Development and Validation of a Prognostic Model for Transarterial Chemoembolization in Unresectable Hepatocellular Carcinoma Based on Preoperative Serum Prealbumin.

Purpose: We aimed to develop a prognostic nomogram utilizing preoperative serum prealbumin levels to predict the overall survival (OS) in patients undergoing transarterial chemoembolization (TACE) for unresectable hepatocellular carcinoma (HCC). Patients and Methods: A total of 768 individuals with unresectable HCC who underwent TACE at three medical facilities in Suzhou between January 2007 December 2018 were included. The patient cohort was assigned to a training set (n = 461) and a validation set (n = 307). Cox regression analysis identified independent prognostic factors, which were then used to construct a prognostic nomogram. Internal validation was performed in the testing group, and its effectiveness and capability were evaluated with reference to the concordance index (C-index), area under the curve (AUC), calibration curve, and decision curve analysis (DCA). Results: Independent risk factors identified through Cox regression analyses included the BCLC stage, cirrhosis, invasion, tumor number, preoperative serum PALB, performance status (PS), and tumor size. The nomogram demonstrated a C-index of 0.734 (95% confidence interval (CI): 0.710-0.758) in the training set and 0.717 (95% CI: 0.678-0.756) in the validation set, indicating strong discriminatory ability. The nomogram also demonstrated favorable discriminatory performance with AUC values of 0.873, 0.820, and 0.833 for 1-, 2-, and 3-year OS, respectively, in the training set, and 0.854, 0.765, and 0.724 in the validation set. The AUC value of the nomogram (0.843) was significantly higher than that of the four conventional staging systems. Moreover, calibration graphs confirmed a strong concordance between the predicted and observed results. Furthermore, DCA underscored the significant clinical utility of the nomogram. Additionally, the low-risk group exhibited considerably superior rates of survival compared to the high-risk group. Conclusion: The developed nomogram demonstrated excellent prognostic capability, which served as a valuable tool for personalized clinical decision-making for patients with HCC.

Long Non-Coding RNA CASC9 And HIF-1α Form A Positive Feedback Loop To Facilitate Cell Proliferation And Metastasis In Lung Cancer.

BACKGROUND: The long noncoding RNA cancer susceptibility 9 (CASC9) has been recognized as an important modulator of cell growth and metastasis in many cancers. However, its detailed roles in lung cancer remain unclear. In this study, we aimed to investigate its functions and molecular mechanism in lung cancer progression. METHODS: Expression of CASC9 was determined in lung cancer tissues and cell lines by real-time PCR. CCK-8, colony formation, wound healing and transwell assays were done to evaluate the cell proliferation, migration and invasion capacities in vitro. Real-time PCR, Western blot and RNA immunoprecipitation (RIP) assays were performed to dissect the mechanisms. RESULTS: CASC9 was overexpressed in lung cancer specimens and cell lines. Knockdown of CASC9 inhibited cell proliferation, migration, invasion and EMT in lung cancer cells. While overexpression of CASC9 in normal lung epithelial cells did the opposite. CASC9 interacted with HIF-1α and enhanced its protein stability. They formed a positive feedback loop by reciprocally inducing each other expression and regulated cell proliferation and metastasis. CONCLUSION: Our findings demonstrated a novel regulatory signaling pathway, namely the CASC9/HIF-1α axis, which was involved in lung cancer progression. These findings can provide valuable insights on the potential therapy application for lung cancer.

Nonintubated-Awake Anesthesia for Uniportal Video-Assisted Thoracic Surgery Procedures.

Nonintubated video-assisted thoracic surgery (VATS) strategies are gaining popularity. This review focuses on noninutbated VATS, and discusses advantages, indications, anesthetic techniques, and approaches to intraoperative crisis management. Advances in endoscopic, endovascular, and robotic techniques have expanded the range of surgical procedures that can be performed in a minimally invasive fashion. The nonintubated thoracoscopic approach has been adapted for use with major lung resections. The need for general anesthesia and endotracheal intubation has been reexamined, such that regional or epidural analgesia may be sufficient for cases where lung collapse can be accomplished with spontaneous ventilation and an open hemithorax.

Subxiphoid uniportal video-assisted thoracoscopic surgery (VATS) for lobectomy: a report of 105 cases.

BACKGROUND: To address the feasibility and advantages of subxiphoid uniportal video-assisted thoracoscopic surgery (VATS) for lobectomy. METHODS: Since August 2014, 105 cases of subxiphoid uniportal VATS lobectomy were successfully performed. The clinical information was retrospectively analyzed. RESULTS: 96 cases underwent unilateral operation and 9 underwent bilateral operations. Surgeries were successfully performed with a complication rate of 10.5%. The average pain scores 8 hours, day 1, 2 and 3 after surgery, as well as the day before discharge were 2.39±0.99, 2.06±0.85, 1.68±0.87, 1.29±0.78, and 0.48±0.51, respectively, which were significantly lower than those in the control group (standard intercostal uniportal VATS) (P<0.001). CONCLUSIONS: The subxiphoid uniportal VATS lobectomy is safe and reliable, which is appropriate for bilateral lung diseases, and significantly relieves postoperative incision pain.

Diagnosis and Treatment Evaluation of 48 Cases of Broncholithiasis.

Background Broncholithiasis is a rare disease with various clinical classifications. The aim of this study was to evaluate the imaging diagnosis and surgical treatment of broncholithiasis. Methods and Materials Forty-eight patients with broncholithiasis were enrolled in this retrospective study between January 1985 and December 2009. Patients were classified into intraluminal, transluminal, and extraluminal broncholith according to the anatomy between the calculus and the bronchial lumen confirmed by chest computed tomography (CT), bronchoscopy, and pathology after operation. Result Forty-eight patients were enrolled, with 33 males and 15 females. The sex ratio (male:female) was 2.2:1, and average age was 54.3 ± 13.6 years. There were 8, 19, and 21 patients in intraluminal, transluminal, and extraluminal broncholith group, respectively. Cough, hemoptysis, and chest pain were the most common symptoms. Four patients with intraluminal broncholith and two with transluminal broncholith underwent broncholith removal via bronchoscopy, and the other 42 patients underwent thoracotomy. Conclusion Bronchoscopy combined with CT examination is helpful in diagnosing and typing broncholithiasis. An optimal treatment method, either bronchoscopic removal of broncholithiasis or thoracotomy, according to the clinical typing and indications, is the key to improve the treatment effect.

A comparative study of video-assisted thoracoscopic resection versus thoracotomy for neurogenic tumours arising at the thoracic apex.

OBJECTIVES: The surgical outcome of neurogenic tumours arising at the thoracic apex remains largely undefined. In this retrospective study, we compared the efficacy and safety of thoracoscopic surgery and thoracotomy for neurogenic tumours at the thoracic apex in 63 patients who received surgical treatment between 1992 and 2012 at our medical centre. METHODS: Forty-four (69.8%) patients received thoracotomy (Group A) and 19 (30.2%) patients underwent video-assisted thoracoscopic surgery (Group B). Operative time, estimated blood loss (EBL), postoperative length of hospital stay and nervous system complications were recorded. RESULTS: The two groups of patients were comparable in demographic and baseline characteristics except that Group A patients had a significantly larger tumour size (mean, 4.9 ± 1.0 cm) than Group B patients (mean, 4.1 ± 1.2 cm; P = 0.01). The mean operative time was markedly greater for Group A (120.2 ± 41.2 min) than Group B (93.2 ± 34.5 min; P = 0.009). Group A had significantly greater EBL (245.23 ± 197.78 ml) than Group B (117.4 ± 138.2 ml; P < 0.001). Total tumour resection was achieved in all patients and all neurogenic tumours were benign. The mean length of postoperative hospital stay was markedly longer in Group A (7.0 ± 2.1 days) than Group B (4.8 ± 2.0; P < 0.001). Postoperatively, brachial plexus injury was found in 1 patient (2.3%) in Group A and 4 patients (21.1%) in Group B (P = 0.026). CONCLUSIONS: Though thoracoscopic surgery is associated with diminished blood loss, reduced operative time and shortened hospital stay, it has a markedly increased incidence of brachial plexus injury.

Common genetic variants on 3q28 contribute to non-small cell lung cancer susceptibility: evidence from 10 case-control studies.

The association between common variations (rs10937405, rs4488809) on 3q28 and lung cancer has been widely evaluated in various ethnic groups, since it was first identified through genome-wide association approach. However, the results have been inconclusive. To derive a more precise estimation of the relationship and the effect of factors that might modify the risk, we performed this meta-analysis. The random-effects model was applied, addressing heterogeneity and publication bias. A total of 10 articles involving 36,221 cases and 58,108 controls were included. Overall, the summary per-allele OR of 1.19 (95 % CI 1.14-1.25, P < 10(-5)) and 1.17 (95 % CI 1.10-1.23, P < 10(-5)) was found for the rs10937405 and rs4488809 polymorphisms, respectively. Significant results were also observed in heterozygous and homozygous when compared with wild genotype for these polymorphisms. Significant results were found in East Asians when stratified by ethnicity, whereas no significant associations were found among Caucasians. After stratifying by sample size, study design, control source and sex, significant associations were also obtained. In addition, our data indicate that these polymorphisms are involved in lung cancer susceptibility and confer its effect primarily in lung adenocarcinoma when stratified by histological subtype. Furthermore, significant associations were also detected both never-smokers and smokers for these polymorphisms. In conclusion, this meta-analysis demonstrated that rs10937405 and rs4488809 are a risk factor associated with increased non-small cell lung cancer susceptibility, particularly for East Asian populations.

Progressive chest wall bleeding caused by bronchial stump nails after lobectomy.

BACKGROUND: Postoperative intrathoracic active bleeding is a serious complication after general thoracic surgery. Yet, progressive chest wall bleeding caused by a bronchial stump nail after lobectomy has rarely been reported. The purpose of this report was to review the causes, surgical treatment, and prevention of progressive chest wall bleeding caused by a bronchial stump nail in patients after lobectomy. METHODS: Between January 2011 and February 2013, approximately 5,000 patients underwent lobectomies for various thoracic diseases in the Department of Thoracic Surgery of Shanghai Pulmonary Disease Hospital in China. Among the 5,000 patients, four required reexploration for progressive postoperative chest wall bleeding caused by bronchial stump nails. RESULTS: Staples were used without covers for the bronchial stumps in these patients. At the time of reoperation, we noted that the main site of bleeding was the pleura corresponding to the bronchial stump. The bleeding pleura sites were coagulated and sutured, and complete hemostasis of the pleura was achieved. The nails on the staple that may have caused the bleeding were removed. Then, muscle or hemostatic material was applied to separate the bronchial stump and corresponding pleura. CONCLUSIONS: Performing surgery carefully and understanding the risk from bronchial stump nails are keys to preventing progressive postoperative bleeding.

Tumor thrombus in left atrium from pulmonary adenosquamous carcinoma.

We report a case of pulmonary adenosquamous carcinoma with a tumor thrombus in the left atrium. The left atrial tumor thrombus and lung cancer were removed via a right pneumonectomy and atriotomy under cardiopulmonary bypass. Simultaneous resection of a left atrial tumor thrombus and lung cancer can prevent systemic embolization, mitral obstruction, and sudden death, and improve the prognosis in selected patients.

Surgical treatment of bronchiectasis: a retrospective observational study of 260 patients.

OBJECTIVE: This study aims to demonstrate our surgical experience for bronchiectasis and analyze the risk factors related with the surgery outcome. METHODS: We retrospectively reviewed medical records of 260 consecutive patients who underwent surgery for bronchiectasis between January 2000 and December 2010. The factors related with the outcome were analyzed and the candidate factors were screened by χ(2) test and t test. Furthermore, logistic regression analysis was used for multiple factor analysis to obtain the independent factors that affected the surgical outcome. RESULTS: Complications occurred in 30 (11.5%) patients during perioperative period. The univariate analysis showed that significant differences can be observed in age (P = 0.000), sputum volume (P = 0.000), smoking history (P = 0.033), pulmonary function (P = 0.003), Gram-negative bacillus infection (P = 0.000), bronchial stump coverage (P = 0.016) using intercostals muscles or pedicle pleura embedding and surgical approach (P = 0.003) between the patients with excellent and poor outcome. The multivariable analyses showed that sputum volume (P = 0.000), Gram-negative bacillus infection (P = 0.000) and bronchial stump coverage (P = 0.000) were the three independent factors related with surgical outcome. CONCLUSION: Surgery is an effective treatment option for bronchiectasis. Sputum volumes lower than 30 mL, negative proof of Gram-negative bacteria and bronchial stump coverage using intercostals muscles or pedicle pleura embedding are the key factors for successful treatment. Special attention has to be given to any complications in elderly patients.

Simplified carinal wedge resection and reconstruction.

Carinal resection remains a technical challenge to thoracic surgeons. There is no single, ideal technique for reconstruction. Reduction of anastomotic tension is the principal concern for carinal resection and reconstruction. We report a case of carinal wedge resection for a carinal tumor; the medial walls of left and right main bronchus were sutured together to create a "neocarina." Thus, maintaining the continuity between the trachea and bronchus has no longitudinal tension. This procedure is feasible for carinal reconstruction with a limited wedge resection.

Association between CLPTM1L polymorphisms (rs402710 and rs401681) and lung cancer susceptibility: evidence from 27 case-control studies.

Genome-wide association studies have identified two SNPs (rs402710 and rs401681) of CLPTM1L at chromosome 5p15.33 as a new lung cancer (LC) susceptibility locus in populations of European descent. Since then, the relationship between these SNPs and LC has been reported in various ethnic groups; however, these studies have yielded inconsistent results. To investigate this inconsistency, we performed a meta-analysis of 27 studies involving a total of 60,828 cases and 109,135 controls for the two polymorphisms to evaluate its effect on genetic susceptibility for LC. An overall random-effects per-allele odds ratio of 1.14 (95% CI 1.11-1.16, P < 10(-5)) and 1.15 (95% CI 1.12-1.19, P < 10(-5)) was found for the rs401681 and rs402710 polymorphism, respectively. Significant results were also observed for under dominant and recessive genetic models. After stratified by ethnicity, significant associations were found among Caucasians and East Asians. In the subgroup analysis by sample size, significantly increased risks were found for these polymorphisms in all genetic models. In addition, we find both rs402710 and rs401681 conferred significantly greater risks for adenocarcinoma and squamous cell carcinoma when stratified by histological type of tumors. Furthermore, associations of these polymorphisms with LC risk were observed among current smokers and former smokers, as well as never smokers. Our findings demonstrated that rs402710 and rs401681 are risk-conferring factors for the development of lung cancer.

Prognostic role of station 3A mediastinal nodes for non-small-cell lung cancers.

OBJECTIVES: Station 3A nodes have been commonly neglected in surgical practice. This retrospective study collected information on the incidence and risk factors of Station 3A node to ascertain the prognostic role of 3A nodal involvement. METHODS: A total of 180 consecutive pN2 (stage IIIa) non-small-cell lung cancer (NSCLC) cases who underwent systemic lymphadenectomy and contained Station 3A nodes were enrolled. Survival rates were calculated according to the final pathology of Station 3A lymph node: Station 3A node (+) and Station 3A node (-). Statistical analysis was conducted using Kaplan-Meier and Cox regression models. RESULTS: Station 3A nodal metastasis was validated in 32 cases, and the incidence of Station 3A node involvement was 17.8%. Station 3A nodes involvement was strongly associated with the metastatic status of Station 4R nodes and histological nature of pulmonary cancer. The overall 3-year survival was 53% and median survival time was 40.6 months. The 3-year survival difference was significant between Station 3A node (-) and Station 3A node (+) (63 vs 22%, χ(2) = 16.426, P < 0.001). Moreover, the overall 3-year survival was closely related with the number of involved nodal zones (χ(2) = 31.156, P < 0.001). Multivariate analysis showed two statistically significant risk factors for survival including metastasis of Station 3A node and the number of positive nodal zones (hazard ratios [HR]: 2.702; 95% confidence intervals [CI]: 1.008-7.242; P = 0.027; and HR: 7.404; 95% CI: 3.263-16.936, P < 0.001, respectively). CONCLUSIONS: The involvement of Station 3A lymph nodes predicts poor prognosis of right-sided stage pIIIa-N2 NSCLC patients. Therefore, systemic lymphadenectomy for right-sided cancers should include Station 3A nodes when ascertaining a complete resection.

[Clinical analysis of 81 cases of pulmonary cryptococcosis].

OBJECTIVE: To clarify the clinical feature, diagnosis and therapy of the pulmonary cryptococcosis (PC). METHODS: A retrospective study of cases with PC who were diagnosed by pathological examinations between January 1996 and December 2010 was conducted. Eighty-one cases were enrolled in the study (58 male and 23 female patients; mean age of (51±11) years). Forty-one cases were asymptomatic at the time of diagnosis. There were single pulmonary lesions in 50 cases, and multiple lesions in 31 cases. Fourteen lesions (17.3%) were located in left upper lobe, 27 (33.3%) in left lower lobe, 21 (25.9%) in right upper lobe, 3 (3.7%) in right middle lobe, 28 (34.6%) in right lower lobe, and 3 (3.7%) diffusely involved bilateral lungs. The tumors ranged from 0.8 to 10.0 cm in diameter with a mean of (2.9±1.8) cm. All the cases were misdiagnosis prior to the surgical resection, and histologically confirmed by postoperative pathological specimens. RESULTS: All the cases received surgical treatment including complete resection in 69 cases, and palliative resection in 12 cases. Resections were performed by means of video-assisted thoracoscopy in 31 cases and thoracotomy in 50 cases. Surgical resections included pulmonary wedge excisions in 42 cases, and lobectomies in 39 cases. After histological confirmation, 63 cases (77.8%) were treated with antifungal agents, which consisted of fluconazole in 38 cases, itraconazole in 18 cases, amphotericin B in 6 cases, and flucytosine in 4 cases. There were no intraoperative death, but two cases died for cryptococcal meningoencephalitis in the postoperative period. Operative morbidity occurred in 7 (8.6%) cases. The median follow-up was 42.5 months (6 to 84 months). There were 2 local relapses of PC, and 9 cases with complications of anti-fungal agents. CONCLUSIONS: The clinical manifestations of PC are mild and non-specific, with no characteristic radiographic manifestations. Surgical resection is usually indicated for definite diagnosis and treatment. Antifungal drug therapy is indispensable even after complete resection.

Surgical treatment for pulmonary aspergilloma: a 35-year experience in the Chinese population.

The surgical treatment of pulmonary aspergilloma is challenging and controversial. This study was designed to evaluate the clinical profile, indications and surgical outcomes of pulmonary aspergilloma operated on in our institute. A total of 256 patients with pulmonary aspergilloma underwent surgical treatment from 1975 to 2010. The patients were divided into two groups: Group A (simple aspergilloma, n = 96) and Group B (complex aspergilloma, n = 160). The principal underlying lung disease was tuberculosis (71.1%). The surgical procedures consisted of 212 lobectomies in both groups; eight cavernoplasties, 10 bilobectomies, 16 pneumonectomies and six thoracoplasties in Group B; four segmentectomies and six wedge resections in Group A. Postoperative complications occurred in 40 patients (15.6%). The major complications were residual pleural space (3.9%), prolonged air leak (3.1%), bronchopleural fistula (1.6%), excessive bleeding (1.6%), respiratory insufficiency (1.9%) and empyema (1.2%). No intraoperative deaths occurred. The overall mortality within 30 days post-operation was 1.2%, occurring only in Group B. There was no statistically significant difference in the postoperative morbidity between Groups A and B (P = 0.27). With the good selection of patients, meticulous surgical techniques and good postoperative management, aggressive surgical treatment with anti-fungal therapy for pulmonary aspergilloma is safe and effective, and can achieve favourable outcomes.

[Surgery treatment for pulmonary sclerosing hemangioma].

OBJECTIVE: To investigate the clinicopathological features and surgical treatment of pulmonary sclerosing hemangioma (PSH). METHODS: Clinic data of PSH patients admitted by surgical resection from January 1985 to December 2010 was analyzed retrospectively. One hundred and sixty-five patients were enrolled in the study. There were 27 male and 138 female patients with a mean age of (48 ± 13) years. Seventy-nine patients were asymptomatic at the time of diagnosis. Eighty-nine tumors arose in the right lung (27 in right upper lobe, 24 in right middle lobe, 34 in right lower lobe, 2 in right upper lobe with invasion of right middle lobe, 1 in right middle lobe with invasion of right lower lobe, and 1 case with multiple lobe lesions), 75 in the left (33 in left upper lobe, 42 in left lower lobe), and 1 in the bilateral. There were huge mass lesions in 2 cases, endobronchial lesions in 2 cases, and multiple lesions in 6 cases. The mean size of the lesion was (2.6 ± 0.9) cm (ranging from 0.9 to 10.0 cm). Forty-eight cases (29.1%) were misdiagnosed as malignancies preoperatively, and 41 cases (24.8%) were misdiagnosed intraoperatively. RESULTS: Resections were performed by means of video-assisted thoracoscopy (n = 53) and thoracotomy (n = 112). Surgical resection included pulmonary wedge excision in 61 patients, lobectomy in 89 patients, right bilobectomy in 5 patients, anatomic segmentectomy in 2 patient, enucleation in 6 patients, and synchronous bilateral pulmonary wedge resection in 1 patient. Operative mortality and morbidity occurred in 0 and 2 (4.3%) patients, respectively. Mean follow-up was 34.7 months (ranging from 6 to 62 months). There was no local recurrence or death from PSH. CONCLUSIONS: PSH is a rare benign lung tumor. It is difficult to make accurate diagnosis preoperatively, and sometimes even intraoperative frozen sections can't differentiate it from malignant tumors. Surgical resection is usually indicated for definite diagnosis and treatment. Partial resection is a sufficient treatment in view of uncommon tumor recurrence. Thoracoscopic surgery is recommended for PSH.

Smoking reduces survival in young females with lung adenocarcinoma after curative resection.

The aim of this study was to investigate effects of smoking on the overall survival of young female lung adenocarcinoma patients after curative resection. A total of 282 surgically treated young females (younger than 40) with histologically confirmed primary lung adenocarcinoma were studied retrospectively. Overall survivals (OS) and related prognostic factors were analyzed. The 5-year OS of current-smokers and non-smokers were 20 and 36.6%, respectively (P = 0.03). As for patients with stage I disease, the 5-year OS of current-smokers and non-smokers were 50 and 68.8%, respectively, (P = 0.02). Smoking (RR = 3.15, CI 1.726-8.786) was identified as an independent prognostic factor. Current-smokers (21.4 vs. 14.5%, P = 0.03) and non-smokers (37.9 vs. 28.8%, P = 0.02) all benefited from adjuvant chemotherapy. Among young female patients with adenocarcinoma, current-smokers have a lower survival rate than non-smokers, especially patients with stage I disease.

Local extension at the hilum region is associated with worse long-term survival in stage I non-small cell lung cancers.

BACKGROUND: The prognostic significance of hilar structures invasion, which remains undefined for non-small cell lung cancer (NSCLC), may have potential application for cancer staging. Tumor extension along the bronchus and pulmonary vessels was examined for survival significance. METHODS: In all, 213 pathologically proved central-type stage I NSCLC cases were enrolled. Four study groups were assigned based on the extent of resections: standard lobectomy (group L, n=32), bronchoplastic procedures (group B, n=94), standard lobectomy combined with pulmonary angioplasty (group A, n=48), and bronchial sleeve resection combined with pulmonary artery angioplasty (group BA, n=39). Univariate and multivariate analysis were performed by the Kaplan-Meier method and the Cox regression model. RESULTS: There were 2 postoperative deaths (pulmonary embolism and serious pulmonary infection). Complications were noted in 39 patients (18.3%). Among these patients, the overall 5-year survival rate was 60.2%±0.05%, with a median survival time of 75.0±7.5 months. The 5-year survival rates of subgroups were 79.5%, 59.7%, 59.0%, and 47.9%, respectively for groups L, B, A, and BA. Univariate analysis indicated tumor size, bronchial invasion, arterial involvement, and type of operation as closely associated with long-term survival. Multivariate analysis indicated that type of operation and tumor size were the most prominent prognostic factors of 5-year survival. CONCLUSIONS: Proximal tumor extension into bronchus, invasions into extrapericardial pulmonary vessels, and tumor size were the most important risk factors for 5-year survival with central-type stage I NSCLC. Tumor extension in the hilum was highly related to prognosis and might provide pertinent information to accurately define a tumor ("T") subclass.