Foreign Body Reaction Mimicking Lymph Node Metastasis is Not Rare After Lung Cancer Resection.

BACKGROUND: Mediastinal lymphadenopathies with high 18-fluorodeoxyglucose uptake in patients previously operated on for lung cancer are alarming for recurrence and necessitate invasive diagnostic procedures. Peroperative placement of oxidized cellulose to control minor bleeding may lead to a metastasis-like image through a foreign body reaction within the dissected mediastinal lymph node field at postoperative examinations. In this study, we investigated clinicopathological features and the frequency of foreign body reaction mimicking mediastinal lymph node metastasis. METHODS: Patients who underwent surgery for lung cancer between January 2016 and August 2021 and who were subsequently evaluated for mediastinal recurrence with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) were included. Patients were grouped according to the results of EBUS-TBNA as metastasis, foreign body, and reactive. Clinicopathological features of these patients were compared and characteristics of patients in the foreign body group were scrutinized. RESULTS: EBUS-TBNA was performed on a total of 34 patients during their postoperative follow-up due to suspicion of mediastinal recurrence. EBUS-TBNA pathological workup revealed metastasis in 18 (52.9%), foreign body reaction in 10 (29.4%) and reactive lymph nodes in 6 (17.6%) patients. Mean maximum standardized uptake value (SUVMax) for metastasis group and foreign body group were 9.39 ± 4.69 and 5.48 ± 2.54, respectively (p = 0.022). Time interval between the operation and EBUS-TBNA for the metastasis group was 23.72 ± 10.48 months, while it was 14.90 ± 12.51 months in the foreign body group (p = 0.015). CONCLUSION: Foreign body reaction mimicking mediastinal lymph node metastasis is not uncommon. Iatrogenic cause of mediastinal lymphadenopathy is related to earlier presentation and lower SUVMax compared with metastatic lymphadenopathy.

N1 lymph node detection in lymph node harvesting in non-small cell lung cancer: Formaldehyde exposure is a drawback?

OBJECTIVE: This study aimed to evaluate the effect of lymph node dissection method on staging results, diagnosis of tumor metastasis in single or multiple N1 lymph nodes and survival rates in patients with non-small cell lung cancer (NSCLC). METHODS: Patients with NSCLC who underwent anatomic resection between September 2014 and October 2019 were examined prospectively. All patients with similar clinico-demographic characteristics were randomly assigned to either the surgical group (n = 83) or the pathology group (n = 87). Lymph node dissection was performed by the surgeon in the surgical group and by the pathologists after formaldehyde exposure in the pathology group. Data were analyzed according to formaldehyde exposure, N1 positivity, and number of N1 positive lymph nodes. RESULTS: There were no significant differences in N1 lymph node positivity between the two groups (p = 0.482). On average 9.08 lymph node sampling was performed in the surgical group and 2.39 in the pathology group (p = 0.0001). Multiple lymph node involvement was significantly higher in the surgical group (P = 0.0001) than in the pathology group. CONCLUSION: It is easier to detect lymph node involvement without introducing formaldehyde into the sample. We recommend that N1 lymph node dissection be performed on fresh specimens to detect more lymph node involvement.

Is intensive care necessary after major thoracic surgery? A propensity score-matched study.

Background: This study aims to compare the surgical results, complications, mortality rates, and inpatient costs in two patient groups followed, whether in the intensive care unit or general ward after a major thoracic procedure and to examine clinical and surgical factors related to the development of complications. Methods: Between January 2018 and June 2021, a total of 485 patients (150 males, 335 females; mean age: 58.3±13.2 years; range, 22 to 86 years) who underwent a major thoracic surgery in our clinic were retrospectively analyzed. The patients were divided into two groups as the intensive care unit patients (n=254) and general ward patients (n=231). In the former group, the patients were followed in the intensive care unit for a day, while in the general ward group, the patients were taken directly to the ward. The groups were compared after propensity score matching. All patients were analyzed for risk factors of morbidity development. Results: After propensity score matching, 246 patients were enrolled including 123 patients in each group. There was no statistically significant difference between the groups in any features except for late morbidity, and inpatient costs were higher in the intensive care unit group (p<0.05). In the multivariate analysis, age, American Society of Anesthesiologists Class 3, and secondary malignancy were found to be associated with morbidity (p<0.05). Conclusion: In experienced centers, it is both safe and costeffective to follow almost all of the major thoracic surgery patients postoperatively in the general ward.

Differential Impact of Spread Through Air Spaces on Subtypes of Early-stage Lung Cancer.

OBJECTIVE: To investigate the prognostic significance of STAS (Spread through air spaces) and its effect on survival in the various types of non-small cell lung cancer (NSCLC). STUDY DESIGN: Descriptive analytical study. Place and Duration of the Study: Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkiye, between 2018 and 2021. METHODOLOGY: Early-stage lung cancer patients who underwent lobectomy were included. STAS was defined as presence of tumour cell clumps, solid nests or set of single cells located in airway spaces apart from the main tumour border and determined by pathological work-up. The clinical significance of STAS was investigated by means of histopathological subtype, tumour size, and maximum standardised uptake value (SUVmax) on PET-CT scan in early-stage lung cancer by grouping it as adenocarcinoma and non-adenocarcinoma. Five-year overall and disease-free survival, and recurrence were the outcome measures. RESULTS: A total of 165 patients were included in the study. No recurrence was observed in 125 patients, 40 patients developed recurrence. Five-year overall survival (OS) was 69.6% in STAS (+) cohort and 74.5% in STAS (-) cohort (p=0.88). Five-year disease-free survival (DFS) was 51.1% in STAS (+) cohort and 73.1% for STAS (-) cohort (p=0.034). While the absence of STAS in the adenocarcinoma group was associated with better DFS, lower SUVMax and smaller tumour size, similar results were not found to be at statistically significant level in the non-adenocarcinoma group. CONCLUSION: STAS positivity makes a difference in DFS, tumour size and SUVmax, especially in adenocarcinoma, however, it does not create a significant difference in survival or clinic pathological features in the non-adenocarcinoma. KEY WORDS: Lung Cancer, Lobectomy, Spread through air spaces, Survival, Prognosis.

Effect of coolant spray on rib fracture pain of geriatric blunt thoracic trauma patients: a randomized controlled trial.

OBJECTIVE: This study aimed to evaluate the effectiveness of cryotherapy in elderly patients with rib fractures due to blunt thoracic trauma. METHODS: In this prospective randomized controlled study, geriatric patients were assigned to groups to receive either coolant spray (n=51) or placebo spray (n=50). The visual analog scale scores of all patients were recorded before starting spray application (V0), as well as at 10th (V1), 20th (V2), 30th (V3), 60th (V4), 120th (V5), and 360th (V6) minute. The mean decreases in the visual analog scale scores were calculated. RESULTS: The differences between V0 and V1, V0 and V2, V0 and V3, and V0 and V4 mean visual analog scale scores measured in the coolant spray group were found to be significantly higher (p<0.001). In V1, V2, V3, and V4 measurements, the incidence of "clinical effectiveness" in the coolant spray group was significantly higher than in the placebo group (p=0.001). CONCLUSIONS: Coolant spray therapy can be used as a component of multimodal therapy to provide adequate analgesia due to rib fractures in geriatric patients.

Effect of coolant spray on rib fracture pain of geriatric blunt thoracic trauma patients: a randomized controlled trial

SUMMARY OBJECTIVE: This study aimed to evaluate the effectiveness of cryotherapy in elderly patients with rib fractures due to blunt thoracic trauma. METHODS: In this prospective randomized controlled study, geriatric patients were assigned to groups to receive either coolant spray (n=51) or placebo spray (n=50). The visual analog scale scores of all patients were recorded before starting spray application (V0), as well as at 10th (V1), 20th (V2), 30th (V3), 60th (V4), 120th (V5), and 360th (V6) minute. The mean decreases in the visual analog scale scores were calculated. RESULTS: The differences between V0 and V1, V0 and V2, V0 and V3, and V0 and V4 mean visual analog scale scores measured in the coolant spray group were found to be significantly higher (p<0.001). In V1, V2, V3, and V4 measurements, the incidence of "clinical effectiveness" in the coolant spray group was significantly higher than in the placebo group (p=0.001). CONCLUSIONS: Coolant spray therapy can be used as a component of multimodal therapy to provide adequate analgesia due to rib fractures in geriatric patients.

Adipose tissue provides a cushioning effect in low-energy isolated blunt thoracic trauma: a prospective observational study.

INTRODUCTION: This study aimed to investigate the specific effects of subcutaneous adipose tissue thickness (SATT) on trauma-related injury (TRI) development in patients with low-energy isolated blunt thoracic trauma. PATIENTS AND METHODS: This prospective observational study was performed between March 2018-March 2019. Patients admitted to our hospital because of blunt thoracic trauma were enrolled. SATT in axial CT images of the thorax was measured using the four anatomically designated localizations. Patients were analyzed in terms of demographic data, BMI, comorbid diseases, causes of injury, vital parameters, visual analog scale, trauma score, injury type, treatment, and hospitalization. A poor clinical outcome was defined as the development of a TRI. RESULTS: The study group consisted of 152 patients (43 female, 109 male). The mean age was 49 ± 19.1 years. There was a positive linear association between the BMI and SATT for all the patients in the study. TRI frequency was higher in the low-SATT subgroup than in the high-SATT group (p < 0.001). BMI and mean SATT values were related to a poor logistic regression analysis outcome (p < 0.01). Being in the low-BMI subgroup was a risk factor for TRI development (p < 0.01; OR:0.23;95% CI:0.08-0.61). CONCLUSION: We found that a low SATT and BMI were related to a poor clinical outcome in our study group. It is essential to carefully examine these patients in detail, even in low-energy trauma. Subcutaneous tissue over the thorax serves as a protective shield for other thoracic structures in patients with LEBTT.

Short-Term Outcomes of Fiberoptic Bronchoscopy-guided Resection and Anastomosis Control in Thoracic Surgery.

BACKGROUND: In thoracic surgery practice, bronchial closure and anastomosis are relatively easy in technical terms; however, it is also the procedure that is most open to the development of complications with high morbidity. This study aimed to investigate the effect of simultaneous evaluation of bronchial closure under fiberoptic bronchoscopy guidance during lung resection on the development of complications. MATERIALS AND METHODS: Patients aged over 18 years who underwent elective lung resection in our clinic between 2017 and 2021 were included in the study. Postoperative complications were recorded and statistically analyzed. RESULTS: The mean age of the patients was 61.4±10.4 years, and 267 patients were male (75.4%) and 87 (24.6%) were female. Thoracotomy was performed in 258 (72.9%) patients and lung resection with the video-assisted thoracoscopic surgery technique in 96 (27.1%) patients. During the follow-up, complications were observed during the first 30 days in 78 (22.0%) of the patients and later in 9 (2.5%). Surgical mortality occurred in 11 patients (3.1%), and the rate of readmission to the intensive care unit was 5.6% (n=20). CONCLUSION: We consider that the control of the resection line with the active use of fiberoptic bronchoscopy during surgery is important for the prevention of the development of bronchial morbidity. Complications in the early period can be reduced by ensuring that the remaining bronchus is not narrowed, there are no residual stump structures that may disrupt the bronchial line, such as cartilage, and bronchial washing is frequently undertaken.

Comparison of ibuprofen and piroxicam gel in the treatment of trauma pain: A randomized double-blind trial of geriatric population.

OBJECTIVE: This study aimed to compare the analgesic efficacy of topical ibuprofen and topical piroxicam for acute musculoskeletal injuries. METHODS: In this prospective, randomized, controlled, double-blinded study, geriatric patients were assigned to groups to receive either topical ibuprofen (n = 70) or topical piroxicam (n = 69). The first dose of gel was applied in the emergency department and the remaining doses were self-administered at home by the patients thrice daily for 72 h. For each patient, the initial baseline visual analog scale (VAS) score (V 0) was compared with the VAS scores at the 60 min (V1), 120 min (V2), 24 h (V3) and 72 h (V4) time points. The decreases in VAS scores, clinical effectiveness of the treatments, and incidence of adverse events were evaluated. RESULTS: In the topical ibuprofen group, the VAS scores were significantly lower at each measurement time point compared to baseline (p < .001). The results were as follows: V0 -V: 1.08, 95% CI: 0.56-1.61; V0 -V2: 1.09, 95% CI: 0.49-1.69; V0 -V3: 1.44, 95% CI: 0.81-2.07; V0 -V4: 1.59, 95% CI: 0.91-2.26. The mean percentage decrease in the VAS scores in the topical ibuprofen group was significantly higher than that in the topical piroxicam group (p < .001). The clinical effect of treatment was found to be significantly higher for the ibuprofen gel group (p < .001). There was no substantial difference in treatment-related adverse events between the groups (p > .05). CONCLUSION: Ibuprofen gel, which is a safe treatment option for geriatric patients, is more clinically effective than piroxicam gel. Response to Reviewers.

Prognostic Importance of the Lymph Node Factor in Surgically Resected Non-Small Cell Lung Cancer.

BACKGROUND: Patients with N1 non-small cell lung cancer represent a heterogeneous population. The aim of this study is to determine the difference of survival rate between subtypes of N1 disease in surgically resected non-small cell lung cancer patients and to compare the survival in these patients with multi-N1 and single N2 (skip metastasis) disease. METHODS: Patients who underwent anatomical pulmonary resection in our institution between 2007 and 2014 with a pathological diagnosis of N1 and single N2 positive non-small cell lung cancer were included in the study. N1 positive patients were divided into three groups as single hilar; single interlobar, lobar, or segmental; and multiple N1 positive patients. These groups were compared among themselves as well as with incidentally found single N2 patients. RESULTS: A total of 1,742 patients who had non-small cell lung cancer underwent anatomical lung resection. The survival was better in single hilar lymph nodes than other subtypes of N1 disease (p = 0.015). There was no statistically significant difference in terms of survival between the other subtypes of N1 disease (p = 0.332). The difference in survival for single N2 disease compared with multi-N1 was not statistically significant (p = 0.054). Also, when we divided the groups as single and multi-N1, there was a significant difference in survival (p = 0.025). CONCLUSION: Single hilar lymph nodes with direct invasion have better survival rate than other subtypes of N1. Also, patients with multiple N1 positive lymph nodes have similar survival results compared with single N2 patients. Our results should be confirmed with larger series to better explain N1 disease.

Results of surgical resection in lung cancer with synchronous brain metastasis.

BACKGROUND: This study aims to investigate the factors affecting the survival of operated non-small cell lung cancer patients with synchronous brain metastasis. METHODS: Clinical outcomes of a total of 16 patients (14 males, 2 females; mean age 60 years; range, 41 to 71 years) who were diagnosed with non-small cell lung cancer and concomitant solitary/oligo brain metastasis and who underwent an intervention primarily for cranium, followed by lung resection in our clinic between January 2012 and January 2016 were retrospectively analyzed. Cranial surgery or gamma-knife radiosurgery was performed in the treatment of brain metastases. RESULTS: Twelve patients with solitary brain metastasis underwent cranial surgery, while four patients with solitary/oligo metastases underwent gamma-knife radiosurgery prior to pulmonary resection. Definitive pathological examination revealed adenocarcinoma in 13 patients and squamous-cell lung carcinoma in three patients. Mean survival time was 15.3±8.6 months. One-year and two-year survival rates were 56.2% and 32%, respectively. The number of brain metastases, treatment type, tumor cell type, resection type, and status of lymph nodes were not statistically significantly associated with survival (p>0.05). CONCLUSION: Cranial surgery or gamma-knife radiosurgery followed by aggressive lung resection can be effectively applied in selected non-small cell lung cancer patients with synchronous brain metastasis. However, the suitability of the primary tumor and brain metastases for complete resection is of utmost importance in patient selection.

Rapidly growing cystic hygroma in an adult patient.

Cystic hygroma is a benign tumor of lymphatic tissue. It usually develops before the second year of life and is rarely seen in adults. A 26-year-old woman was referred to our clinic with a swelling in the left supraclavicular region, which had appeared 5 months earlier and grown rapidly. Ultrasonography, computed tomography, and magnetic resonance imaging showed a 7-cm cystic lesion in the neighborhood of the carotid artery and jugular vein medially and the supraclavicular region inferiorly The lesion was dissected completely from the surrounding tissue. The patient had no complications and was discharged on postoperative day one.

The Feasibility of Thoracoscopic Resection in Bronchiectasis.

INTRODUCTION: Minimally invasive surgery is the treatment of choice in early-stage lung cancer. However, experience in infectious lung disease, primarily bronchiectasis, is limited probably because of the presence of dense pleural adhesions, multiple lymph nodes, and spiral bronchial arteries. The present study shows our experience of video-assisted thoracoscopic surgery (VATS) lobectomy and segmentectomy in the treatment of bronchiectasis. MATERIALS AND METHODS: Patients who underwent VATS lobectomy or segmentectomy in our clinic between April 2008 and 2015 were retrospectively evaluated. Surgery was indicated in patients with radiologic localized bronchiectasis who also had a history of recurrent lower respiratory tract infection or expectorating mucopurulent secretion. The patients were analyzed in terms of age, sex, thoracotomy conversion rate, postoperative drainage amount, chest tube removal time, length of hospital stay, morbidity, and mortality. RESULTS: A total of 44 patients initially underwent VATS pulmonary anatomic resection and 41 procedures were completed on 40 patients. One patient had bilateral resection. Fifteen patients were male individuals and 26 were female individuals. The average age was 31.4 (15 to 57) years. Forty lobectomies and 1 segmentectomy were performed. The conversion rate was 6.8%. VATS was performed on 28 patients by 3 ports, 8 patients by 2 ports, and 5 patients by a single port. In terms of anatomic resections, 18 patients underwent left lower lobectomy, 8 right lower lobectomy, 8 middle lobectomy, 6 right upper lobectomy, and 1 patient underwent lingular segmentectomy. No major postoperative complication or mortality was observed. Prolonged air leak was observed in 2 patients and subcutaneous emphysema occurred in 2 patients. The average postoperative drainage amount, chest tube removal time, and length of hospital stay were 320 mL, 3.1 (1 to 11) days, and 4.6 (2 to 11) days, respectively. CONCLUSIONS: VATS pulmonary resection is a safe, feasible, and effective treatment in the surgery of bronchiectasis with low morbidity and mortality rates. Moreover, because of cosmetic results, patients with benign diseases such as bronchiectasis could be initiated by minimally invasive surgery options just like patients with malignancies.

The Effect of Pregabalin and Methylcobalamin Combination on the Chronic Postthoracotomy Pain Syndrome.

BACKGROUND: Chronic postthoracotomy pain (CPTP) consists of different types of pain. Some characteristics of CPTP are the same as those of recognized neuropathic pain syndromes. We aimed to determine the safety and efficacy of pregabalin and methylcobalamin combination (PG-B12) in comparison with diclofenac potassium (DP) in patients with CPTP. METHODS: One hundred consecutive patients with CPTP after posterolateral/lateral thoracotomy were prospectively randomly assigned and evaluated. Fifty patients were given PG-B12 and another 50 patients were given DP treatment. Visual Analogue Scale (VAS) and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scorings were performed previous to the treatment (day 0) and on the 15th, 30th, 60th, and 90th days. Adverse events were questioned. RESULTS: The mean ages were 58.7 ± 12.2 and 54.6 ± 14.5 years, and the mean durations of pain were 4.01 ± 1.04 and 3.8 ± 1.02 months, respectively. The number of patients with a VAS score less than 5 at the latest follow-up (VAS90 < 5) was 44 (88%) and 18 (36%) in the PG-B12 and DP groups, respectively (p < 0.05). Forty-four patients (88%) in the PG-B12 group and 16 patients (32%) in the DP group had a LANSS score less than 12 at the latest follow-up (p < 0.05). Minor adverse events that did not mandate discontinuation of the treatment were observed in 14 patients (28%) in the PG-B12 group and 2 patients (4%) in the DP group. CONCLUSIONS: PB-B12 is safe and effective in the treatment of CPTP with minimal side effects and a high patient compliance. These results should be supported by multidisciplinary studies with larger sample sizes and longer follow-ups.

Management and Surgical Outcomes of Concurrent Tuberculosis and Lung Cancer.

Background Concurrent pulmonary tuberculosis (TB) and lung cancer are rarely encountered in Western countries; however, it is more common in developing countries. We aim to share the diagnostic and treatment approaches in this study. Materials and Methods Clinical files of all patients undergoing lung resection for non-small cell carcinoma with concurrent pulmonary TB between February 2006 and December 2012 were investigated retrospectively in terms of patient characteristics, operation methods, definite pathology and stage of tumor, postoperative treatment schemes, and associated complications. Results TB was detected in 17 (1.3%) of 1,266 operated carcinoma patients. Eleven had squamous cell carcinoma and six had adenocarcinoma. Mean age was 54.9 years. Two patients received anti-TB treatment preoperatively. Fifteen patients were given anti-TB treatment postoperatively, as soon as definite microbiological confirmation was obtained, and concurrently given adjuvant therapy after 3 weeks of sole four-drug TB treatment. Pneumonectomy was performed in four (23.5%), sleeve lobectomy in three (17.6%), lobectomy in eight (47%), and bilobectomy in two (11.7%) patients. Postoperative complications occurred in four (23.5%) patients, with bronchopleural fistula being seen in only one pneumonectomy patient. No postoperative mortality or reactivation of TB was seen. Mean survival time was 32 ± 2 months. Conclusion Resection following a 3-week anti-TB treatment or concurrent anti-TB and postoperative adjuvant chemotherapy does not constitute an additional postoperative risk for patients with concomitant lung malignancy and pulmonary TB. The determination of optimum treatment for these patients presents a challenge in developing countries, where TB is still a common disease.

The Most Minimally Invasive Lobectomy: Videomediastinoscopic Lobectomy.

Transcervical approaches are well-described procedures. However, they are performed in a limited number of experienced centers. Transcervical lobectomies are even rarer. However, these lobectomy cases defined in the literature are performed through a collar incision with the aid of a sternal retractor. The case presented here describes the first right upper lobectomy through videomediastinoscopy without sternal elevation.

Is single port enough in minimally surgery for pneumothorax?

BACKGROUND: Video-assisted thoracoscopic surgery is a widespread used procedure for treatment of primary spontaneous pneumothorax patients. In this study, the adaptation of single-port video-assisted thoracoscopic surgery approach to primary spontaneous pneumothorax patients necessitating surgical treatment, with its pros and cons over the traditional two- or three-port approaches are examined. METHODS: Between January 2011 and August 2013, 146 primary spontaneous pneumothorax patients suitable for surgical treatment are evaluated prospectively. Indications for surgery included prolonged air leak, recurrent pneumothorax, or abnormal findings on radiological examinations. Visual analog scale and patient satisfaction scale score were utilized. RESULTS: Forty triple-port, 69 double-port, and 37 single-port operations were performed. Mean age of 146 (126 male, 20 female) patients was 27.1 ± 16.4 (range 15-42). Mean operation duration was 63.59 ± 26 min; 61.7 for single, 64.2 for double, and 63.8 min for triple-port approaches. Total drainage was lower in the single-port group than the multi-port groups (P = 0.001). No conversion to open thoracotomy or 30-day hospital mortality was seen in our group. No recurrence was seen in single-port group on follow-up period. Visual analog scale scores on postoperative 24th, 48th, and 72nd hours were 3.42 ± 0.94, 2.46 ± 0.81, 1.96 ± 0.59 in the single-port group; significantly lower than the other groups (P = 0.011, P = 0.014, and P = 0.042, respectively). Patient satisfaction scale scores of patients in the single-port group on 24th and 48th hours were 1.90 ± 0.71 and 2.36 ± 0.62, respectively, indicating a significantly better score than the other two groups (P = 0.038 and P = 0.046). CONCLUSIONS: This study confirms the competency of single-port procedure in first-line surgical treatment of primary spontaneous pneumothorax.