Malignant Solitary Fibrous Tumor of the Mediastinum with Multiple Recurrences and a Rare Metastasis to the Thyroid Gland: A Case Report.

Solitary fibrous tumors (SFTs) are rare neoplasms arising from mesenchymal cells. Although most SFTs are benign, rare cases of metastasis have been reported at various sites. Complete surgical resection is the mainstay of treatment for both primary and recurrent or metastatic SFTs. Herein, we present a case of an SFT initially identified in the anterior mediastinum that later developed multiple metastases, even to the thyroid gland. The patient underwent repeated surgical resection and is currently being followed up in an outpatient setting.

Genetic Alterations and Risk Factors for Recurrence in Patients with Non-Small Cell Lung Cancer Who Underwent Complete Surgical Resection.

A definitive surgical resection is the preferred treatment for early-stage non-small cell lung cancer (NSCLC). Research on genetic alterations, including epidermal growth factor receptor (EGFR) mutations, in early-stage NSCLC remains insufficient. We investigated the prevalence of genetic alterations in early-stage NSCLC and the association between EGFR mutations and recurrence after a complete resection. Between January 2019 and December 2021, 659 patients with NSCLC who underwent curative surgical resections at a single regional cancer center in Korea were recruited. We retrospectively compared the clinical and pathological data between the recurrence and non-recurrence groups. Among the 659 enrolled cases, the median age was 65.86 years old and the most common histology was adenocarcinoma (74.5%), followed by squamous cell carcinoma (21.7%). The prevalence of EGFR mutations was 43% (194/451). Among them, L858R point mutations and exon 19 deletions were 52.3% and 42%, respectively. Anaplastic lymphoma kinase (ALK) rearrangement was found in 5.7% of patients (26/453) and ROS proto-oncogene 1 (ROS1) fusion was found in 1.6% (7/441). The recurrence rate for the entire population was 19.7%. In the multivariate analysis, the presence of EGFR mutations (hazard ratio (HR): 2.698; 95% CI: 1.458-4.993; p = 0.002), stage II (HR: 2.614; 95% CI: 1.29-5.295; p = 0.008) or III disease (HR: 9.537; 95% CI: 4.825-18.852; p < 0.001) (vs. stage I disease), and the presence of a pathologic solid type (HR: 2.598; 95% CI: 1.405-4.803; p = 0.002) were associated with recurrence. Among the recurrence group, 86.5% of the patients with EGFR mutations experienced distant metastases compared with only 66.7% of the wild type (p = 0.016), with no significant difference in median disease-free survival (52.21 months vs. not reached; p = 0.983). In conclusion, adjuvant or neoadjuvant targeted therapy could be considered more actively because EGFR mutations were identified as an independent risk factor for recurrence and were associated with systemic recurrence. Further studies on perioperative therapy for other genetic alterations are necessary.

Intracardiac Thymoma with Superior Vena Cava and Left Brachiocephalic Vein Extension: A Case Report.

Thymomas are common anterior mediastinal tumors with a relatively favorable prognosis compared to that of other types of thoracic malignancies. However, thymomas that invade surrounding structures, such as the heart or vena cava, have been infrequently reported, and intracardiac thymomas are exceedingly rare. Treatment of invasive thymoma is difficult because the high rate of incomplete resection results in a high rate of recurrence. Herein, we present a rare case of a thymoma that originated in the right atrium and extended into the superior vena cava and brachiocephalic vein.

Surgical Experience with Descending Necrotizing Mediastinitis: A Retrospective Analysis at a Single Center.

Background: We analyzed our experience with descending necrotizing mediastinitis (DNM) treatment and investigated the efficacy of video-assisted thoracoscopic surgery (VATS) for mediastinal drainage. Methods: This retrospective analysis included patients who underwent surgical drainage for DNM at our hospital from 2005 to 2020. We analyzed patients' baseline characteristics, surgical data, and perioperative outcomes and compared them according to the mediastinal drainage approach among patients with type II DNM. Results: Twenty-five patients (male-to-female ratio, 18:7) with a mean age of 54.0±12.9 years were enrolled in this study. The most common infection sources were pharyngeal infections (60%). Most patients had significantly increased white blood cell counts, elevated C-reactive protein levels, and decreased albumin levels on admission. The most common DNM type was type IIB (n=16, 64%), while 5 and 4 patients had types I and IIA, respectively. For mediastinal drainage, the transcervical approach was used in 15 patients and the transthoracic approach (VATS) in 10 patients. The mean length of hospital stay was 26.5±23.8 days, and the postoperative morbidity and in-hospital mortality rates were 24% and 12%, respectively. No statistically significant differences were found among patients with type II DNM between the transcervical and VATS groups. However, the VATS group showed shorter mean antibiotic therapy duration, drainage duration, and hospital stay length than the transcervical group. Conclusion: DNM manifested as severe infection requiring long-term inpatient treatment, with a mortality rate of 12%. Thus, active treatment with a multidisciplinary approach is crucial, and mediastinal drainage using VATS is considered relatively safe and effective.

Prognostic significance of location index in resected T1-sized early-stage non-small cell lung cancer.

BACKGROUND: While the central location is a known adverse prognostic factor in lung cancer, a precise definition of central lung cancer has not yet emerged. PURPOSE: To determine the prognostic significance of central lung cancer (defined by location index) in resected T1-sized early-stage non-small cell lung cancer (NSCLC). MATERIAL AND METHODS: Patients with resected T1-sized early-stage NSCLC between 2010 and 2015 at a single tertiary cancer center were retrospectively reviewed. Central lung cancer was defined by a location index of the second tertile or less. Kaplan-Meier analysis with log-rank test and multivariable Cox regression analysis were performed to analyze the relationship between central lung cancer and the prognosis of relapse-free survival (RFS) and overall survival (OS). Inter-observer agreement was assessed using Cohen's kappa value and intraclass correlation coefficient (ICC). RESULTS: Overall, 289 patients (169 men; median age 65 years; interquartile range 58-70 years) were evaluated. Central lung cancer (defined by location index) was adversely associated with RFS (P = 0.005) and OS (P = 0.01). Multivariable Cox regression analysis showed that central lung cancer was independently associated with poor RFS (adjusted hazard ratio 1.91; 95% confidence interval [CI] 1.12-3.24; P = 0.017) and OS (adjusted hazard ratio 1.69; 95% CI 1.04-2.74; P = 0.033). Location index demonstrated excellent inter-observer agreement (Cohen's kappa value 0.88; 95% CI 0.82-0.93) with a high ICC (0.98; 95% CI 0.97-0.98). CONCLUSION: Central lung cancer defined by a location index of the second tertile or lower is an independent adverse prognostic factor in resected T1-sized early-stage NSCLC.

Silicone Granuloma Mimicking a Lymphatic Metastasis in a Lung Cancer Patient: A Case Report.

Silicone granulomas are rare, benign lesions that may occur after breast augmentation. Occasionally, a careful differential diagnosis is necessary because lymphadenopathy or malignancy is suspected based on an imaging study. A 56-year-old woman who visited the hospital due to a lung nodule in the left upper lobe (LUL) underwent a staging work-up with the suspicion of lung cancer. Positron emission tomography/computed tomography and chest computed tomography revealed the LUL nodule and a lesion in the left internal mammary chain (IMC), suggesting lymphadenopathy. Diagnostic wedge resection was performed, followed by curative surgery. The final biopsy result confirmed that the LUL nodule was pathologic stage IB adenocarcinoma; unexpectedly, the lesion in the left IMC was a silicone granuloma.

[Mediastinal Teratoma: A Pictorial Essay]. / ì¢ ê²©ë™ ê¸°í˜•ì¢ : 임상 화보.

The mediastinum is the most prevalent site of extragonadal teratomas. Patients with mediastinal mature teratomas are usually young adults, and the condition does not show significant sexual differences. Mediastinal teratomas are mostly located in the anterior mediastinum. Patients are usually asymptomatic, although they can have several complications when the teratomas become large or rupture. Most mediastinal teratomas can be diagnosed using CT. Diagnosing ruptured or malignant teratomas is challenging because of their atypical clinical and radiological presentations. In this article, we describe various manifestations of mediastinal teratomas, with an emphasis on radiologic features.

Successful treatment with femoro-femoral venovenous extracorporeal membrane oxygenation in traumatic tracheal injury: a case report.

BACKGROUND: Traumatic tracheal injury is a rare type of trauma. In this type of injury, catastrophes may occur owing to a failure to secure the patient's airway. Extracorporeal membrane oxygenation (ECMO) is rescue therapy available for the treatment of urgent cardiorespiratory distress until the patient's vital signs have stabilized. The various applications of ECMO configurations have expanded the scope for this therapy. CASE PRESENTATION: We describe the case of a 66-year-old man with tracheal rupture with thyroid cartilage fracture due to cultivator handle who was treated with veno-venous ECMO. This case reflects the role and limitations of veno-venous ECMO, in which patient survival was possible with a bi-femoral configuration while also ensuring a clear airway. CONCLUSION: We shared our experience with bi-femoral veno-venous ECMO as a therapeutic option to contribute to choosing an appropriate approach. Based on our review of the literature, the present case was an uncommon report of survival after tracheal rupture due to trauma without other complications.

Minimally Invasive Surgical Treatment of Hepatic Hydrothorax Complicated by Empyema: A Case Report.

Hepatic hydrothorax complicated by empyema is difficult to manage. A 53-year-old man with liver cirrhosis was admitted for refractory right pleural effusion. He had a pleural catheter inserted 2 months prior. Pleural fluid appeared as exudate, and bacteria were identified in the pleural fluid culture. After confirming full ipsilateral lung expansion, minimally invasive surgery was performed. A diaphragmatic defect found by creating a pneumoperitoneum was closed, followed by talc pleurodesis. Postoperatively, overnight positive-pressure ventilation and 5-day peritoneal drainage were performed; chest tube drainage dramatically reduced over this time. At the 10-month follow-up, no recurrence of pleural effusion or signs of infection were observed.

Clinical implication of interstitial lung abnormality in elderly patients with early-stage non-small cell lung cancer.

BACKGROUND: Interstitial lung abnormality (ILA) is closely related to lung cancer. This study aimed to assess whether the presence of ILA is associated with the clinicoradiological features of elderly patients (≥70 years) with early-stage non-small cell lung cancer (NSCLC). METHODS: Elderly patients who underwent surgical resection for stage I or II NSCLC with preserved lung function between 2012 and 2019 were retrospectively identified. ILA was evaluated using a three-point scale. Univariate analyses were performed for clinicoradiological features based on the presence of ILA. Logistic and linear regression analyses were performed for cancer staging and tumor size, respectively. RESULTS: A total of 254 patients were evaluated. The presence of ILA (score = 2) was significantly associated with male sex, current or former smoker status, higher pack-years of smoking, low forced expiratory volume in one second/forced vital capacity ratios and diffusing capacity of the lung for carbon monoxide, and presence of emphysema (≥5%). Tumor characteristics, such as lower lobe and outer one-third location, squamous cell carcinoma, and higher cancer stage (stage II) were significantly associated with ILA. The presence of ILA independently predicted a higher cancer stage (adjusted odds ratio, 1.81; 95% confidence interval, 1.10-2.96; p = 0.02) and a larger tumor size in linear regression analysis (p = 0.04). CONCLUSIONS: Patients with ILA showed clinicoradiological features similar to those of idiopathic pulmonary fibrosis in elderly patients with early-stage NSCLC. Identifying the clinical implications of ILA in early-stage lung cancer will guide clinicians in providing appropriate management for these patients.

Open surgical treatment of subclavian artery pseudoaneurysm after endovascular repair: a case report.

BACKGROUND: Subclavian artery aneurysms are rare but may cause life-threatening complications. Surgical repair has been performed as a treatment of choice, but recently, with the development of endovascular treatment, many endovascular repairs have been performed to prevent surgical complications. CASE PRESENTATION: A patient undergoing endovascular repair with a subclavian artery aneurysm was diagnosed with a type II endoleak with an enlarged aneurysmal sac. Surgical repair was performed to remove the aneurysmal sac compressing the adjacent organs. CONCLUSIONS: The highly mobile subclavian artery has abundant collaterals. Therefore, regular follow-up is essential for endovascular repair. Surgical repair is effective when adjacent organs are compressed by the aneurysm sac.

Diagnostic Accuracy and Prognostic Relevance of Immunoglobulin Heavy Chain Rearrangement and 18F-FDG-PET/CT Compared With Unilateral Bone Marrow Trephination for Detecting Bone Marrow Involvement in Patients With Diffuse Large B-Cell Lymphoma.

BACKGROUND: In diffuse large B-cell lymphoma (DLBCL), bone marrow involvement (BMI) has an important clinical implication as a component of staging and International Prognostic Index. This study aimed to determine whether molecular analysis of immunoglobulin heavy chain (IgH) genes and positron emission tomography-computed tomography (PET/CT) could overcome the limitation of defining morphologic BMI by trephination biopsy and could increase the diagnostic accuracy or prognostic prediction. METHODS: A total of 94 de novo patients with DLBCL underwent PET/CT, polymerase chain reaction (PCR) test for detection of IgH gene rearrangement, and unilateral bone marrow (BM) trephination at diagnosis. RESULTS: A total of 9 patients (9.6%) were confirmed to present morphologic BMI (mBMI) based on trephination biopsy. On the other hand, 21 patients (22.3%) were confirmed to have IgH clonality (IgH BMI), while 16 (17.0%) were classified with BMI based on the assessment of PET/CT (PET BMI). Each IgH rearrangement PCR and PET/CT showed the high negative predictive value of detecting the BMI. However, the combined assessment of IgH rearrangement and PET/CT could increase the diagnostic accuracy and specificity with 87.2% and 97.0%, respectively. The survival outcome of patients with double positive PET BMI and IgH BMI was significantly worse than that with either single positive PET BMI or IgH BMI, and even less than patients with neither PET BMI nor IgH BMI (3-year PFS: 50.0% vs. 75.4% vs. 97.9%, P = 0.007, 3-year OS: 50.0% vs. 75.6% vs. 80.1%, P = 0.035, respectively). CONCLUSION: This study suggests that the combined evaluation of PET/CT and IgH rearrangement could give additional information for predicting therapeutic outcomes in patients with negative morphologic BMI as an important part of the prognosis.

Predictive Value of Interstitial Lung Abnormalities for Postoperative Pulmonary Complications in Elderly Patients with Early-stage Lung Cancer.

PURPOSE: Identifying pretreatment interstitial lung abnormalities (ILAs) is important because of their predictive value for complications after lung cancer treatment. This study aimed to assess the predictive value of ILAs for postoperative pulmonary complications (PPCs) in elderly patients undergoing curative resection for early-stage non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: Elderly patients (age ≥ 70 years) who underwent curative resection for pathologic stage I or II NSCLC with normal preoperative spirometry results (pre-bronchodilator forced expiratory volume in 1 s to forced vital capacity [FVC] ratio > 0.70 and FVC ≥ 80% of the predicted value) between January 2012 and December 2019 were retrospectively identified. Univariable and multivariable regression analyses were performed to assess risk factors for PPCs. The Kaplan-Meier method and log-rank test were used to analyze the relationship between ILAs and postoperative mortality. One-way analysis of variance was performed to assess the correlation between ILAs and hospital stay duration. RESULTS: A total of 262 patients (median age, 73 [interquartile range, 71-76] years; 132 male) were evaluated. A multivariable logistic regression model revealed that, among several relevant risk factors, fibrotic ILAs independently predicted both overall PPCs (adjusted odds ratio [OR], 4.84; 95% confidence interval [CI], 1.35-17.38; p=0.016) and major PPCs (adjusted OR, 8.72; 95% CI, 1.71-44.38; p=0.009). Fibrotic ILAs were significantly associated with higher postoperative mortality and longer hospital stay (F=5.21, p=0.006). CONCLUSION: Pretreatment fibrotic ILAs are associated with PPCs, higher postoperative mortality, and longer hospital stay.

Successful Surgical Management of a Tracheo-Innominate Artery Fistula in a Patient with Duchenne Muscular Dystrophy: A Case Report.

Tracheo-innominate artery fistula (TIF) is a rare, life-threatening complication of tracheostomy that makes it difficult to secure the airway due to massive bleeding, constituting a medical emergency. Therefore, most successful surgical treatments include innominate artery debridement and tracheal fistula repair. Herein, we report a case of successful surgical treatment of a TIF while maintaining cerebral blood flow through an artificial vascular graft.

CD8+ TILs in NSCLC differentiate into TEMRA via a bifurcated trajectory: deciphering immunogenicity of tumor antigens.

BACKGROUND: CD8+ tumor-infiltrating lymphocytes (TILs) comprise phenotypically and functionally heterogeneous subpopulations. Of these, effector memory CD45RA re-expressing CD8+ T cells (Temra) have been discovered and characterized as the most terminally differentiated subset. However, their exact ontogeny and physiological importance in association with tumor progression remain poorly understood. METHODS: We analyzed primary tumors and peripheral blood samples from 26 patients with non-small cell lung cancer and analyzed their phenotypes and functional characteristics using flow cytometry, RNA-sequencing, and bioinformatics. RESULTS: We found that tumor-infiltrating Temra (tilTemra) cells largely differ from peripheral blood Temra (pTemra), with distinct transcriptomes and functional properties. Notably, although majority of the pTemra was CD27-CD28- double-negative (DN), a large fraction of tilTemra population was CD27+CD28+ double-positive (DP), a characteristic of early-stage, less differentiated effector cells. Trajectory analysis revealed that CD8+ TILs undergo a divergent sequence of events for differentiation into either DP or DN tilTemra. Such a differentiation toward DP tilTemra relied on persistent expression of CD27 and CD28 and was associated with weak T cell receptor engagement. Thus, a higher proportion of DP Temra was correlated with lower immunogenicity of tumor antigens and consequently lower accumulation of CD8+ TILs. CONCLUSIONS: These data suggest a complex interplay between CD8+ T cells and tumors and define DP Temra as a unique subset of tumor-specific CD8+ TILs that are produced in patients with relatively low immunogenic cancer types, predicting immunogenicity of tumor antigens and CD8+ TIL counts, a reliable biomarker for successful cancer immunotherapy.

Thoracoscopic pulmonary metastasectomy in metastatic colorectal cancer: Surgical outcomes and prognostic factors.

BACKGROUND: This study aimed to confirm the effectiveness of thoracoscopic metastasectomy for colorectal cancer (CRC) and determine its prognostic factors. METHODS: Of the 181 patients who underwent video-assisted thoracoscopic surgery (VATS) for pulmonary metastases from CRC between 2011 and 2017, 173 were retrospectively reviewed. Surgical outcomes, long-term survival, and the factors affecting the prognosis were analyzed. RESULTS: The patients in the study were predominantly male (n = 104, 60.1%), and the median age was 65 years (range, 25-83 years). The median follow-up time was 46 months (range, 0-114 months). The surgical procedures were 156 wedge resections, five segmentectomies, and 12 lobectomies. Conversion to thoracotomy was required in nine patients. The postoperative complication rate was 2.9%, and the in-hospital mortality rate was 1.2%. The overall 1-, 3-, and 5-year survival rates were 94.8%, 70.6%, and 51.8%, respectively. Univariate analysis showed that the prognostic factors for survival were age (p = 0.027), pathological stage of CRC (p = 0.019), prior extrathoracic metastasis (p = 0.005), preoperative carcinoembryonic antigen level (p = 0.020), number of pulmonary metastases (p = 0.011), and disease-free interval (p = 0.026). In the multivariate analysis, two factors were related to prognosis: age (hazard ratio [HR], 1.881; 95% confidence interval [CI]; 1.189-2.976; p = 0.007) and prior extrathoracic metastasis (HR, 2.170; 95% CI; 1.269-3.711; p = 0.005). CONCLUSIONS: VATS for pulmonary metastasectomy for CRC can be performed relatively safely, and our results regarding long-term survival are comparable with those of other studies. In this study, older age (≥70 years) and prior extrathoracic metastasis were independent prognostic factors of poor prognosis.

Glutathione Peroxidase 3 as a Biomarker of Recurrence after Lung Cancer Surgery.

We aimed to examine the usefulness of serum glutathione peroxidase 3 (GPx3) as a biomarker of lung cancer recurrence after complete resection. We prospectively collected serial serum samples at the baseline, as well as 3, 6 and 12 months after surgery from complete resection cases in 2013. GPx3 levels were measured by enzyme-linked immunosorbent assay. Statistical tests including t-tests and Cox proportional hazard regression analyses were performed. Totally, 135 patients were enrolled, and 39 (28.9%) showed relapse during the median follow-up period (63.60 months; range, 0.167-81.867). The mean GPx3 change was significantly higher in the recurrence group at 6 months (0.32 ± 0.38 vs. 0.15 ± 0.29, p = 0.016) and 12 months (0.40 ± 0.37 vs. 0.13 ± 0.28, p = 0.001). The high GPx3 change group showed significantly higher 60-months recurrence rates than the low group (48.1% vs. 25.2% at 3 months, p = 0.005; 54.5% vs. 28.9% at 6 months, p = 0.018; 38.3% vs. 18.3% at 12 months, p = 0.035). High GPx3 change at 3 months were independent risk factors of recurrence (hazard ratio (HR) 3.318, 95% confidence interval (CI), 1.582-6.960, p = 0.002) and survival (HR 3.150, 95% CI, 1.301-7.628, p = 0.011). Therefore, serum GPx3 changes after surgery may be useful predictive biomarkers for recurrence in lung cancer. Larger-scale validation studies are warranted to confirm these findings.

Artificial intelligence and lung cancer treatment decision: agreement with recommendation of multidisciplinary tumor board.

BACKGROUND: IBM Watson for Oncology (WFO) is a cognitive computing system helping physicians quickly identify key information in a patient's medical record, surface relevant evidence, and explore treatment options. This study assessed the possibility of using WFO for clinical treatment in lung cancer patients. METHODS: We evaluated the level of agreement between WFO and multidisciplinary team (MDT) for lung cancer. From January to December 2018, newly diagnosed lung cancer cases in Chonnam National University Hwasun Hospital were retrospectively examined using WFO version 18.4 according to four treatment categories (surgery, radiotherapy, chemoradiotherapy, and palliative care). Treatment recommendations were considered concordant if the MDT recommendations were designated 'recommended' by WFO. Concordance between MDT and WFO was analyzed by Cohen's kappa value. RESULTS: In total, 405 (male 340, female 65) cases with different histology (adenocarcinoma 157, squamous cell carcinoma 132, small cell carcinoma 94, others 22 cases) were enrolled. Concordance between MDT and WFO occurred in 92.4% (k=0.881, P<0.001) of all cases, and concordance differed according to clinical stages. The strength of agreement was very good in stage IV non-small cell lung carcinoma (NSCLC) (100%, k=1.000) and extensive disease small cell lung carcinoma (SCLC) (100%, k=1.000). In stage I NSCLC, the agreement strength was good (92.4%, k=0.855). The concordance was moderate in stage III NSCLC (80.8%, k=0.622) and relatively low in stage II NSCLC (83.3%, k=0.556) and limited disease SCLC (84.6%, k=0.435). There were discordant cases in surgery (7/57, 12.3%), radiotherapy (2/12, 16.7%), and chemoradiotherapy (15/129, 11.6%), but no discordance in metastatic disease patients. CONCLUSIONS: Treatment recommendations made by WFO and MDT were highly concordant for lung cancer cases especially in metastatic stage. However, WFO was just an assisting tool in stage I-III NSCLC and limited disease SCLC; so, patient-doctor relationship and shared decision making may be more important in this stage.

Minimally invasive surgical strategy for refractory hepatic hydrothorax.

OBJECTIVES: Treatment of refractory hepatic hydrothorax, a complication of liver cirrhosis, is complex. We aimed to investigate the usefulness of the '4-step approach', which is a minimally invasive surgical strategy combining 4 therapeutic modalities: (i) pneumoperitoneum to localize diaphragmatic defects; (ii) thoracoscopic pleurodesis; (iii) postoperative positive-pressure ventilation; and (iv) peritoneal drainage for abdominal decompression. METHODS: We retrospectively analysed the medical records of 12 patients with hepatic hydrothorax who underwent surgical treatment using the 4-step approach from January 2013 to December 2017. Nine of them (75.0%) were Child C cases; the median model for end-stage liver disease score was 20.5. The diaphragmatic defects localized after forming a pneumoperitoneum were treated with primary closure followed by thoracoscopic pleurodesis, postoperative positive-pressure ventilation and peritoneal drainage. RESULTS: Diaphragmatic defects were localized in all patients except one. The median postoperative positive-pressure ventilation duration was 20.1 h. Peritoneal drainage was performed for a median duration of 5 days; the peritoneal drains were removed at a median of 8 postoperative days. The median duration of postoperative hospital stay until discharge/transfer was 9.5 days. No operative mortalities occurred. The median duration of follow-up was 10.9 months. Eight deaths (66.7%) occurred during the follow-up period; however, no deaths were surgery-associated. Ipsilateral pleural effusion recurred in 3 patients (25%), among whom reoperation was performed in 1 without recurrence at the 13-month follow-up. CONCLUSIONS: The 4-step approach seems to be a safe and effective minimally invasive surgical strategy for treating refractory hepatic hydrothorax.