Comparative evaluation of staging algorithms proven N2 non-small cell lung cancer treated by lung resection after neoadjuvant therapy.

Background: In this study, we aimed to compare the performances of clinical methods, minimally invasive methods, mediastinoscopy, and re-mediastinoscopy used in the restaging of patients receiving neoadjuvant therapy for pathologically proven N2. Our secondary objective was to determine the most optimal algorithm for initial staging and restaging after neoadjuvant therapy. Methods: Between April 2003 and August 2017, a total of 105 patients (99 males, 6 females; mean age: 54.5±8.2 years; range, 27 to 73 years) who were diagnosed with pathologically proven Stage 3A-B N2 non-small cell lung cancer and received neoadjuvant therapy and subsequently lung resection were retrospectively analyzed. Staging algorithm groups (Group 1=first mediastinoscopy-second clinic, Group 2=first mediastinoscopy-second minimally invasive, Group 3=first mediastinoscopy-second re-mediastinoscopy, and Group 4=first minimally invasive-second mediastinoscopy) were created and compared. Results: In the first stage, N2 diagnosis was made in 90 patients by mediastinoscopy and in 15 patients by minimally invasive method. In the second stage, 44 patients were restaged by the clinical method, 23 by the minimally invasive method, 23 by re-mediastinoscopy, and 15 by mediastinoscopy. The false negativity rates of Groups 1, 2, 3, and 4 were 27.2%, 26.1%, 21.8%, and 13.3%, respectively. The most reliable staging algorithm was found to be the minimally invasive method in the first step and mediastinoscopy in the second step. The mean overall five-year survival rate was 46.3±4.4%, and downstaging in lymph node involvement was found to have a favorable effect on survival (54.3% vs. 21.8%, respectively; p=0.003). Conclusion: The staging method to be chosen before and after neoadjuvant therapy is critical in the treatment of Stage 3A-B N2 non-small cell lung cancer. In re-mediastinoscopy, the rate of false negativity increases due to technical difficulties and insufficient sampling. As the most optimal staging algorithm, the minimally invasive method is recommended in the first step and mediastinoscopy in the second step.

Comparison of Thoracic Epidural and Intravenous Analgesia from the Perspective of Recovery of Respiratory Function in the Early Post-Thoracotomy Period in Lung Cancer Surgery.

OBJECTIVE: Thoracic epidural analgesia (TEA) reduces pulmonary complications after thoracotomy. Hypothetically, this advantage is partially because of the preserved pulmonary function, which is achieved by the reduction of postoperative pain and immobility. This study aimed to compare the principal methods of analgesia through early postoperative spirometric performance and gas exchange parameters after elective lung cancer surgery. TEA or intravenous analgesia (IVA) involving pethidine was used as the principal method in our sample population. MATERIAL AND METHODS: A total of 62 patients operated via the posterolateral thoracotomy approach were enrolled. Postoperative analgesia was secured using multimodal analgesia with either TEA with 0.1% bupivacaine or IVA. Pain perception was assessed with the visual analog scale (VAS) while at rest and on coughing. Arterial blood samples were collected at 1, 24, and 72 hours postoperatively. Preoperative and third postoperative day spirometric measurements were recorded. RESULTS: There were no significant differences among the groups in terms of demographic characteristics, properties of surgical technique, and disease-associated conditions. VAS scores of the TEA group were lower at the 72-hour follow-up, but a considerable fraction of these differences did not reach statistical significance. Reduction in the forced expiratory volume in the first second and forced vital capacities was more prominent in the IVA group on the third postoperative day, but these were not statistically significant either. Oxygenation parameters favored TEA but remained comparable. Finally, the pH values were significantly lower in the IVA group at 1 and 72 hours postoperatively (p=0.008 and p=0.02, respectively). CONCLUSION: We believe that TEA is advantageous over IVA with alteration of respiratory volumes during the early postoperative period.

The prognostic impact of the mediastinal fat tissue invasion in patients with non-small cell lung cancer.

BACKGROUND: The prognosis of the mediastinal fat tissue invasion in non-small cell lung cancer (NSCLC) patients has not yet been clearly defined. The present study aimed to investigate the prognostic impact of the mediastinal fat tissue invasion in NSCLC patients. METHOD: We analyzed 36 patients who were found mediastinal fat tissue invasion by pathological evaluation (mediastinal fat group) and 248 patients who were classified as T4-NSCLC according to the 8th TNM classification (T4 group; invasion of other mediastinal structures in 78 patients, ipsilateral different lobe satellite pulmonary nodule in 32 patients, and tumor diameter > 7 cm in 138 patients). RESULT: Resection was regarded as complete (R0) in 255 patients (89.7%). Mediastinal fat group showed significantly higher incidence of incomplete resection (R1) and more left-sided tumors than the T4 group (p = 0.01, and p = 0.002, respectively). The survival was better in T4 group than mediastinal fat group (median 57 months versus 31 months), although it was not significant (p = 0.205). Even when only N0/1 or R0 patients were analyzed, the survival was not different between two groups (p = 0.420, and p = 0.418, respectively). 5-year survival rates for T4 subcategories (invasion of other structures, ipsilateral different lobe pulmonary nodule, and tumor diameter > 7 cm) were 39.4%, 41.9%, and 50.3%, respectively (p = 0.109). Multivariate analysis showed that age (p < 0.0001), nodal status (p = 0.0003), and complete resection (p < 0.0001) were independently influenced survival. CONCLUSION: There is no significant difference in the prognosis between mediastinal fat tissue invasion and T4 disease in NSCLC patients.

A Comparison of the Currently Used Nodal Stage Classification with the Number of Metastatic Lymph Nodes and the Number of Metastatic Lymph Node Stations for Non-Small Cell Lung Cancer; Which of These Is the Best Prognostic Factor?

OBJECTIVES: We aimed to compare the currently used nodal staging system (pN) with the number of metastatic lymph node (LN) stations (sN) and the number of metastatic LNs (nN) on survival in patients with NSCLC. METHODS: Between 2010 and 2017, 1038 patients resected for NSCLC were analyzed. We performed three-different stratifications of LN status assessment: pN-category (pN0, pN1 and pN2); sN-category (sN0, sN1; one station metastasis, sN2; two-three stations metastases, and sN3; ≥ 4 stations metastasis); nN-category (nN0, nN1; one-three LNs metastasis, nN2; four-six Lns metastasis, and nN3; ≥ 7 LNs metastasis). RESULTS: Five-year survival rate was 70.1% for N0 in all classifications. It was 54.3% for pN1, and 26.4% for pN2 (p < 0.0001). Five-year survival rates for N1, N2, and N3 categories were 54.1%, 42.4% and 16.1% according to sN, and 51.4%, 36.1%, and 7.9% according to nN, respectively (p < 0.0001). In multivariate analysis, sN and nN were independent risk factors such as pN (p < 0.0001). Hazard ratios versus N0 for N1, N2, and N3 were more significant for sN and nN than pN (1.597, 2.176, and, 3.883 for sN, 1.645, 2.658, and, 4.118 for nN, and 1.576, 3.222 for pN, respectively). When the subcategories of sN and nN were divided into pN1 and pN2 subgroups, the anatomic location of the LN involvement lost importance as tumor burden and tumor spreading increased. CONCLUSION: The number of metastatic LN stations and the number of metastatic LNs are better prognostic factors than currently used nodal classification in NSCLC.

A Case Report of A Drop Foot Developed After Common Femoral Artery Cannulation for Venoarterial Extracorporeal Membrane Oxygenation.

The drop foot cases that are associated with developing neuropathies as a result of acute compartment syndrome or femoral artery ischemia after having cannulation for venoarterial extracorporeal membrane oxygenation (VA-ECMO) have been reported rarely in literature. In this case report, female patients who are 21 years old and developed drop foot depending on ECMO during the process of lung transplantation will be presented as both to be one of the rare neurological complications connected to ECMO and its possible causes will be analyzed.

The effect of sodium hyaluronate-carboxymethyl cellulose membrane in the prevention of parenchymal air leaks: an experimental and manometric study in rats.

INTRODUCTION: We aimed to examine effectiveness of sodium hyaluronate-carboxymethly cellulose (NaH/CMC) for sealing pulmonary air leaks during postoperative period. MATERIALS AND METHODS: The study was conducted in 16 male Sprague-Dawley rats. A linear insicion (length= 0.2 cm, depth= 0.1 cm) to the lung parenchyma on the inflated by a cutter was made. The animals were randomly divided; the control group (n= 8) and NaH/CMC-treated group (the study group, n= 8). Control group was left for physiologic healing while a NaH/CMC membrane was applied over the the incisional area in the study group. Then the pressure point where the air leakage observed was noted. RESULT: No polymorphonucleer leucocytes (PMNL) infiltration was detected in control group, whereas PMNL infiltration was 0.38 ± 0.5 cell per 100 high field in study group (p= 0.234). The degree of macrophage, lymphocyte infiltration and the mean fibroblast count were found to be higher in study group compared with control group (p= 0.007, p= 0.02, p= 0.05, respectively). The mean pressure value for air leak to occur in the control group was 43.50 ± 9.55 mmHg whereas it was 73.75 ± 16.68 mmHg in the study group (p< 0.001). CONCLUSIONS: The data revealed that bioabsorbable NaH/CMC membrane accelerates healing with preserving the expansile character of lung parenchyma even in high ventilation pressures. However, further studies are required to assess the prevent impact of the pulmonary air-leak for NaH/CMC membrane.

The incidence of hoarseness after mediastinoscopy and outcome of video-assisted versus conventional mediastinoscopy in lung cancer staging.

Objectives Theoretically, video-assisted mediastinoscopy (VM) should provide a decrease in the incidence of hoarseness in comparison with conventional mediastinoscopy (CM). Methods An investigation of 448 patients with the NSCLC who underwent mediastinoscopy (n = 261 VM, n = 187 CM) between 2006 and 2010. Results With VM, the mean number of sampled LNs and of stations per case were both significantly higher (n = 7.91 ± 1.97 and n = 4.29 ± 0.81) than they were for CM (n = 6.65 ± 1.79 and n = 4.14 ± 0.84) (p < 0.001 and p = 0.06). Hoarseness was reported in 24 patients (5.4%) with VM procedures resulting in a higher incidence of hoarseness than did CM procedures (6.9% and 3.2%) (p = 0.08). The incidence of hoarseness was observed to be more frequent in patients with left-lung carcinoma who had undergone a mediastinoscopy (p = 0.03). Hoarseness developed in 6% of the patients sampled at station 4L, whereas this ratio was 0% in patients who were not sampled at 4L (p = 0.07). A multivariate analysis showed that the presence of a tumor in the left lung is the only independent risk factor indicating hoarseness (p = 0.09). The sensitivity, NPV, and accuracy of VM were calculated as to be 0.87, 0.95, and 0.96, respectively. The same staging values for CM were 0.83, 0.94, and 0.95, respectively. Conclusion VM, the presence of a tumor in the left-lung, and 4L sampling via mediastinoscopy are risk factors for subsequent hoarseness. Probably due to a wider area of dissection, VM can lead to more frequent hoarseness.

Are neutrophil/lymphocyte ratio and platelet/lymphocyte ratio reliable parameters as prognostic indicators in malignant mesothelioma?

BACKGROUND: Malignant mesothelioma (MM) is an aggressive asbestos-related pleural tumor. The incidence is increasing with intensive use of asbestos in developing countries. We need an easily accessible, inexpensive, and reliable method for determining the low survival time prognosis of this tumor. The aim of our study was to investigate the viability of neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) as prognostic indicators in MM. PATIENTS AND METHODS: Thirty-six patients with MM, whose histopathologic diagnosis and follow-up were performed by our clinic and whose complete archive data were accessible, were included in this retrospective study. The patients' histopathologic disease types and stages, complete blood count parameters at diagnosis, and survival were recorded. RESULTS: Eighteen of the patients with MM were male and the remaining 18 of them were female; the average follow-up period was 24.83±3.61 months. The PLR levels of the patients were statistically significant (P<0.05). The NLR and PLR area under the receiver operating characteristic curve values were 0.559 and 0.749, respectively (P=0.631 and P=0.044, respectively). CONCLUSION: PLR was a significant prognostic indicator of MM at diagnosis on complete blood count parameters; however, NLR was not a significant prognostic indicator. A large number of prospective studies are needed to prove the reliability of the parameters.

A bioabsorbable membrane (Seprafilm®) may prevent postoperative mediastinal adhesions following mediastinoscopy: an experimental study in rats.

INTRODUCTION: The aim of this experimental study was to investigate the anti-adhesion property of a bioabsorbable membrane following mediastinoscopy in a rat model. METHODS: The study was conducted in 20 male Sprague-Dawley rats. Mediastinoscopy was performed all of them. Rats were divided into two groups; control group (n=10); mediastinoscopy alone, study group (n=10); mediastinoscopy and sodiumhyaluronate-carboxymethlycellulose film (Seprafilm®; Genzyme Corporation, Cambridge, Mass. USA). It was used to the mediastinal surface at the end of the surgical procedure in study group. Re-mediastinoscopy was performed after 7 days. Adhesion and vascularity grade description scores were analyzed. The parameters evaluated were presence of polymorhphonucleer leucocyte, macrophage, lymphocyte, fibroblasts, edema, neovascularisation, collagenisation, and foreing body reaction. RESULTS: All the rats survived uneventfully until being sacrificed without any postoperative complications. The mean adhesion score was found to be significantly higher in control group (n=2.5±0.5) compared with study group (n=1.0±0.1) (P=0.007). Vascularity grade description score was significantly higher in control group (n=2.3±0.6) than in study group (n=1.4±0.6) (P=0.009). There were no statistical differences between the groups with regard to edema, lymphocyte and macrophage infiltration, fibroblast proliferation and foreign body reactions (P>0.05). CONCLUSION: The used of Seprafilm® during the primary procedure can reduce to the mediastinal adhesions. However, further studies are required to assess the precise impact of the anti-adhesive agents on adhesion.

The Prognostic Significance of Metastasis to Lymph Nodes in Aortopulmonary Zone (Stations 5 and 6) in Completely Resected Left Upper Lobe Tumors.

INTRODUCTION: We investigated the prognostic effect of lymph nodes metastasis in aortopulmonary (AP) zone in resected non-small cell lung cancer of the left upper lobe (LUL). METHODS: Between 1998 and 2010, 181 patients with LUL carcinoma underwent complete resection and were retrospectively analyzed. The patients were divided into four groups according to N status: N0 (n = 68, 37.6%), N1 (n = 64, 35.3%), N2(5,6+) (only metastasized to stations 5 and/or 6, n = 36, 19.9%), and N2(7+) (only metastasized to stations 7, n = 13, 7.2%). N1 were divided according to single and multiple (N1(single) n = 49, N1(multiple) n = 15) or peripheral and hilar (N1(peripheral) n = 39, N1(hilar) n = 25). RESULTS: Overall 5-year survival rate was 55.1%. Five-year survivals were 76.1% for N0, 54.3% for N1, and 20.7% for N2. N1(peripheral) had a better survival than N1(hilar) (60.3 vs. 29.4%, p = 0.09). Five-year survival of N1(single) was 60.1%, whereas it was 36.6% for N1(multiple) (p = 0.02). Five-year survival rate was 24.6% for N2(5,6+). Skip metastasis for lymph nodes in AP zone (n = 13) was a factor of better prognosis as compared to nonskip metastasis (n = 23) (29.9 vs. 19.2%). There was no statistically significant difference between the N2(5,6+) and N1(hilar) (p = 0.772), although N1(peripheral) had a significantly better survival than N2(5,6+) (p = 0.02). AP zone metastases alone had a significantly worse survival than N1(single) (p = 0.008), whereas there was no statistically significant difference between the N1(multiple) and N2(5,6+) (p = 0.248). N2(7+) was not expected to survive 3 years after operation. They had a significantly worse prognosis than N2(5,6+) (p = 0.02). CONCLUSION: LUL tumors with metastasis in the AP zone lymph nodes, especially skip metastasis, were associated with a more favorable prognosis than other mediastinal lymph nodes. However, the therapy of choice for lung cancer with N2(5,6+) has not been clarified yet.

Endobronchial argon plasma coagulation for treatment of Dieulafoy disease.

Dieulafoy disease of the bronchus is a rare condition. A 28-y-old male patient with recurrent exacerbations of hemoptysis (producing up to 300 mL) over the previous 4 y was admitted to our hospital following an acute episode. A 3-mm sessile lesion covered with somewhat ulcerated smooth mucosa was detected at the distal end of the left main bronchus, at the entrance to the upper lobe bronchus. Bleeding was controlled by argon plasma coagulation, and total coagulation of the lesion was also therapeutic. The patient has been followed for 2 y with no further bleeding. In the very few reported cases of Dieulafoy disease, surgical resection and selective embolization were the treatments used. Endobronchial treatment has not been described before as a therapeutic approach. We emphasize that argon plasma coagulation can be a treatment option in such cases.

Anterior muscle and neurovascular-sparing thoracotomy and posterolateral thoracotomy: postoperative pain and morbidity assessment.

BACKGROUND: We conducted this study to evaluate the thoracotomy approaches commonly used nowadays for treating thoracic pathologies and to decide whether it was necessary to make a choice between them for different situations. We used prospective analysis to compare hospital stay, analgesic usage, morbidity and postoperative chest pain between anterior muscle and neurovascular-sparing thoracotomy (AST) with disconnection of anterior rib cartilage, and serratus-sparing posterolateral thoracotomy (PLT). We also looked for a correlation between localization of the lesion and thoracotomy type for this factors. MATERIALS AND METHODS: A total of 152 patients who had undergone a thoracotomy for major lung surgery from January through November 2011 were recruited in this study. Of these, 52 patients received AST and 100 underwent PLT. Location of the lesions in the thoracic cavity and all detected postoperative complications were documented. Postoperative chest pain was evaluated using a PIQ-6 pain questionnaire. Analgesic usage and duration of hospitalization were also noted. RESULTS: Pain questionnaire scores were equivalent for both groups in all of the evaluations. Postoperative total median narcotic analgesic usage was lower in AST group than in PLT group. Complication rates were close in both groups. Median hospital stay was also shorter in patients who received AST. CONCLUSION: We conclude that AST is a reasonable thoracotomy alternative to standard PLT for major lung surgery. But our study fails to demonstrate a clear advantage regarding postoperative pain and complications.

Does video-assisted mediastinoscopy offer lower false-negative rates for subcarinal lymph nodes compared with standard cervical mediastinoscopy?

OBJECTIVES: Theoretically, video-assisted mediastinoscopy (VAM) offers improved staging of subcarinal lymph nodes (LNs) compared with standard cervical mediastinoscopy (SCM). Materials and METHODS: Between 2006 and 2011, 553 patients (SCM, n = 293; VAM, n = 260) with non-small cell lung carcinoma who underwent mediastinoscopy were investigated. Mediastinoscopy was performed only in select patients based on computed tomography (CT) or positron emission tomography CT scans in our center. RESULTS: The mean number of LNs and stations sampled per case was significantly higher with VAM (n = 7.65 ± 1.68 and n = 4.22 ± 0.83) than with SCM (n = 6.91 ± 1.65 and 3.92 ± 86.4; p < 0.001). The percentage of patients sampled in station 7 was significantly higher with VAM (98.8%) than with SCM (93.8%; p = 0.002). Mediastinal LN metastasis was observed in 114 patients by mediastinoscopy. The remaining 439 patients (203 patients in VAM and 236 in SCM) underwent thoracotomy and systematic mediastinal lymphadenectomy (SML). SML showed mediastinal nodal disease in 23 patients (false-negative [FN] rate, 5.2%). The FN rate was higher with SCM (n = 14, 5.9%) than with VAM (n = 9, 4.4%), although this difference was not statistically significant (p = 0.490). Station 7 was the most predominant station for FN results (n = 15). The FN rate of station 7 was found to be higher with SCM (n = 9, 3.8%) than with the VAM group (n = 6, 2.9%; p = 0.623). CONCLUSION: FN were more common in mediastinoscopy of subcarinal LNs. VAM allows higher rates of sampling of mediastinal LN stations and station 7, although it did not improve staging of subcarinal LNs.

Size of pneumothorax can be a new indication for surgical treatment in primary spontaneous pneumothorax: a prospective study.

PURPOSE: Surgical treatment of primary spontaneous pneumothorax (PSP) is usually performed in cases of prolonged air leak (PAL) or recurrence. We investigated the effect of the size of pneumothorax in surgically treated PSP cases. METHODS: Between 2007 and 2008, 181 patients hospitalized with the diagnosis of PSP were prospectively recorded. The size of pneumothorax was calculated in percentages by the method defined by Kircher and Swartzel. Patients were divided into two groups, according to pneumothorax size: Group A (large pneumothorax, ≥50%), and Group B (small or moderate pneumothorax, <50%). RESULTS: The mean size of pneumothorax was 80.5 ± 10.4% in Group A (n = 54, 29%) and 39.5 ± 6.5% in Group B (n = 127, 71%). History of smoking and smoking index were significantly higher in Group A patients (p = 0.02, p <0.001, respectively). Fifty-five patients (29.3%) required surgery because of PAL or ipsilateral recurrence. The rate of patients requiring surgical operation was significantly higher in Group A (51.9%) than in Group B (n = 25; p <0.001). Rates of PAL and recurrence were higher in Group A than in Group B (p = 0.007, p = 0.004, respectively). CONCLUSION: The size of pneumothorax is larger in those with a smoking history and a higher smoking index. Surgical therapy can be considered in cases with a pneumothorax size ≥50% after the first episode immediately.

Endotracheal ectopic parathyroid adenoma mimicking asthma.

Primary benign tumors of the trachea are uncommon. These tumors may cause tracheal occlusion and lead to a misdiagnosis of asthma. Ectopic parathyroid adenoma (EPA) can be seen anywhere between the mandibular angle and the mediastinum. The distal part of the trachea is a rare location for EPA, and EPA obstructing the endotracheal lumen has not been reported in the literature. We herein describe a 52-year-old female with a several-year history of asthma treatment who presented with progressive dyspnea. Computed tomography revealed a mass that was obstructing the tracheal lumen. Total mass excision was performed via endobronchial treatment, and pathologic examination revealed EPA.

Impact of extended cervical mediastinoscopy in staging of left lung carcinoma.

BACKGROUND: Extended cervical mediastinoscopy (ECM) is a method for staging lung carcinoma. We aimed to demonstrate the impact of ECM in the staging of lung carcinoma. METHODS: Between 1998 and 2011, 159 patients with left lung carcinoma who underwent ECM simultaneously with standard cervical mediastinoscopy (SCM), were retrospectively analyzed. Until 2006, ECM had been performed routinely (n = 90, routine ECM), however, after 2006 ECM was performed only in patients selected based on computed tomography and positron emission tomography scans (n = 69, selective ECM). RESULTS: Mediastinal lymph node metastasis was present in 36 patients by mediastinoscopy. Aortopulmonary window (APW) lymph node metastasis was present in 26 patients (10 in the routine group, 16 in the selective group), whereas the 10 patients who had mediastinal lymph node metastasis that could only be accessed by SCM, but had no APW lymph node metastasis, were excluded. The remaining 123 patients (72 in the routine group, 51 in the selective group) were identified as cN0/N1 by SCM/ECM, and lobectomy, pneumonectomy, and exploratory thoracotomy were performed on 64, 43, and 16 of these patients, respectively. According to the lymphadenectomy, APW lymph node metastasis was determined in 11 patients (seven in the routine group, four in the selective group). Sensitivity, negative predictive value (NPV), and accuracy of ECM were calculated as 0.70, 0.90, and 0.92, respectively. Staging values of routine/selective ECM protocols were 0.58/0.80, 0.89/0.91 and 0.91/0.94, respectively. The complication rate was 5% (n = 8). CONCLUSIONS: ECM has an adequate NPV and accuracy in determining metastasis to the APW lymph nodes in patients with left lung carcinoma.