (5 vs. 7 days and 8 vs. 14 days, respectively). CONCLUSION: This study showed that radiological interventions reduced the duration of drainage and the length of hospital stay, allowing an earlier return to normal life. To overcome several limitations of this study, a prospective, randomized controlled trial with a larger number of patients is recommended.

The prognostic significance of tumor-infiltrating lymphocytes assessment with hematoxylin and eosin sections in resected primary lung adenocarcinoma.

The prognostic significance of tumor-infiltrating lymphocytes has been determined in cancers of the lung, colon and breast, though there is no standardized method for using this prognostic indicator for lung cancer. We applied a modified version of the method proposed by the International Immuno-Oncology Biomarkers Working Group to primary lung adenocarcinoma, which uses histologic findings of hematoxylin and eosin sections. The study included a total cohort of 146 lung adenocarcinoma patients who underwent lobectomy with lymph node dissection at two hospitals between 2008 and 2012. The full-face sections of hematoxylin and eosin-stained slides were reviewed, and we evaluated the level of tumor-infiltrating lymphocytes as a percentage of the area occupied out of the total intra-tumoral stromal area. Histopathologic factors include histologic grade, necrosis, extracellular mucin, lymphovascular invasion, lymph node metastasis, level of tumor infiltrating lymphocytes, tertiary lymphoid structures around the tumor, and the presence of a germinal center in tertiary lymphoid structures. The high level of tumor-infiltrating lymphocytes was found to be significantly correlated with the histologic grade (p = 0.023), necrosis (p = 0.042), abundance of tertiary lymphoid structures(p<0.001) and presence of a germinal center in tertiary lymphoid structures (p = 0.004). A high level of tumor-infiltrating lymphocytes was associated with better progression-free survival (p = 0.011) as well as overall survival (p = 0.049). On multivariable analysis, high tumor-infiltrating lymphocyte levels were a good independent prognostic factor for progression-free survival (Hazard ratio: 0.389, 95% confidence interval: 0.161-0.941, p = 0.036). Histologic evaluation of tumor-infiltrating lymphocytes level in lung adenocarcinoma with H&E sections therefore has prognostic value in routine surgical pathology.

Endoscopic Intraluminal Drainage: An Alternative Treatment for Phlegmonous Esophagitis.

Phlegmonous esophagitis must be treated aggressively; therefore, appropriate antibiotic therapy and drainage are critical. Although a conventional surgical approach has been used previously, internal drainage could be another treatment option in light of advances in endoscopic techniques. We report 2 cases in which patients suffering from phlegmonous esophagitis were successfully treated with endoscopic intraluminal drainage and antibiotics.

Successful Diagnosis and Treatment of a Pancreaticopleural Fistula in a Patient Presenting with Unusual Empyema and Hemoptysis.

Pancreaticopleural fistula (PPF) is a rare complication in patients with pancreatitis. Its symptoms are similar to those of empyema or pleural effusion; therefore, it is important to consider PPF in the differential diagnosis. Herein, we describe the diagnosis and treatment of PPF in a patient presenting with unusual empyema and delayed hemoptysis.

Factors Affecting Postoperative Lung Expansion in Patients with Pyogenic Empyema.

BACKGROUND: In patients with parapneumonic empyema, decortication is usually preferred to ensure functional lung re-expansion. However, there could be patients exhibiting incomplete postoperative lung expansion and inadequate drainage despite decortication. Therefore, we evaluated factors affecting postoperative lung expansion in patients undergoing decortication. METHODS: A total of 221 patients with pyogenic empyema who underwent video-assisted thoracoscopic surgery (VATS) between January and October 2016 in our hospital were reviewed in terms of surgical success. The following factors were evaluated: age; the time between identification of a localized effusion and surgical referral; chest tube drainage durations; any underlying morbidity preoperative blood culture data; and the thickness of the visceral pleura. RESULTS: Several factors that significantly prolonged the postoperative time to lung expansion were evident in patients with diabetes mellitus (DM) and bacteremia; postoperative chest tube drainage was significantly longer in those with DM (p = 0.009) and bacteremia (p = 0.01); and postoperative hospitalization time was significantly longer in patients with bacteremia (p = 0.01). The thickness of the visceral pleura was strongly correlated with postoperative chest tube drainage duration and postoperative hospitalization time (Pearson correlation coefficient, r = 0.245, p = 0.00). CONCLUSIONS: In patients with DM, bacteremia, or thickened pleura, the time to lung expansion after operation was longer. Therefore, stricter pre- and post-operative control of blood-sugar levels and adequate antibiotics are required to facilitate postoperative lung re-expansion. In patients with thickened pleurae, prolonged chest tube placement is unavoidable.

Location of Ruptured Bullae in Secondary Spontaneous Pneumothorax.

BACKGROUND: The surgical treatment of secondary spontaneous pneumothorax (SSP) can be complicated by fragile lung parenchyma. The preoperative prediction of air leakage could help prevent intraoperative lung injury during manipulation of the lung. Common sites of bulla development and ruptured bullae were investigated based on computed tomography (CT) and intraoperative findings. METHODS: The study enrolled 208 patients with SSP who underwent air leak control through video-assisted thoracoscopic surgery (VATS). We retrospectively reviewed the sites of bulla development on preoperative CT and the rupture sites during VATS. RESULTS: Of the 135 cases of right-sided SSP, the most common rupture site was the apical segment (31.9%), followed by the azygoesophageal recess (27.4%). Of the 75 cases on the left side, the most common rupture site was the apical segment (24.0%), followed by the anterior basal segment (17.3%). CONCLUSION: The azygoesophageal recess and parenchyma along the cardiac border were common sites of bulla development and rupture. Studies of respiratory lung motion to measure the pleural pressure at the lung surface could help to determine the relationship between cardiogenic and diaphragmatic movement and bulla formation or rupture.

[A Case of Hemorrhage of an Esophageal Duplication Cyst Improved by Endoscopic Drainage].

Esophageal duplication cyst is a rare congenital gastrointestinal malformation. It is the second most common duplication cyst following small bowel duplication cyst in the gastrointestinal tract. Patients with an esophageal duplication cyst are generally asymptomatic; however, some patients may present the following symptoms: dysphagia, chest pain, stridor, unproductive cough, and epigastric discomfort by compression of the surrounding structures. Surgical removal is the treatment of choice in symptomatic cases and can be considered in asymptomatic cases if they are at risk for developing complications, such as ulceration or perforation. Herein, we report a case of hemorrhage of an esophageal duplication cyst, which was improved by endoscopic drainage.

Delayed right chylothorax after left blunt chest trauma: a case report.

BACKGROUND: Chylothorax is a disease that has various causes such as neoplasm, infection, post-surgery trauma, congenital, and venous thrombosis. In approximately 15% of cases of chylothorax, the exact cause is unknown. We report a case of delayed occurrence of right chylothorax in a patient who had multiple segmental ribs fracture on his left side. CASE PRESENTATION: A 70-year-old Asian man had a "rollover" accident in which the cultivator he was driving overturned. He presented to our hospital with the main complaint of severe dyspnea. On chest computed tomography, multiple ribs fracture from the first to the eighth rib of the left side of his chest and left-sided hemopneumothorax were presented, but there was no evidence of fracture in the right side of his chest. After closed thoracostomy, an emergency operation for open reduction of fractured ribs was performed. On the fifth postoperative day, tubal feeding was performed. On the next day, a plain chest X-ray image showed pleural effusion of the right side of his chest. After insertion of a small-bore chest tube, 3390 ml of fluid for 24 hours was drained. The body fluid analysis revealed triglycerides levels of 1000 mg/dL, which led to a diagnosis of chylothorax. Although non-oral feeding and total parenteral nutrition were sustained, drain amount was increased on the fifth day. Surgical treatment (thoracoscopic thoracic duct ligation and pleurectomy) was performed in the early phase. The right chest tube was removed on the 14th postoperative day after the effusion completely resolved and he was uneventfully discharged. CONCLUSIONS: In this case, as our patient was in old age and had multiple traumas, surgical treatment for chylothorax needed to be performed in the early phase.

Thoracoscopic surgery under epidural anesthesia for intractable secondary spontaneous pneumothorax.

OBJECTIVE: Surgical intervention might be required in secondary spontaneous pneumothorax (SSP) with prolonged air leak; however, operation under general anesthesia (GA) could be critical in compromised patients. In this study, we performed video-assisted thoracic surgery (VATS) under epidural anesthesia (EA) in compromised patients with SSP and evaluated its feasibility. METHODS: Of 212 patients who underwent VATS for SSP, 179 patients had surgery under GA and 33 under EA from 2006 to 2014. All medical records were retrospectively reviewed for operative time, pre- and postoperative chest tube drainage, postoperative complications, and hospital death. To evaluate the efficacy of VATS under EA, these factors were compared between EA and GA groups. RESULTS: The mean operative time and the mean duration of postoperative drainage, respectively was 106.2±45.3 minutes and 6.15±10.51 days in GA, and 102.6±43.1 minutes and 6.10±7.20 days in EA. Of 18 cases with recurrence and 13 cases with complications, only one recurrence and one complication developed in EA. CONCLUSION: In case with patients having intractable SSP with compromised pulmonary function, VATS under EA could be an effective and safe option to approach the appropriate goals of air leak control and less recurrence of pneumothorax.

Outcomes of Extracorporeal Life Support During Surgery for the Critical Airway Stenosis.

Anesthetic management of critical airway stenosis is often very challenging. Extracorporeal membrane oxygenation (ECMO) may provide adequate respiratory support when conventional approaches fail. We report our experience of ECMO support for critical airway surgery. Between April 2012 and March 2015, nine patients underwent ECMO-supported airway operation. The reason for surgery was tracheal stenosis in nine patients, and tracheomalacia, tracheal tumor, and external tracheal compression by mediastinal mass in one patient each. Resection and end-to-end anastomosis was performed in four patients; the remainder underwent diverse procedures, including tracheoplasty, tracheal ballooning, tracheostomy, and debulking of mediastinal mass. Extracorporeal membrane oxygenation support was sufficient for gas exchange during surgery and six patients were successfully weaned off intraoperatively. The median time on ECMO was 2.42 hours (range: 14.43-216 hours). No ECMO-related complications occurred. The median intensive care unit stay, median hospital stay, and mean follow-up period were 2 days (range: 1-61 days), 33 days (range: 9-303 days), and 17.1 ± 10.8 months, respectively. The rate of freedom from reintervention was 71.4%; the mean survival rates over 1 and 2 years were 76.2% and 63.5%, respectively. Our experience indicates that ECMO is a feasible and safe method for critical airway surgery.