Impact of pulmonary vein-first ligation during lobectomy on the postoperative survival and recurrence rates in patients with non-small cell lung cancer: a multicenter propensity score-matched study.

PURPOSE: Surgical manipulation of the lungs increases the number of circulating tumor cells and the subsequent risk of metastasis in patients with lung cancer. This study investigated whether or not ligating the tumor-draining pulmonary vein first during lobectomy could improve the prognosis of these patients. METHODS: We retrospectively evaluated patients who underwent curative lobectomy for solitary nonsmall-cell lung carcinoma between January 2012 and December 2016. We divided the patients into the vein-first group, in which all associated pulmonary veins were dissected and severed before cutting the pulmonary artery, bronchus, or pulmonary fissure, and the other procedure group. RESULTS: Overall, we included 177 and 413 patients in the vein-first and other procedure groups, respectively. Propensity score matching yielded 67 pairs of patients. The 5-year overall survival (85.6% [95% confidence interval, 77.3-94.8%] vs. 69.4% [58.7-81.9%], P = 0.03%) and recurrence-free survival (73.4% [63.3-85.1%] vs. 53.5% [42.5-67.3%], P = 0.02) were significantly better in the vein-first group than in the other procedure group. The cumulative recurrence rate at 5 years post-surgery was significantly lower in the vein-first group than in the other procedure group (21.7% vs. 38.3%, P = 0.04). CONCLUSION: Our study suggests that ligating the pulmonary vein first during lobectomy for lung cancer can improve the overall survival, recurrence-free survival, and cumulative recurrence rate.

Accurate etiological diagnosis of Mycoplasma hominis mediastinitis in immunocompetent patients using metagenomic next-generation sequencing: a case series and literature review.

Background: As a culture-independent method, metagenomic next-generation sequencing (mNGS) is widely used in microbiological diagnosis with advantages in identifying potential pathogens, guiding antibiotic therapy, and improving clinical prognosis, especially in culture-negative cases. Mycoplasma hominis (M. hominis) mediastinitis is a rare and severe disease for which etiological diagnosis is important but challenging. The application of mNGS in the etiological diagnosis of mediastinitis has seldom been studied. Methods: By searching the electronic medical history retrieval system with "Mycoplasma hominis" and "mediastinitis", seven patients diagnosed with M. hominis mediastinitis were reviewed in Zhongshan Hospital, Fudan University, Shanghai from 9 December 2020 to 14 February 2023. Microbiological cultures and mNGS were conducted for blood, abscess, and/or mediastinal fluid. Adjustment of the antibiotic therapy due to mNGS was assessed. A literature review was conducted in the PubMed database beginning in 1970 for M. hominis infection and mediastinitis. Results: For the seven patients, cultures of blood, abscess, and mediastinal fluid were negative whereas mNGS identified M. hominis in serum, abscess, and/or mediastinal fluid and was used to guide specific antibiotic therapy. The stringent mapped reads number of genera (SMRNG), stringent mapped reads number of species (SMRN), and coverage rate of M. hominis detection by mNGS were significantly higher in body fluid (abscess or mediastinal fluid) than in serum. All seven patients had underlying heart diseases and underwent previous cardiac surgery. The most common symptoms were fever and sternal pain. After detection of M. hominis, antibiotics were adjusted to quinolones or doxycycline except for one patient, whose diagnosis was clarified after death. Two patients died. Literature review since 1970 identified 30 cases of extra-genital infection caused by M. hominis. Including our seven new cases, 2 (5.4%) were neonates and 35 (94.6%) were adults. Thirty (81.1%) cases were postoperative infection and 15 (40.5%) had implanted devices. Five patients (13.5%) died. Conclusions: mNGS might be a promising technology in the detection of fastidious pathogens such as M. hominis. Accurate etiological diagnosis by mNGS could guide antibiotic therapy and facilitate clinical management.

Dose Optimization of Intravenous Indocyanine Green for Malignant Lung Tumor Localization.

Background: Intravenously administered indocyanine green (ICG) accumulates in lung tumors, facilitating their detection via a fluorescence spectrum measurement. This method aids in identifying tumor locations that are invisible to the naked eye. We aim to determine the optimal ICG dose and administration method for accurate tumor identification during lung resection surgeries, utilizing a novel ICG fluorescence spectroscopy system for precise tumor localization. Materials and Methods: ICG should be dissolved in the provided solution or distilled water and administered intravenously approximately 24 h before surgery, beginning with an initial dose of 0.5 mg/kg. If the tumor detection rate is insufficient, the dose may be gradually increased to a maximum of 5.0 mg/kg to determine the optimal dosage for effective tumor detection. This fluorescence spectroscopy during surgery may reveal additional lesions that remain undetected in preoperative assessments. The primary endpoint includes the correct diagnostic rate of tumor localization. The secondary endpoints include the measurement of the intraoperative ICG fluorescence spectral intensity in lung tumors, the assessment of the operability and safety of intraperitoneal ICG administrations, the measurement of the ICG fluorescence spectral intensity in surgical specimens, the comparison of the spectral intensity in lung tissues during collapse and expansion, the correlation between ICG camera images and fluorescence spectral intensity, and the comparison of fluorescence analysis results with histopathological findings. The trial has been registered in the jRCT Clinical Trials Registry under the code jRCTs011230037. Results and Conclusions: This trial aims to establish an effective methodology for localizing and diagnosing malignant lung tumors, thereby potentially improving surgical outcomes and refining treatment protocols.

A simple and safe surgical technique for nonpalpable lung tumors: One-stop Solution for a nonpalpable lung tumor, Marking, Resection, and Confirmation of the surgical margin in a Hybrid operating room (OS-MRCH).

When performing thoracoscopic partial resections of nonpalpable lung tumors such as ground-glass opacities (GGOs) and small tumors, detecting the location of the lesion and assessing the resection margins can be challenging. We have developed a novel method to ease this difficulty, the One-stop Solution for a nonpalpable lung tumor, Marking, Resection, and Confirmation of the surgical margin in a Hybrid operating room (OS-MRCH), which uses a hybrid operating room wherein the operating table is seamlessly integrated with cone-beam computed tomography (CBCT). We performed the OS-MRCH method on 62 nodules including primary lung cancer presenting with GGO. Identification of the lesion and confirmation of the margin were performed in 58 of the cases, while nodules were detected in all. The frequency of computed tomography (CT) scans performed prior to resection was one time in 51 cases, two times in eight cases, and ≥3 times in three cases. Additional resection was performed in two cases. The median operative time was 85.0 minutes, and the median pathological margin was 11.0 mm. The key advantages of this method are that all surgical processes can be completed in a single session, specialized skill sets are not required, and it is feasible to perform in any facility equipped with a hybrid operating room. To overcome its disadvantages, such as longer operating time and limited patient positioning, we devised various methods for positioning patients and for CT imaging of the resected specimens. OS-MRCH is a simple, useful, and practical method for performing thoracoscopic partial resection of nonpalpable lung tumors.

Developing a Virtual Reality Simulation System for Preoperative Planning of Robotic-Assisted Thoracic Surgery.

Background. Robotic-assisted thoracic surgery (RATS) is now standard for lung cancer treatment, offering advantages over traditional methods. However, RATS's minimally invasive approach poses challenges like limited visibility and tactile feedback, affecting surgeons' navigation through com-plex anatomy. To enhance preoperative familiarization with patient-specific anatomy, we devel-oped a virtual reality (VR) surgical navigation system. Using head-mounted displays (HMDs), this system provides a comprehensive, interactive view of the patient's anatomy pre-surgery, aiming to improve preoperative simulation and intraoperative navigation. Methods. We integrated 3D data from preoperative CT scans into Perspectus VR Education software, displayed via HMDs for in-teractive 3D reconstruction of pulmonary structures. This detailed visualization aids in tailored preoperative resection simulations. During RATS, surgeons access these 3D images through Tile-ProTM multi-display for real-time guidance. Results. The VR system enabled precise visualization of pulmonary structures and lesion relations, enhancing surgical safety and accuracy. The HMDs offered true 3D interaction with patient data, facilitating surgical planning. Conclusions. VR sim-ulation with HMDs, akin to a robotic 3D viewer, offers a novel approach to developing robotic surgical skills. Integrated with routine imaging, it improves preoperative planning, safety, and accuracy of anatomical resections. This technology particularly aids in lesion identification in RATS, optimizing surgical outcomes.

Tumor-to-thoracic height ratio as an easy method to predict the feasibility of reduced-port video-assisted thoracic surgery for mediastinal lesions in children: a single-center experience.

In the last few decades, reduced-port video-assisted thoracic surgery (RP-VATS) has been developed to minimize surgical invasiveness. Nevertheless, VATS in children can occasionally be difficult because the lesion occupies a small thoracic cavity, limiting the working space. This study aimed to assess the feasibility of RP-VATS for the resection of mediastinal lesions in children in association with the tumor-to-thoracic height ratio (TTH ratio). We reviewed all patients aged ≤10 years who underwent resection for mediastinal lesions in our institute between January 2008 and August 2022. Patients who underwent diagnostic procedures were excluded from this study. The TTH ratio was calculated as tumor height divided by thoracic height. Seven patients in the RP-VATS group and six in the conventional procedures (multi-portal VATS or open surgery) group were included in this study. The TTH ratio was significantly lower in the RP-VATS group than in the conventional procedures group (median, 26.3% vs. 50.8%; P=0.007). The operating time (P=0.01) and duration of drainage (P=0.003) were significantly shorter and the blood loss (P=0.001) was significantly lower in the RP-VATS group than in the conventional procedures group. After adjusting for age, a lower TTH ratio was significantly associated with the completion of RP-VATS (odds ratio: 0.776; 95% confidence interval: 0.529-0.926; P=0.048). In conclusion, RP-VATS can be performed appropriately in carefully selected cases of pediatric mediastinal lesions. A low TTH ratio may predict the feasibility of RP-VATS. Further studies are warranted to determine the criteria for the indications of RP-VATS in children, so that more children can benefit from RP-VATS.

Machine learning-based radiomic computed tomography phenotyping of thymic epithelial tumors: Predicting pathological and survival outcomes.

OBJECTIVE: For patients with thymic epithelial tumors, accurately predicting clinicopathological outcomes remains challenging. We aimed to investigate the performance of machine learning-based radiomic computed tomography phenotyping for predicting pathological (World Health Organization [WHO] type and TNM stage) and survival outcomes (overall and progression-free survival) in patients with thymic epithelial tumors. METHODS: This retrospective study included patients with thymic epithelial tumors between January 2001 and January 2022. The radiomic features were extracted from preoperative unenhanced computed tomography images. After strict feature selection, random forest and random survival forest models were fitted to predict pathological and survival outcomes, respectively. The model performance was assessed by the area under the curve (AUC) and validated internally by the bootstrap method. RESULTS: In total, 124 patients with a median age of 61 years were included. The radiomics random forest models of WHO type and TNM stage showed satisfactory performance with an AUCWHO of 0.898 (95% CI, 0.753-1.000) and an AUCTNM of 0.766 (95% CI, 0.642-0.886). For overall survival and progression-free survival prediction, the radiomics random survival forest models showed good performance (integrated AUCs, 0.923; 95% CI, 0.691-1.000 and 0.702; 95% CI, 0.513-0.875, respectively), and the integrated AUCs increased to 0.935 (95% CI, 0.705-1.000) and 0.811 (95% CI, 0.647-0.942), respectively, when combined with clinicopathological features. CONCLUSIONS: Machine learning-based radiomic computed tomography phenotyping might allow for the satisfactory prediction of pathological and survival outcomes and further improve prognostic performance when integrated with clinicopathological features in patients with thymic epithelial tumors.

Parietal pleural small holes found in patients with primary spontaneous pneumothorax associated with relatively mild chest wall flatness: a retrospective study.

Background: During surgery for spontaneous pneumothorax, parietal pleural small holes (PPSHs) are occasionally found around the apex of the intrapleural space; however, this has not been well recognized. Additionally, chest wall flatness is usually observed in patients with primary spontaneous pneumothorax (PSP) and PPSHs. This study aimed to investigate the prevalence of PPSH and evaluate the characteristics of patients with PPSH. We also investigated the degree of chest wall flatness in patients with PPSHs. Methods: We retrospectively reviewed all patients who underwent thoracoscopic surgery for pneumothorax at our department between April 2014 and May 2021. A propensity-matched analysis was used to compare the characteristics of patients with and without PPSH. Results: A total of 490 patients were enrolled in this study. PPSH was found in 45 of 297 (15.2%) patients with PSP and one of 193 (0.5%) patients with secondary pneumothorax. PSP was independently associated with the presence of PPSH after adjusting for age and sex [primary/secondary, odds ratio (OR) =34.3, 95% confidence interval (CI): 4.7-250.9; P<0.001]. Among patients with PSP, the flatness of the chest wall in patients with PPSH was not as severe as that in patients without PPSH {thoracic anteroposterior diameter (APDT) to transverse diameter (TDT) ratio; with PPSH: median =0.517 [interquartile range (IQR) =0.480-0.554] vs. without PPSH: median =0.487 (IQR =0.463-0.529; P=0.031)} after propensity score matching. Conclusions: PPSH is found in a non-negligible proportion of patients with PSP, and patients with PPSHs show a relatively mild flat chest among patients with PSP. Clinicians should be aware of PPSH, and further understanding of this condition may contribute to a better understanding of PSP.

A novel system for analyzing indocyanine green (ICG) fluorescence spectra enables deeper lung tumor localization during thoracoscopic surgery.

Background: Palpation of tumors during thoracoscopic surgery remains difficult, and identification of deep-seated tumors may be impossible. This preclinical study investigated the usefulness of a novel indocyanine green (ICG) fluorescence spectroscopy system for tumor localization. Methods: ICG was diluted to 5.0×10-2 mg/mL in fetal bovine serum (FBS) and mixed with silicone resin to prepare pseudo-tumors. Sponges of different densities and a porcine lung were placed on top of the pseudo-tumors, which were examined using a novel fluorescence spectroscopy system and a near-infrared (NIR) camera. Spectra were measured for different sponge and lung thicknesses, and the lung spectra were measured during both inflation and deflation. Results: The fluorescence spectroscopy system was able to identify tumors at depths ≥15 mm, while the NIR system was not. The spectroscopy system also detected tumors at greater depths when the density of the intervening material was lower. Depending on the density and thickness of the intervening material, the system could detect spectra as deep as 40 mm for sponges and 30 mm for lungs. Conclusions: This new fluorescence spectroscopy system can be used to identify lung tumors up to a depth of 30 mm in experiments using pseudo-tumors and a porcine lung, which may aid in tumor identification during thoracoscopic surgery.

Pathological tumor long-to-short axis ratio as a prognostic factor in patients with thymic epithelial tumors.

BACKGROUND: Thymic epithelial tumors (TETs) exhibit irregular shapes reflective of the heterogeneity in tumor growth and invasive properties. We aimed to identify the prognostic value of the pathological tumor long-to-short axis (L/S) ratio in TETs. METHODS: A retrospective study was performed on patients with TETs who underwent extended thymectomy between January 1999 and December 2019 in our institute. Patients were divided into two groups according to the threshold of the L/S ratio. Overall survival (OS) and progression-free survival (PFS) were evaluated by Kaplan-Meier analysis. The independent prognostic factors of TETs were identified by multivariate analysis. The performance of prediction models for the above survival outcomes with and without the L/S ratio was evaluated using an integrated time-dependent area under the curve (iAUC). RESULTS: Eligible patients were divided into two groups based on higher (n = 42) and lower (n = 94) L/S ratios according to a threshold value of 1.39. A significant difference was found between the two groups only in disease progression (p = 0.001). Poorer survival outcomes were found from Kaplan-Meier curves in the higher L/S ratio group (p < 0.05). In the multivariable analysis, the L/S ratio showed significant effects on OS and PFS (p < 0.05). The performance of models with the L/S ratio was better than that without the L/S ratio in predicting survival outcomes. CONCLUSIONS: The pathological tumor L/S ratio is an independent prognostic factor for OS and PFS in patients with TETs, and an L/S ratio >1.39 is associated with worse survival outcomes.

Noninvasive monitoring of allograft rejection in a rat lung transplant model: Application of machine learning-based 18F-fluorodeoxyglucose positron emission tomography radiomics.

BACKGROUND: Standardized uptake values (SUVs) derived from 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) are valuable but insufficient for detecting lung allograft rejection (AR). Using a rat lung transplantation (LTx) model, we investigated correlations of AR with the SUVmax and PET-derived radiomics and further evaluated the performance of machine learning (ML)-based radiomics for monitoring AR. METHODS: LTx was performed on 4 groups of rats: isograft, allograft-cyclosporinecontinuous (CsAcont), allograft-CsAdelayed, and allograft-CsA1week. Each rat underwent 18F-FDG PET at week 3 or 6. The SUVmax and radiomic features were extracted from the PET images. Least absolute shrinkage and selection operator regression was used to construct a radiomics score (Rad-score). Ten modeling algorithms with 7 feature selection methods were performed to develop 70 radiomics models (49 ML models and 21 logistic regression models) for monitoring AR, validated using the bootstrap method. RESULTS: In total, 837 radiomic features were extracted from each PET image. The SUVmax and Rad-score showed significant positive correlations with histopathology (p < .05). The area under the curve (AUC) of SUVmax for detecting AR was 0.783. The median AUC of ML models was 0.921, which was superior to that of logistic regression models (median AUC, 0.721). The optimal ML model using a random forest modeling algorithm with random forest feature selection method exhibited the highest AUC of 0.982 (95% confidence interval, 0.875-1.000) in all models. CONCLUSIONS: SUVmax provided a good correlation with AR, but ML-based PET radiomics further strengthened the power of 18F-FDG PET functional imaging for monitoring AR in LTx.

Exacerbation of Secondary Pulmonary Hypertension by Flat Chest after Lung Transplantation.

A 40-year-old woman with idiopathic pleuroparenchymal fibroelastosis (IPPFE) and flat chest underwent left single lung transplantation (SLT). Although she had developed over-systemic pulmonary arterial pressure (PAP) at transplantation, it was alleviated. However, her PAP gradually increased again. Her transplanted lung was well-inflated, but progression of fibrosis in her right native lung appeared to have caused a mediastinal shift, and her flat chest caused obstruction of the outflow tract of the pulmonary vein. She died of heart failure and associated infection 1.5 years after transplantation. An autopsy confirmed irreversible pulmonary arterial and venous changes in the transplanted lung, suggestive of chronic pressure overload. The flat chest associated with IPPFE can affect pulmonary circulation after SLT.

Elevated serum CYFRA 21-1 level as a diagnostic marker for thymic carcinoma.

BACKGROUND: No useful tumor markers have been identified for the diagnosis of thymic carcinomas. Serum cytokeratin 19 fragment, measured using the CYFRA 21-1 immunoassay, is used as a tumor marker for squamous cell carcinomas in various malignant tumors. Here, we evaluated the value of CYFRA 21-1 in diagnosing thymic carcinoma. METHODS: We retrospectively reviewed 94 patients with pathological diagnoses of thymic carcinoma or thymoma (32 and 62 patients, respectively) who were referred to our departments between January 2000 and March 2019. Primary outcomes included tumor marker levels and their diagnostic accuracy. RESULTS: Patients with thymic carcinoma were significantly more likely to be male (thymic carcinoma, 68.8%; thymoma, 40.3%; p = 0.02), have an advanced TNM stage (p < 0.01), and a significantly higher CYFRA 21-1 level than those with thymoma (thymic carcinoma: median = 4.2 ng/ml; interquartile range [IQR] = 2.1-6.1 ng/ml vs. thymoma: median = 1.2 ng/ml; IQR = 0.9-1.7 ng/ml; p < 0.01). Receiver operating characteristic curves demonstrated that the area under the curve for CYFRA 21-1 to distinguish thymic carcinoma from thymoma was 0.86 (95% confidence interval [CI]: 0.74-0.93; cutoff = 2.7 ng/ml; sensitivity = 68.8%; specificity = 95.2%). Multivariable analysis demonstrated that CYFRA 21-1 (odds ratio = 25.6; 95% CI: 4.6-141.6; p < 0.01) was an independent predictor for thymic carcinoma after adjusting for TNM stage. CONCLUSIONS: Serum CYFRA 21-1 level may help in diagnosing thymic carcinoma.

Lung Transplantation for Pleuroparenchymal Fibroelastosis.

Pleuroparenchymal fibroelastosis (PPFE), a new disease entity associated with interstitial pneumonia, is characterized by fibrosis and elastosis involving the pleura and subpleural lung parenchyma, predominantly in the upper lobe. As the awareness of this disease entity has increased, many studies have revealed the prevalence and incidence, clinical and pathological characteristics, and disease course of PPFE. Patients with PPFE reportedly have several unique clinical characteristics-including an extremely low body mass index with a slender body and chest wall deformity, known as "flat chest". As this disease progresses, shrinking of the lungs often causes life-threatening complications, such as pneumothorax, and associated air leak syndrome. Lung transplantation is considered the only effective treatment for patients with advanced PPFE; however, little is known about the influences of the characteristics of PPFE on the outcome of lung transplantation. This review focuses on the unique clinicopathologic characteristics of PPFE and associated outcomes of lung transplantation for these patients.

Pneumatosis Intestinalis After Living Donor Lung Transplantation Associated With Alpha-Glucosidase Inhibitor Treatment: A Case Report.

INTRODUCTION: Pneumatosis intestinalis (PI) is a rare but critical condition in which gas is found in the bowel wall. Although organ transplant recipients have an increased PI risk because of long-term immunosuppression, alpha-glucosidase inhibitors (α-GI), a standard diabetes therapy, often contribute to PI. However, little is known about the postorgan transplantation relationship between PI and α-GI. To the best of our knowledge, this is the first reported case of PI in a lung transplant recipient treated with α-GI. CASE REPORT: A 59-year-old man underwent hybrid (living-donor and cadaveric) lung transplantation (LTx). The patient was treated with prednisolone and tacrolimus as immunosuppressive therapy and α-GI for diabetes for 4 years. He developed asymptomatic PI 1031 days after transplantation without any acute abdominal finding. After excluding other possible causes of PI, his PI was attributed to α-GI. The suspected α-GI was immediately withdrawn. The patient was managed conservatively with bowel rest and oxygen therapy. After 11 days of α-GI discontinuation, PI improved, and the patient completely recovered. CONCLUSION: Physicians should keep this rare adverse drug reaction in mind when prescribing α-GI, particularly in patients with diabetes after organ transplantation and including LTx. The management strategy for asymptomatic PI caused by α-GI is the immediate discontinuation of α-GI therapy, followed by conservative management initiation.

Outcomes of lung transplantation for idiopathic pleuroparenchymal fibroelastosis.

PURPOSE: This study was performed to compare the outcome of lung transplantation (LT) for idiopathic pleuroparenchymal fibroelastosis (IPPFE) with that of LT for idiopathic pulmonary fibrosis (IPF). METHODS: We reviewed, retrospectively, all adult patients who underwent LT for IPPFE or IPF in Japan between 1998 and 2018. RESULTS: There were 100 patients eligible for this study (31 with IPPFE and 69 with IPF). Patients with IPPFE tended to have a significantly lower body mass index (BMI) than those with IPF (median, 16.7 vs. 22.6 kg/m2, respectively; P < 0.01). However, Kaplan-Meier survival curves showed no significant difference in overall survival between the groups. The BMI did not increase in patients with IPPFE, even 1 year after LT (pretransplant, 16.5 ± 3.2 kg/m2 vs. 1 year post-transplant, 15.6 ± 2.5 kg/m2; P = 0.08). The percent predicted forced vital capacity (%FVC) 1 year after LT was significantly lower in the IPPFE group than in the IPF group (48.4% ± 19.5% vs. 68.6% ± 15.5%, respectively; P < 0.01). CONCLUSIONS: Despite extrapulmonary problems such as a flat chest, low BMI, and associated restrictive impairment persisting in patients with IPPFE, patient survival after LT for IPPFE or IPF was equivalent.

Thoracoscopic Bronchial Artery Resection for Multiple Bronchial Artery Aneurysms.

We describe a 36-year-old asymptomatic female with multiple bronchial artery aneurysms (BAAs) and a bronchial artery (BA) to pulmonary artery (PA) fistula. She was treated with thoracoscopic BA resection without lobectomy in lieu of catheter embolization as first-line treatment. The configuration of the BA and the location of the BAAs were clearly visualized using three-dimensional computed tomography (3DCT); therefore, the segment of the BA to resect was assessed preoperatively and complete resection of all BAAs was performed. Preoperative BA angiography delineated the BA to PA fistula, and guided surgical decision-making.

Tumor Maximum Area May Determine the Survival Outcomes of Patients with Thymic Epithelial Tumors.

BACKGROUND: The tumor maximum area (TMA) of thymic epithelial tumors (TETs) is not mentioned in current staging systems. This study aimed to assess whether TMA is of prognostic significance in TETs. METHODS: Patients who underwent extended thymectomy for TETs from 2001 to 2019 at our institute were retrospectively reviewed. TMA was examined by computed tomography imaging prior to surgery. Time-dependent receiver operating characteristic (ROC) curves were used to divide the cohort into two groups. The relationships between the TMA and clinicopathological characteristics or survival outcomes were assessed. Cox proportional hazards models were used to identify independent prognostic factors. RESULTS: A total of 122 TET patients were included for evaluation, with a median age of 61 years (range 27-83). The time-dependent ROC curve indicated that the difference in 10-year overall survival (OS) was most significant for a TMA of 1392 mm2 (area under the curve 0.793); therefore, the two groups of larger (n = 40) and smaller (n = 82) TMAs were divided. The differences in adjuvant therapy, TNM stage, and disease progression between the two groups were significant (p < 0.05). Kaplan-Meier curves indicated that TET patients with a larger TMA had worse survival outcomes, including OS, progression-free survival (PFS) and disease-free survival (DFS) [p < 0.05]. TMA was demonstrated to be an independent prognostic factor of all of the above survival outcomes in multivariate analysis (p < 0.05). CONCLUSIONS: A larger TMA is associated with a more advanced TNM stage and disease progression in TET patients and may indicate worse survival outcomes, even if more patients receive adjuvant therapy.

Rat lung transplantation model: modifications of the cuff technique.

BACKGROUND: Although the cuff technique in rat lung transplantation (LTx) has a long history, it remains technically challenging. We have developed key tricks and modifications in the devices and the cuff technique that optimize the rat LTx model to achieve successful operations during a short learning period. METHODS: Altogether, 180 consecutive rats underwent orthotopic left LTx performed by a single surgeon using our modified devices and procedures. Allogeneic and syngeneic transplantation were performed using Lewis rats as recipients and Brown Norway and Lewis rats as donors. Allogeneic recipients were treated with cyclosporine during the first week. Recipients were sacrificed at various time points after ≥2 weeks. RESULTS: A special cuff-preparation plate was created using a petri dish and two foam blocks. This modified plate stabilizes the preparation and prevents donor lung compression. A "┴"-shaped incision was carved into the front wall of the pulmonary artery (PA) using micro-scissors. "V"-shaped incisions were made from the inferior-to-superior branches of the pulmonary vein (PV) and bronchus. A "pendulum model" was applied at implantation to make the hilar anastomosis tension-free and technically easier to perform. There were no intraoperative complications. Ten rats (5.6%) experienced partial or full pulmonary atelectasis. Five deaths (2.8%) due to pleural effusion occurred during the follow-up period. The operative times for heart-lung block retrieval, cuff preparation, cold ischemia, warm ischemia, and total procedure time were 8.4±0.8, 11.6±1.5, 25.1±2.2, 8.1±1.2, and 46.7±2.8 min, respectively. CONCLUSIONS: The key tricks and improvements we made in the cuff technique for rat LTx provided the advantages of expeditiousness, a low complication rate, and a high success rate.

Outcomes of marginal donors for lung transplantation after ex vivo lung perfusion: A systematic review and meta-analysis.

OBJECTIVE: Ex vivo lung perfusion (EVLP) is reportedly a useful strategy that permits marginal donor lungs to be evaluated and reconditioned for successful lung transplantation (LTx). This systematic review and meta-analysis was performed to evaluate the outcomes of EVLP conducted for marginal donor lungs. METHODS: We searched PubMed, the Cochrane Library, and Embase to select studies describing the results of LTx following EVLP for marginal donor lungs compared with standard LTx without EVLP. We performed a meta-analysis to examine donor baseline characteristics, recipient baseline characteristics, and postoperative outcomes. RESULTS: Of 1380 studies, 8 studies involving 1191 patients met the inclusion criteria. Compared with the non-EVLP group (ie, standard LTx without EVLP), the EVLP group (ie, EVLP of marginal donors following LTx) had similar donor age and sex and recipient baseline age, sex, body mass index, bridge by ventilator/extracorporeal life support/extracorporeal membrane oxygenation, and rate of double LTx but more abnormal donor lung radiographs (P = .0002), a higher smoking history rate (P = .03), and worse donor arterial oxygen tension/inspired oxygen fraction (P < .00001). However, there were no significant differences in outcomes between the EVLP and non-EVLP groups with respect to the length of postoperative intubation, postoperative extracorporeal life support/extracorporeal membrane oxygenation use, length of intensive care unit stay, length of hospital stay, 72-hour primary graft dysfunction of grade 3, 30-day survival, or 1-year survival (all P values > .05). CONCLUSIONS: Posttransplant outcomes were similar between EVLP-treated LTx and standard LTx without EVLP, although the quality of donor lungs was worse with EVLP-treated LTx.