Lung cancer resection in patients with underlying usual interstitial pneumonia: a meta-analysis.

OBJECTIVE: Patients with lung cancer with underlying idiopathic pulmonary fibrosis and usual interstitial pneumonia (UIP) pattern on CT represent a very high-risk group in terms of postoperative UIP acute exacerbations (AEs) and in-hospital mortality. We sought to investigate the outcomes in these patients. METHODS: We carried out a meta-analysis, searching four international databases from 1 January 1947 to 27 April 2022, for studies in any language reporting on the acute postoperative outcomes of patients with lung cancer undergoing surgical resection with underlying UIP (the primary outcome). Random effects meta-analyses (DerSimonian and Laird) were conducted. We analysed the difference in incidence of postoperative AE as well as the difference in long-term overall survival among subpopulations. These were stratified by the extent of surgical resection, with meta-regression testing (uniivariate and multivariate) according to the stage of disease, operative decision making and country of origin. This study was registered with PROSPERO (CRD42022319245). RESULTS: The overall incidence of AE of UIP postoperatively from 10 studies (2202 patients) was 14.6% (random effects model, 95% CI 9.8 to 20.1, I2=74%). Sublobar resection was significantly associated with a reduced odds of postoperative AE (OR 0.521 (fixed effects model), 95% CI 0.339 to 0.803, p=0.0031, I2=0%). The extent of resection was not significantly associated with overall survival following lung cancer resection in UIP patients (HR for sublobar resection 0.978 (random effects model), 95% CI 0.521 to 1.833, p=0.9351, I2=71%). CONCLUSIONS: With appropriate implementation of perioperative measures such as screening for high-risk cases, appropriate use of steroids, antifibrotics and employing sublobar resection in select cases, the risk of local recurrence versus in-hospital mortality from AEUIP can be balanced and long-term survival can be achieved in a super-selected group of patients. Further investigation in the form of a randomised study is warranted.

Recurrent endobronchial occlusion and aorto-bronchial fistula formation in Behcet's disease.

BACKGROUND: Behcet's disease is a multi-system inflammatory disorder. A small subset of patients with Behcet's develop relapsing polychondritis which is classified as a separate disease known as Mouth and Genital ulcers with inflamed cartilage (MAGIC syndrome). It has previously been observed that this condition can also affect the cartilaginous tissue in the tracheobronchial tree. CASE PRESENTATION: We present the case of a 44-year-old lady with Behcet's Disease, Mouth and Genital ulcers with inflamed cartilage (MAGIC) syndrome and an aortic Frozen Elephant Trunk (FET) who presented to hospital with recurrent episodes of left lobar collapse of the lung. During bronchoscopy, we found the presence of multiple inflammatory endobronchial webs occluding segments of the left bronchial tree. Repeated examinations showed evidence that these inflammatory webs were progressing in size, density and location. Furthermore, we noticed herniation of her descending aortic FET into her left bronchial tree forming an aorto-bronchial fistula which was complicated by a graft infection. Her descending aortic FET section was surgically replaced with an open procedure and bronchoscopic interventions attempted to remove the occlusions in her bronchial tree. Despite optimisation of medical management and surgical correction, this patient continued to develop progressive occlusion of her left bronchial tree, resulting in a chronically collapsed left lung. CONCLUSIONS: A multi-disciplinary team approach is of paramount importance in order to optimally manage patients with Behcet's disease, balancing immunosuppressive regimens that need close monitoring and titration in the context of potential surgical intervention and the risk for intercurrent infection.

Feasibility study of a randomised controlled trial of preoperative and postoperative nutritional supplementation in major lung surgery.

OBJECTIVES: Malnutrition and weight loss are important risk factors for complications after lung surgery. However, it is uncertain whether modifying or optimising perioperative nutritional state with oral supplements results in a reduction in malnutrition, complications or quality of life. DESIGN: A randomised, open label, controlled feasibility study was conducted to assess the feasibility of carrying out a large multicentre randomised trial of nutritional intervention. The intervention involved preoperative carbohydrate-loading drinks (4×200 mL evening before surgery and 2×200 mL the morning of surgery) and early postoperative nutritional protein supplement drinks two times per day for 14 days compared with the control group receiving an equivalent volume of water. SETTING: Single adult thoracic centre in the UK. PARTICIPANTS: All adult patients admitted for major lung surgery. Patients were included if were able to take nutritional drinks prior to surgery and give written informed consent. Patients were excluded if they were likely unable to complete the study questionnaires, they had a body mass index <18.5 kg/m2, were receiving parenteral nutrition or known pregnancy. RESULTS: All patients presenting for major lung surgery were screened over a 6-month period, with 163 patients screened, 99 excluded and 64 (41%) patients randomised. Feasibility criteria were met and the study completed recruitment 5 months ahead of target. The two groups were well balanced and tools used to measure outcomes were robust. Compliance with nutritional drinks was 97% preoperatively and 89% postoperatively; 89% of the questionnaires at 3 months were returned fully completed. The qualitative interviews demonstrated that the trial and the intervention were acceptable to patients. Patients felt the questionnaires captured their experience of recovery from surgery well. CONCLUSION: A large multicentre randomised controlled trial of nutritional intervention in major lung surgery is feasible and required to test clinical efficacy in improving outcomes after surgery. TRIAL REGISTRATION NUMBER: ISRCTN16535341.

Infected mediastinal cysts following endobronchial ultrasound guided biopsy-a case series.

Mediastinal cysts are commonly an incidental finding simulating a benign or malignant diagnosis. Infection is a recognised complication of mediastinal cyst and therefore early surgical management is essential. Endobronchial ultrasound guided biopsy (EBUS) has been used to diagnose and manage mediastinal cyst. We present a case series of three patients who presented with sepsis following diagnostic EBUS of mediastinal cyst. We would recommend that EBUS guided biopsy be applied cautiously if there is a high suspicion of mediastinal cyst to avoid post procedural infection, which can thus complicate any future therapeutic options.

Chest wall resection and reconstruction for recurrent breast cancer - A multidisciplinary approach.

BACKGROUND: Despite therapeutic advances in the management of breast cancer, a significant number of patients present with locoregional recurrence. Treatment with hormonal, chemo or radiotherapy remains standard in such cases. However, in selected patients of recurrent breast cancer involving chest wall, multidisciplinary surgical approach could be considered. METHODS: Between 2010 and 2018, 21 patients with recurrent breast cancer, involving chest wall, were treated at a tertiary care center with resection and reconstruction. The mean age of the patients was 55 years (22-77 years). RESULTS: The median interval from first breast resection to chest wall resection (CWR) for recurrent disease was 6 years (1-24 years). Eighteen patients underwent bony resection and 3 patients required extensive soft tissue resection. Complete resection was achieved in 90% of patients. All patients had chest wall reconstruction. There was no in-hospital mortality. During follow-up, 8 patients died, of which 7 were due to distant metastases. The 1 year and 3-year overall survival were 90% (95% CI 66-97) and 61% (95% CI 31-81) respectively. The disease-free survival at 1 and 3 years was the same at 70% (95% CI 45-86). At a mean follow up of 23 months, the average survival in patients operated for local recurrence is 51.7 months (95% CI 37.7-65.7) and 24.5 months (95% CI 7.3-41.7) for patients with distant metastatic recurrence. CONCLUSION: A multidisciplinary oncoplastic approach for recurrent breast cancer, which includes chest wall resection and reconstruction is a useful adjunct in selected group of patients. This improves local disease control, symptoms and possibly disease-free survival.

Perioperative immune function and pain control may underlie early hospital readmission and 90 day mortality following lung cancer resection: A prospective cohort study of 932 patients.

BACKGROUND: Mortality following lung cancer resection has been shown to double between 30 and 90 days and readmission following surgery is associated with an increased risk of mortality. The aim of this study was to describe the causes of readmission and mortality and enable the identification of potentially modifiable factors associated with these events. METHODS: Prospective cohort study at a United Kingdom tertiary referral centre conducted over 55 months. Binary logistic regression was used to identify factors associated with death within 90 days of surgery. RESULTS: The 30 day and 90 day mortality rates were 1.4% and 3.3% respectively. The most common causes of death were pneumonia, lung cancer and Acute Respiratory Distress Syndrome/Multi Organ Failure. Potentially modifiable risk factors for death identified were: Postoperative pulmonary complications (Odds ratio 6.1), preoperative lymphocyte count (OR 0.25), readmission within 30 days (OR 4.2) and type of postoperative analgesia (OR for intrathecal morphine 4.8). The most common causes of readmission were pneumonia, shortness of breath and pain. CONCLUSIONS: Postoperative mortality is not simply due to fixed factors; the impacts of age, gender and surgical procedure on postoperative survival are reduced when the postoperative course of recovery is examined. Perioperative immune function, as portrayed by the occurrence of infection and lower lymphocyte count in the immediate perioperative period, and pain control method are strongly associated with 90 day mortality; further studies in these fields are indicated as are studies of psychological factors in recovery. CLINICAL REGISTRATION NUMBER: ISRCTN00061628.

Risk factors and short-term outcomes of postoperative pulmonary complications after VATS lobectomy.

BACKGROUND: Postoperative pulmonary complications (PPCs) are associated with poor outcomes following thoracotomy and lung resection. Video-assisted thoracoscopic surgery (VATS) for lobectomy is now frequently utilised as an alternative to thoracotomy, however patients remain at risk for development of PPC. There is little known of the short-term outcome associated with PPC following VATS lobectomy and if there are any potential risk factors that could be modified to prevent PPC development; our study aimed to investigate this. METHODS: A prospective observational study of consecutive patients undergoing VATS lobectomy for lung cancer over a 4-year period in a regional centre was performed (2012-2016). Exclusion criteria included re-do VATS or surgery for pulmonary infection. All patients received physiotherapy as necessary from postoperative day 1 (POD1) and PPC was determined using the Melbourne Group Scale. Outcomes included hospital LOS, intensive therapy unit (ITU) admission and hospital mortality. RESULTS: Of the 285 patients included in the study, 137 were male (48.1%), the median (IQR) age was 69 (13) years and the mean (±SD) FEV1% predicted was 87% (±19). Patients that developed a PPC (n = 21; 7.4%) had a significantly longer hospital LOS (4 vs. 3 days), higher frequency of ITU admission (23.8% vs. 0.5%) and higher hospital mortality (14.3% vs. 0%) (p < 0.001). PPC patients also required more physiotherapy contacts/time, emergency call-outs and specific pulmonary therapy (p < 0.05). Current smoking and COPD diagnosis were significantly associated with development of PPC on univariate analysis (p < 0.05), however only current smoking was a significant independent risk factor on multivariate analysis (p = 0.015). CONCLUSIONS: Patients undergoing VATS lobectomy remain at risk of developing a PPC, which is associated with an increase in physiotherapy requirements and a worse short-term morbidity and mortality. Current smoking is the only independent risk factor for PPC after VATS lobectomy, thus vigorous addressing of preoperative smoking cessation is urgently needed.

Chest Wall Mechanics In Vivo With a New Custom-Made Three-Dimensional-Printed Sternal Prosthesis.

PURPOSE: Reconstruction after sternal resection is performed according to surgeon intuition; physiologic evidence for selection of prostheses is lacking. We present our experience of the in vivo function of a novel device for sternal reconstruction. DESCRIPTION: A three-dimensional-printed titanium and porous polyethylene sternal prosthesis was made according to the patient's computed tomographic scan. The titanium arms slot over adjacent ribs and are fixed in place with screws. The porous element allows ingrowth of native tissue while preventing lung herniation around the narrow titanium bars. EVALUATION: We performed optoelectronic plethysmography to assess the physiologic function of the device compared with a muscle flap reconstruction. Asynchronous and paradoxical movements of the thoracoabdominal surface were apparent with the muscle flap reconstruction but not with the new device. Considerably higher tidal volumes and a lower respiratory rate achieved the same minute volume with the new device compared with the muscle flap. CONCLUSIONS: Rigid sternal reconstruction with a three-dimensional-printed prosthesis demonstrated superior respiratory mechanics compared with reconstruction with an autologous muscle flap.

Patients want more information after surgery: a prospective audit of satisfaction with perioperative information in lung cancer surgery.

BACKGROUND: Receiving information about their disease and treatment is very important to patients with cancer. There is an association between feeling appropriately informed and better quality of life. This audit aimed to estimate patient satisfaction with perioperative information in those undergoing surgery for lung cancer and any change in satisfaction over time. METHODS: A questionnaire (EORTC-Info-25) was administered prospectively to patients preoperatively and up to six months postoperatively. The preoperative questionnaire was completed by 292 patients and 88 free text comments were completed. Intrapersonal responses were compared over time. RESULTS: Patients were highly satisfied with information prior to surgery. The overall helpfulness of information did not change over time but satisfaction with the amount of information decreased. Patients who received more information about 'the disease' and 'things you can do to help yourself get well' were less likely to report a drop in satisfaction (Odds Ratio 0.858, 95% Confidence interval 0.765 to 0.961, p = 0.008 and OR 0.102, 95% CI 0.018 to 0.590, p = 0.011 respectively). Free text responses revealed patients most frequently wanted more information on the disease, aftercare and self-care. Suffering complications from surgery was not associated with a change in satisfaction with information postoperatively. CONCLUSIONS: Patients want to know more about their diagnosis, but also how to recover and cope with issues once they have gone home after surgery. Postoperative satisfaction with information may improve if patients are given more information on these topics.

Smoking and timing of cessation on postoperative pulmonary complications after curative-intent lung cancer surgery.

BACKGROUND: Smoking is a risk factor for postoperative pulmonary complications (PPC) following non-small cell lung cancer (NSCLC) surgery. The optimal timing for preoperative smoking cessation has not been identified. Our study aimed to observe the impact of preoperative smoking cessation on PPC incidence and other postoperative outcomes including long-term survival. METHODS: A prospective study included consecutive patients following resection for NSCLC in a regional thoracic centre over a 4-year period (2010-2014). Patients were stratified according to self-reported preoperative smoking status. The primary endpoint was PPC incidence, which was assessed from postoperative day one onwards using the Melbourne Group Scale. Secondary endpoints included short-term outcomes (hospital length of stay [LOS], intensive therapy unit [ITU] admission, 30-day hospital readmission rate) and long-term survival. RESULTS: Four hundred and sixty-two patients included 111 (24%) current smokers, 55 (12%) ex-smokers <6 weeks, 245 (53%) ex-smokers ≥6 weeks and 51 (11%) never smokers. PPC occurred in 60 (13%) patients in total. Compared to never smokers, current smokers had a higher frequency of PPC (22% vs. 2%, p = 0.004), higher frequency of ITU admission (14% vs. 0%; p = 0.001) and a longer median (IQR) hospital LOS (6 [5] vs. 5 [2]; p = 0.001). In the ex-smokers there was a trend for a lower frequency of PPC (<6 weeks, 10.9% vs. ≥6 weeks, 11.8%) and ITU admission (<6 weeks, 5.5% vs. ≥6 weeks, 4.5%), but there was no difference between the <6 weeks or ≥6 weeks ex-smoking groups prior to surgery. There was no significant difference in long-term survival found between the groups of differing smoking status (median follow-up 29.8 months, 95%CI 28.4-31.1). CONCLUSION: Current smokers have higher postoperative morbidity; this risk reduces following smoking cessation but 6 weeks does not appear to identify a time-point where differences in outcomes are noted.

Migration of contraceptive implant into the left pulmonary arterial system.

An 18-year-old woman had an etonogestrel implant inserted into her left upper arm 2 years earlier for menorrhagia. Her symptoms were not well controlled and she requested the implant to be removed. However, clinicians were unable to locate the implant on her left arm. Computed tomography showed that the implant had migrated to a sub-lobar branch of the left lower lobe pulmonary artery. The long-term effect of leaving an etonogestrel implant in the pulmonary arterial system is unknown. This report adds to the small body of evidence on intravascular migration of a subdermally placed contraceptive implant.

Postoperative pulmonary complications and rehabilitation requirements following lobectomy: a propensity score matched study of patients undergoing video-assisted thoracoscopic surgery versus thoracotomy†.

OBJECTIVES: : Video-assisted thoracoscopic surgical (VATS) lobectomy is increasingly used for curative intent lung cancer surgery compared to open thoracotomy due to its minimally invasive approach and associated benefits. However, the effects of the VATS approach on postoperative pulmonary complications (PPC), rehabilitation and physiotherapy requirements are unclear; our study aimed to use propensity score matching to investigate this. METHODS: Between January 2012 and January 2016 all consecutive patients undergoing lobectomy via thoracotomy or VATS were prospectively observed. Exclusion criteria included VATS converted to thoracotomy, re-do thoracotomy, sleeve/bilobectomy and tumour size >7 cm diameter (T3/T4). All patients received physiotherapy assessment on postoperative day 1 (POD1), and subsequent treatment as deemed appropriate. PPC frequency was measured daily using the Melbourne Group Scale. Postoperative length of stay (LOS), high dependency unit (HDU) LOS, intensive therapy unit (ITU) admission and in-hospital mortality were observed. Propensity score matching (PSM) was performed using previous PPC risk factors (age, ASA score, body mass index, chronic obstructive pulmonary disease, current smoking) and lung cancer staging. RESULTS: Over 4 years 736 patients underwent lobectomy with 524 remaining after exclusions; 252 (48%) thoracotomy and 272 (52%) VATS cases. PSM produced 215 matched pairs. VATS approach was associated with less PPC (7.4% vs 18.6%; P < 0.001), shorter median LOS (4 days vs 6; P < 0.001), and a shorter median HDU LOS (1 day vs 2; P = 0.002). Patients undergoing VATS required less physiotherapy contacts (3 vs 6; P < 0.001) and reduced therapy time (80 min vs 140; P < 0.001). More patients mobilized on POD1 (84% vs 81%; P = 0.018), and significantly less physiotherapy to treat sputum retention and lung expansion was required ( P < 0.05). CONCLUSIONS: This study demonstrates that patients undergoing VATS lobectomy developed less PPC and had improved associated outcomes compared to thoracotomy. Patients were more mobile earlier, and required half the physiotherapy resources having fewer pulmonary and mobility issues.

A 20-year review of pectus surgery: an analysis of factors predictive of recurrence and outcomes.

OBJECTIVES: Only a few studies report the long-term outcomes following repair of pectus excavatum (PE) and pectus carinatum (PC). Predictors of recurrence after surgery are important in this group of young patients. The purpose of this study was to assess the short- and long-term outcomes of both PE and PC and identify factors associated with postoperative complications and pectus recurrence. METHODS: This was a retrospective observational study that included all patients who underwent primary or recurrent repair of PC and PE in a regional thoracic centre over 20 years. Patients' demographics, type of surgery, complications and recurrence were recorded. Logistic regression analysis was performed to identify factors predictive of pectus recurrence. RESULTS: A total of 297 patients were included (262 men and 35 women). The mean age was 19.8 years (95% CI 19.3-20.5). A total of 169 patients had surgery for PE and 127 for PC. A total of 243 patients had a modified Ravitch procedure (166 without a bar) and 53 patients underwent the Nuss repair. The main postoperative complications were wound infection and bleeding or haematoma. The recurrence rate over the mean follow-up period of 8.6 years was 10%. In PE, patients treated with the Ravitch procedure with the bar experienced more complications. Univariate and multivariate analyses showed that PE patients who developed a complication had a significantly increased chance of recurrence. No risk factors were linked with recurrence of PC. CONCLUSIONS: Life-transforming pectus surgery can be performed with low morbidity and good long-term outcomes. Recurrence of PE deformity is associated with the development of postoperative complications.

Pectus patient information website has improved access to care and patient reported outcomes.

BACKGROUND: Pectus is the most common congenital disorder. Awareness amongst primary care physicians and the general public is poor. NHS commissioning bodies plan to withdraw funding for this surgery because they deem a lack of sufficient evidence of benefit. The purpose of this study is to assess the effects of introducing a patient information website on referral and activity patterns and on patients reported outcomes. METHODS: We produced an innovative information website, www.pectus.co.uk , accessible to the general public, providing information about pectus deformities; management options and advice about surgery. Referral patterns and number of cases where studied before and after the introduction of the website in 2010. Patients' satisfaction post-op was assessed using the Brompton's single step questionnaire (SSQ). RESULTS: The website had considerable traffic with 2179 hits in 2012, 4983 in 2013 and 7416 in 2014. This has led to 1421 contacts and 372 email enquiries. These emails have resulted in an increased number of patients who have been assessed and go on to have surgery. We asked 59 pectus excavatum patients who were operated from 2008 to 2014 to complete the SSQ. We received 32 replies. Eighty-four percent (16/19) of patients who visited the website and then underwent surgery, found the website useful. All patients scored satisfactorily in SSQ. Even though those who visited the website tended to be more satisfied with the surgical outcomes this did not reach statistical significance. This group of patients said that would have the operation again given the option compared to 76.9 % of the group who did not visit the website before surgery (p=0.031). Despite the fact that patients who visited the website experienced more post-operative complications were equally or more satisfied with post-operative outcomes. The overall SSQ obtainable score was not different for the two subgroups, being more widespread in the group that did not visit the website. CONCLUSIONS: The introduction of a pectus patient information website has significantly improved access to specialised services. Patients are overall highly satisfied with the surgical outcomes.

Long-term impact of developing a postoperative pulmonary complication after lung surgery.

INTRODUCTION: Postoperative pulmonary complications (PPC) such as atelectasis and pneumonia are common following lung resection. PPCs have a significant clinical impact on postoperative morbidity and mortality. We studied the long-term effects of PPCs and sought to identify independent risk factors. METHODS: A prospective observational study involved all patients following lung resection in a regional thoracic centre over 4 years. PPCs were assessed daily in hospital using the Melbourne group scale based on chest X-ray, white cell count, fever, purulent sputum, microbiology, oxygen saturations, physician diagnosis and intensive therapy unit (ITU)/high-dependency unit readmission. Follow-up included hospital length of stay (LOS), 30-day readmissions, and mortality. RESULTS: 86 of 670 patients (13%) who had undergone a lung resection developed a PPC. Those patients had a significantly longer hospital LOS in days (13, 95% CI 10.5-14.9 vs 6.3, 95% CI 5.9 to 6.7; p<0.001) and higher rates of ITU admissions (28% vs 1.9%; p<0.001) and 30-day hospital readmissions (20.7% vs 11.9%; p<0.05). Significant independent risk factors for development of PPCs were COPD and smoking (p<0.05), not age. Excluding early postoperative deaths, developing a PPC resulted in a significantly reduced overall survival in months (40, 95% CI 34 to 44 vs 46, 95% CI 44 to 47; p=0.006). Those who developed a PPC had a higher rate of non-cancer-related deaths (11% vs 5%; p=0.020). PPC is a significant independent risk factor for late deaths in non-small cell lung cancer patients (HR 2.0, 95% CI 1.9 to 3.2; p=0.006). CONCLUSIONS: Developing a PPC after thoracic surgery is common and is associated with a poorer long-term outcome.

Survival following Pulmonary Metastasectomy for Sarcoma.

OBJECTIVES: The aim of this study is to report the overall survival after pulmonary metastasectomy in patients with metastatic sarcoma and prognostic factors for survival. METHODS: This is a retrospective observational study of consecutive patients having pulmonary metastasectomy for sarcoma over a 5-year period. Survival was calculated by Kaplan-Meier method. RESULTS: Between August 2007 and January 2014, a total of 80 pulmonary metastasectomies were performed on 66 patients with metastatic sarcoma. There were no postoperative in-hospital deaths. The median age was 51 years (range, 16-79) and 39 (59%) patients were male. Fourteen patients had bilateral lung operations and surgical access was by video-assisted thoracoscopic surgery in 48 (73%) cases. The median number of metastases resected was 3 (range, 1-9). The median disease-free interval was 25 months (range, 0-156). Median overall survival was 25.5 months (range, 1-60). At follow-up, 19 patients (29%) were dead with a median follow-up of 31 months (range, 1-60). Recurrence of metastases significantly affected survival: median of 25.5 months (95% confidence interval [CI], 17.7-33.4) versus 48.4 months (95% CI, 42.5-54.4) in patients with no recurrent metastases (p = 0.004). There was no significant difference in survival between patients with high-grade versus low-grade tumors (p = 0.13), histological type (osteosarcoma vs. other soft tissue sarcoma types, p = 0.14), unilateral versus bilateral lung metastases (p = 0.48), or lung metastases alone versus lung and other sites of metastases (p = 0.5). CONCLUSION: In selected patients, pulmonary metastasectomy for sarcoma is safe and may confer a good medium-term survival. Recurrent metastasis after resection confers a poor prognosis.

The significance of microvascular invasion after complete resection of early-stage non-small-cell lung cancer.

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'in patients with non-small-cell lung cancer who have undergone complete resection, does the presence of microvascular invasion (MVI) significantly impact long-term survival or prognosis?' Altogether, more than 250 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. Outcome parameters that were used in the assessment include 5-year overall survival, event-free or recurrence-free survival (RFS) and incidence of metastatic relapse. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. The majority of the data collected were retrospective. Meta-analysis of data of over 16 000 patients showed that when considering RFS, MVI positivity was associated with a significantly reduced period of RFS; pooled hazard ratio estimates by univariate and multivariate analyses were 3.28 (95% CI 2.14-5.05; P < 0.0001) and 3.98 (95% CI 2.24-7.06; P < 0.0001), respectively. Eight of the studies showed a significantly worse 5-year survival in the presence of MVI, whereas a further study found a reduced median survival with MVI. One study showed no difference, but concurred with five other studies that MVI was associated with a significantly shorter event-free or RFS. Multivariate analyses have furthermore demonstrated that MVI positivity correlates with larger tumour size, an increased risk of distant metastases, visceral pleural involvement, lymphovascular invasion, higher tumour grade and nodal status. We conclude that the presence of microvascular invasion in resected early-stage non-small-cell lung cancer is a negative prognostic factor.

Bronchoscopic management of patients with symptomatic airway stenosis and prognostic factors for survival.

BACKGROUND: Interventional bronchoscopy is effective in the management of patients with symptomatic airway obstruction for both malignant and benign conditions. The main aim of this study is to report our experience with emergency interventional bronchoscopy in patients with symptomatic airway obstruction and identify prognostic factors for survival. METHODS: This is a retrospective observational study of patients undergoing emergency interventional bronchoscopy over a 4-year period. Survival times were analyzed separately for patients with benign and malignant airway obstruction by the Kaplan-Meier method. RESULTS: Between June 2009 and July 2013, 168 emergency interventional bronchoscopies were performed in 112 patients for airway obstruction. The median age was 63 years (range, 20 to 86), and 91 patients (54%) patients were female. Seventy-two cases (43%) had airway obstruction due to malignant disease. There were 3 in-hospital deaths (2.7%). Median survival of the study population was 5.6 months (range, 0 to 51) with a median follow-up of 7.3 months (range, 0 to 51). Median survival for patients with malignant airway obstruction was 3.5 months (range, 0 to 21), and 9.8 months (range, 0.1 to 51) for those with benign disease. Airway intervention facilitated palliative chemotherapy in 32 patients (44%) of those with malignant airway obstruction. At multivariate analysis in patients with malignant airway obstruction, presence of stridor (hazard ratio 1.919, 95% confidence interval: 1.082 to 3.404, p = 0.026) and not receiving postprocedure chemotherapy (hazard ratio 2.05, 95% confidence interval: 1.156 to 3.636, p = 0.014) were independent prognostic factors for death. CONCLUSIONS: Emergency interventional bronchoscopy for airway obstruction is safe, relieved symptoms, and facilitated palliative chemotherapy, which improved survival.