Prognostic significance of mediastinal standardized uptake value on positron emission tomography/computed tomography in patients with left upper lobe non-small cell lung cancer: Is invasive staging of aortopulmonary window lymph nodes necessary?

Background: This study aims to investigate whether the invasive staging of aortopulmonary window lymph nodes could be omitted in the presence of a suspected isolated metastasis in the aortopulmonary window lymph node on positron emission tomography/computed tomography. Methods: Between January 2010 and January 2016, a total of 67 patients (54 males, 13 females; mean age: 59.9±8.7 years; range, 44 to 76 years) with metastatic left upper lobe tumors to aortopulmonary window lymph nodes were retrospectively analyzed. According to positron emission tomography/computed tomography findings in clinical staging, the patients were classified as positive (+) (n=33) and negative (-) (n=34) groups. Results: There was a statistically significant difference between the two groups in terms of sex distribution, lymph node diameter on computed tomography, maximum standardized uptake value of aortopulmonary window lymph nodes, and tumor diameter (p<0.001 for all). A trend toward significance was found to be in pT status, LN #6 metastases, and pathological stage between the two groups (p=0.067). The five-year overall survival rate for all patients was 42.4% and there was no significant difference between the groups (p=0.896). The maximum standardized uptake value of the aortopulmonary window lymph nodes was a poor prognostic factor for survival (area under the curve=0.533, 95% confidence interval: 0.407-0.675, p=0.648). Conclusion: Invasive staging of aortopulmonary window lymph nodes can be omitted in patients with isolated suspected metastasis to aortopulmonary window lymph nodes in non-small cell lung cancer of the left upper lobe.

Can stage-IIB lung cancer be divided into subgroups in terms of prognosis? A modelling study.

INTRODUCTION: Whether changes should be made to the TNM classification of non-small cell lung cancer (NSCLC) according to the newly proposed nodal classification is unclear. We aim to compare the survival between stage-IIB subsets using a modelling study performed using the newly proposed nodal classification. PATIENTS AND METHODS: A total of 682 patients with stage-IIB NSCLC based on the 8th TNM classification were analysed. Hazard ratio (HR) values calculated from survival comparisons between stage-IIB subgroups were used to create a model for patients with stage-IIB NSCLC, and modelling was performed according to the HR values that were close to each other. RESULTS: Patients with T1N1a cancer had the best survival rate (58.2%), whereas the worst prognosis was observed in those with T2bN1b cancer (39.2%). The models were created using the following HR results: Model A (T1N1a, n = 85; 12.4%), Model B (T2a/T2bN1a and T3N0, n = 438; 64.2%), and Model C (T1/T2a/T2bN1b, n = 159; 23.4%). There was a significant difference between the models in terms of overall survival (p = 0.03). The median survival time was 69 months in Model A, 56 months in Model B, and 47 months in Model C (Model A vs. Model B, p = 0.224; Model A vs. Model C, p = 0.01; and Model B vs. Model C, p = 0.04). Multivariate analysis showed that age (p < 0.001), pleural invasion (p < 0.001), and the developed modelling system (p = 0.02) were independently negative prognostic factors. CONCLUSION: There was a prognostic difference between stage-IIB subsets in NSCLC patients. The model created for stage-IIB lung cancer showed a high discriminatory power for prognosis.

Could the probability of surgical indication be determined after first episode of primary spontaneous pneumothorax?

OBJECTIVES: To develop a risk score model for primary spontaneous pneumothorax surgery (prolonged air leak or ipsilateral recurrence). The model was internally validated for risk estimation. METHODS: We analyzed 453 patients with primary spontaneous pneumothorax between 2014 and 2018. Patients were randomly assigned a 2:1 ratio to the development dataset (n = 302, study cohort) or the internal validation dataset (n = 151, validation cohort). The final outcomes of patients with primary spontaneous pneumothorax, the presence or absence of surgical indications, were tracked. Multivariable logistic regression models were prepared to estimate the probability of surgical indication and a scoring model was created. It was internally validated using the validation cohort. Calibration was ascertained using the Hosmer-Lemeshow method and Brier score. RESULTS: The surgery indication rate was 47.8% (n = 217) (prolonged air leak, n = 130; ipsilateral recurrence, n = 87). There were no demographic or radiological differences between the validation and the study cohorts. Logistic regression analysis showed that the presence of bullae or blebs (p < 0.001, odds ratio = 3.340, 95%CI = 1.753-6.363) and pneumothorax volume (p < 0.001, odds ratio = 1.033, 95%CI = 1.019-1.048) were independent risk factors for surgical indication. The scoring model significantly predicted surgical indications (area under the curve, AUC = 0.768, 95%CI = 0.714-0.821, p < 0.001). Our model showed acceptable discrimination with an AUC > 0.75 in the validation set (AUC = 0.777, 95%CI = 0.702-0.852, p < 0.001) and had an adequate calibration (Hosmer-Lemeshow test p = 0.249, Brier score = 0.25). CONCLUSION: The internally validated primary spontaneous pneumothorax scoring model was a good predictor of the need for surgery in patients with primary spontaneous pneumothorax. Prospective external validation studies with larger patient cohorts are required.

Survival impact of unexpected N2 in stage IIIB/N2 non-small cell lung cancer patients.

BACKGROUND: We investigated the effect of unexpected N2 on survival in stage IIIB/N2 cases. METHODS: We retrospectively analyzed 1803 non-small cell lung cancer patients between 2010 and 2016. There were 89 patients (4.9%) with unexpected N2 (pathological (p) IIIB/N2 group), whereas 49 patients (2.7%) with cN2 (clinical (c) IIIB/N2 group). Although pIIIB/N2 group underwent surgery followed by adjuvant therapy, the cIIIB/N2 group of patients had multimodality treatment including induction chemotherapy ± radiotherapy followed by surgery. RESULTS: The five-year overall survival (OS) for all patients was 36.0% [median survival time (MST) 27.9 months], and disease-free survival (DFS) was 28.9% (MST, 18.2 months). The OS was 39.6% (MST: 34.4 months) and the median DFS time was 31.1% (Median: 23.1 months) in the pIIIB/N2 group, whereas it was 29.2% (MST: 23.0 months) for OS and 22% (median: 12.4 months) for DFS in the cIIIB/N2 group. There were no significant OS and DFS differences between the pIIIB/N2 group and the cIIIB/N2 group (p = 0.124 and p = 0.168, respectively). CONCLUSIONS: In stage IIIB/N2 cases, the fact that N2 could not be detected preoperatively with minimally invasive or invasive methods and was detected in the pathological examination after surgery does not provide a survival advantage.

Survival Analysis of Surgically Resected ypN2 Lung Cancer after Neoadjuvant Therapy.

INTRODUCTION: Surgery is widely accepted today when downstaging of mediastinal lymph nodes after neoadjuvant therapy is achieved. However, the role of surgery in patients with persistent N2 disease is still controversial. This study aims to detail the diagnostic problems, prognostic features, and long-term survival of the persistent N2 non-small cell lung cancer patient group. PATIENTS AND METHODS: One-hundred fifty patients who received neoadjuvant therapy and subsequently underwent resection, in-between 2003 and 2015, were retrospectively analyzed. In this study, "persistent N2" group refers to patients who received neoadjuvant therapy for clinically or histologically proven N2, who underwent a surgery after having been classified as "downstaged" at restaging, but in whom ypN2 lesions were subsequently confirmed on the operative specimens. Patients with multistation N2 were included in the study. There were 119 patients who met the criteria, whereas persistent ypN2 was detected in 28.5% (n = 34) of all patients. RESULTS: Overall 5-year survival rate was 47.2%, while it was 23.4% for patients with persistent N2. Factors that adversely affected survival were to have nonsquamous cell histological type (p = 0.006), high ypT stage (p = 0.001), persistent N2 (p = 0.02), and recurrence during follow-up (p < 0.001). A trend toward a shorter survival was observed when the ypN2 zone was subcarinal versus other zones, but did not reach statistical significance (p = 0.08). In addition, a trend toward a shorter survival of patients with multiple N2 involvement (p = 0.412) was observed. CONCLUSION: In the persistent N2 group, when multiple involvement or subcarinal involvement was excluded, relatively good survival was detected.

Comparison of 6th, 7th, and 8th editions of the TNM staging in non-small cell lung cancer patients: Validation of the 8th edition of TNM staging.

Background: In this study, we aimed to evaluate the effects of the transition from the 6th edition of the Tumor, Node, Metastasis (TNM) staging system to the 7th edition, and from the 7th edition to the 8th edition by comparing the stage migrations. We also aimed to externally validate the 8th edition of the TNM staging system. Methods: Between September 2005 and June 2015, a total of 1,077 patients (986 males, 91 females; mean age: 59.6±8.3 years; range, 35 to 84 years) with non-small cell lung cancer who underwent lung resection were retrospectively analyzed. We re-staged patients according to 6th, 7th, and 8th TNM staging and compared the stage migrations of cases among the three staging systems. Results: Stage migration in the transition to the 7th edition of the TNM staging system was observed in 368 (34.1%) patients whereas it was observed in 541 (50.2%) patients in the transition to the 8th edition (p<0.001). The rate of upstaging in transition to the 7th edition staging system was 50.2% (n=185), whereas it was 98.1% (n=531) for the transition to the 8th edition (p<0.001). The survival rates of Stages 1B, 2B and 3A increased with transition to the 7th edition and the survival rates of Stages 1B, 2A, 2B, 3A, and 3B increased with the transition to the 8th edition. The best stratification in the survival curves in the 6th edition was between 1B-1A and 3B-3A. In the 7th edition, it occurred between 1B-1A, 3A-2B and 3B-3A and, in the 8th edition, between 1B-1A and 3B-3A. Conclusion: Stratification according to the 7th edition showed better prognostic validity compared to the 6th edition; and that of the 8th edition was better compared to the 7th edition.

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.

Is there any change in disease presentation and surgical outcomes in patients with pulmonary aspergilloma? An evaluation of the time trend.

Background: This study aims to investigate the changes in the clinical and radiological presentations of pulmonary aspergilloma in patients undergoing surgery and to evaluate changes in the surgical outcomes over time. Methods: Between January 2000 and January 2020, a total of 88 patients (69 males, 19 females; mean age: 45.4±11.2 years; range, 17 to 70 years) who underwent surgery for pulmonary aspergilloma were retrospectively analyzed. Surgeries performed were divided into two groups based on their chronological order: first period (from 2000 to 2010, n=44) and second period (from 2010 to 2020, n=44). Results: The most frequent underlying disorder was tuberculosis (72.7%), whereas 10 patients did not have any predisposing conditions for pulmonary aspergilloma. Regarding the aspects of radiological imaging and operative findings, 22 patients had simple aspergilloma and 66 patients had complex aspergilloma. Complications and mortality rates were 33.0% and 5.7%, respectively. A statistical downward was observed in the second period compared to that in the first period regarding the rate of patients with tuberculosis history (61.4% vs. 84.1%, p=0.01). There were more patients who did not have any predisposing conditions for pulmonary aspergilloma in the second period and in the simple aspergilloma group (p=0.04 and p<0.001, respectively). Simple aspergilloma was often observed in the second period than that in the first period (31.8% vs. 18.2%). There was no significant difference between the periods regarding the type of surgical resection (p=0.506), whereas in the simple aspergilloma group, more patients underwent wedge resection (p<0.001). There were no significant differences between the periods and radiological groups in terms of complications and mortality. Patients who underwent pneumonectomy had significantly higher rates of complications and mortality (p=0.01 and p=0.03, respectively). Conclusion: Although pulmonary aspergilloma patients who underwent surgery in the last 10 years had a lower history of tuberculosis than those who were operated in the previous 10 years, there was no change in postoperative complications and mortality rates. An increase in simple aspergilloma prevalence may reduce the rate of surgical morbidity.

Is There Any Relationship Between the Number of COVID-19 Tests by Country with the Income Inequality of Countries? A Comparison with Income Inequality Metrics.

OBJECTIVE: Coronavirus diseases 2019 test numbers vary from country to country. The present study aims to investigate whether there is a relationship between the number of coronavirus diseases 2019 tests by country with the income inequality of countries. MATERIAL AND METHODS: The association between the number of coronavirus diseases 2019 tests and income inequality metrics was evaluated in 197 countries. Income inequality metrics consisted of the gross domestic product per capita, Gini index, the P80/P20 ratio, human development index ranking, and poverty rate. The share of the tests that gave positive results (positive rate) and fatality rates was calculated by countries. RESULTS: There was a strong positive correlation between the number of coronavirus diseases 2019 tests per million people and the number of coronavirus diseases 2019 patients per million people (rho = 0.697, P < .001). A significant correlation was observed between the number of coronavirus diseases 2019 tests and all income inequality metrics (P < .001). The strongest positive correlation with the number of coronavirus diseases 2019 tests was between gross domestic product per capita (rho = 0.775), while the strongest negative correlation with the number of coronavirus diseases 2019 tests was between human development index ranking (rho = -0.836). The multiple regression analysis showed that age (P = .01), gross domestic product per capita (P < .001), and human development index ranking were independent factors affecting the number of coronavirus diseases 2019 tests per million people (adjusted R2 = 0.301). The fatality rate was associated with the number of coronavirus diseases 2019 tests (P = .01). CONCLUSION: Income inequalities in countries are associated with the number of coronavirus diseases 2019 tests. For this reason, many deaths from coronavirus diseases 2019 may have gone overlooked in countries with poor-income inequality metrics.

Which pneumothorax volume/size measurement method can best predict surgical indication in primary spontaneous pneumothorax patients? A comparison of six different methods.

OBJECTIVES: We determined whether patients requiring surgery could be identified using pneumothorax volume/size in the first episode of primary spontaneous pneumothorax (PSP) and confirmed which of six different measurement methods of pneumothorax volume/size best predicted surgical indication (prolonged air leak, PAL, or ipsilateral recurrence). METHODS: Between 2013 and 2017, 282 patients with PSP were analysed. The volume of the pneumothorax (%) was calculated using volumetric methods (Collins, Rhea, Kircher, Light), while its size (large or small) was determined using the British Thoracic Society (BTS) and American College of Chest Physicians (ACCP) guidelines for the first PSP episode. The optimal cut-off points of pneumothorax volume in patients requiring surgery were based on the most sensitive and specific scores, calculated using receiver operating characteristic analysis. RESULTS: Surgery was indicated in 162 patients (57.4%) because of PAL (n = 92) or ipsilateral recurrence (n = 70). Kircher's method had a better area under the curve (AUC) value than the others (AUC = 0.731, 95% confidence interval [CI] 0.676-0.782). Comparing the calculated cut-off points for each volumetric method and the known thresholds from the BTS/ACCP, the best predictor for surgical indications (for both PAL and ipsilateral recurrence) was Kircher's method (odds ratio = 5.636, 95% CI 3.338-9.516, p < 0.001). The four volumetric methods were significantly correlated with pneumothorax volume (rho ≥ 0.8, p < 0.001, for all comparisons). CONCLUSIONS: Pneumothorax volume/size calculated in the first PSP episode may help predict surgical candidates, with Kircher's method being the best predictor. There was a correlation between all the volumetric methods of the pneumothorax volume.

Impact of preoperative comorbidities on postoperative complication rate and outcome in surgically resected non-small cell lung cancer patients.

OBJECTIVE: This study aimed to analyze whether comorbidities impact postoperative complication rate or survival after anatomical lung resection for non-small cell lung cancer (NSCLC). METHODS: A retrospective analysis of 1219 patients who underwent NSCLC resection between 2000 and 2015 was performed. Analyzed comorbidities included chronic obstructive lung disease (COPD), hypertension, coronary artery disease (CAD), peripheral artery disease, myocardial infarction history, diabetes mellitus, renal insufficiency and other malignancies. RESULTS: Most patients (78.9%) had comorbidities, most commonly hypertension (34.1%) followed by COPD (26.4%) and other malignancies (19%). The overall complication rate was 38.6% (26.4% pulmonary; 14.8% cardiac; and 3.0% gastrointestinal). Hypertension (odds ratio (OR) = 1.492, p = 0.031) was associated with more cardiac complications. Heavy smoking (OR = 1.008, p = 0.003) and low body mass index (BMI) (OR = 0.932, p < 0.001) affected the pulmonary complication rate significantly. None of the included comorbidities affected the overall complication rate or the survival negatively. However, the patient characteristics of advanced age (p < 0.001), low BMI (p = 0.008), and low FEV1 (p = 0.008) affected the overall complication rate as well as survival (each p < 0.001). CONCLUSION: Advanced age, low BMI, and low FEV1 were predictive of greater complication risk and shorter long-term survival in patients who underwent NSCLC resection. Cardiac complications were associated with hypertension and CAD, whereas pulmonary complications were associated with a high pack year count.

Incidence and risk factors for pneumomediastinum in COVID-19 patients in the intensive care unit.

OBJECTIVES: The incidence of pneumomediastinum (PNMD), its causes of development and its effect on prognosis in the coronavirus disease 2019 (COVID-19) are not clear. METHODS: Between March 2020 and December 2020, 427 patients with real-time reverse transcriptase-polymerase chain reaction-confirmed COVID-19 admitted to the intensive care unit were analysed retrospectively. Using receiver operating characteristic analysis, the area under the curve (AUC) for initial invasive mechanical ventilation (MV) variables such as initial peak inspiratory pressure (PIP), PaO2/FiO2 (P/F ratio), tidal volume, compliance and positive end-expiratory pressure was evaluated regarding PNMD development. RESULTS: The incidence of PNMD was 5.6% (n = 24). PNMD development rate was 2.7% in non-invasive MV and 6.2% in MV [odds ratio (OR) 2.352, 95% confidence interval (CI) 0.541-10.232; P = 0.400]. In the multivariate analysis, the independent risk factors affecting the development of PNMD were PIP (OR 1.238, 95% CI 1.091-1.378; P < 0.001) and P/F ratio (OR 0.982, 95% CI 0.971-0.994; P = 0.004). P/F ratio (AUC 0.815, 95% CI 0.771-0.854), PIP (AUC 0.780, 95% CI 0.734-0.822), compliance (AUC 0.735, 95% CI 0.677-0.774) and positive end-expiratory pressure (AUC 0.718, 95% CI 0.668-0.764) were the best predictors for PNMD development. Regarding the multivariate analysis, independent risk factors affecting mortality were detected as age (OR 1.015, 95% CI 0.999-1.031; P = 0.04), comorbidity (OR 1.940, 95% CI 1.100-3.419; P = 0.02), mode of breathing (OR 48.345, 95% CI 14.666-159.360; P < 0.001), PNMD (OR 5.234, 95% CI 1.379-19.857; P = 0.01), positive end-expiratory pressure (OR 1.305, 95% CI 1.062-1.603; P = 0.01) and tidal volume (OR 0.995, 95% CI 0.992-0.998; P = 0.004). CONCLUSIONS: PNMD development was associated with the initial P/F ratio and PIP. Therefore, it was considered to be related to both the patient and barotrauma. PNMD is a poor prognostic factor for COVID-19.

Correlation between outcomes and tumor size in >7 cm T4 non-small cell lung cancer patients: A tumor size-based comparison study.

BACKGROUND: We investigated whether all size-based pathological T4N0-N1 non-small cell lung cancer patients with tumors at any size >7 cm had the same outcomes. METHODS: We reviewed non-small cell lung cancer patients with tumors >7 cm who underwent anatomical lung resection between 2010 and 2016. A total of 251 size-based T4N0-N1 patients were divided into two groups based on tumor size. Group S (n = 192) included patients with tumors of 7.1-9.9 cm and Group L (n = 59) as tumor size ≥10 cm. RESULTS: The mean tumor size was 8.83 ± 1.7 cm (Group S: 8.06 ± 0.6 cm, Group L: 11.3 ± 1.6 cm). There were 146 patients with pathological N0 and 105 patients with pathological N1 disease. Mean overall survival and disease-free survival were 64.2 and 51.4 months, respectively. The five-year overall survival and disease-free survival rates were 51.2% and 43.5% (five-year OS; pT4N0:52.7%, pT4N1:47.9%, DFS; pT4N0:44.3%, pT4N1: 42.3%). No significant differences were observed between T4N0 and T4N1 patients in terms of five-year OS or DFS (p = 0.325, p = 0.505 respectively). The five-year overall survival and disease-free survival rates were 52% and 44.6% in Group S, and 48.5% and 38.9% in Group L. No significant difference was observed between the groups in terms of five-year overall survival or disease-free survival (p = 0.699, p = 0.608, respectively). CONCLUSIONS: Above 7 cm, any further increase in tumor size in non-small cell lung cancer patients had no significant effect on survival, confirming it is not necessary to further discriminate among patients with tumors in that size class.

Does anatomical location-based metastatic lymph node density affect prognosis in lung cancer patients?

OBJECTIVES: The newly proposed N subclassification (new-N) was compared with the combined anatomical location and ratio of the number of metastatic lymph nodes to the total number of resected lymph nodes (anatomic-LNR) in terms of prognosis in resected lung cancer patients. METHODS: Between 2005 and 2018, 961 patients who underwent lung cancer resection were catergorized into the pN1-single (N1a; n = 281), pN1-multiple (N1b; n = 182), pN2-single with skip metastasis (N2a1; n = 116), pN2-single with N1 metastasis (N2a2; n = 222) and pN2-multiple (N2b; n = 160) groups based on new-N. The optimal cut-off points for survival in pN1 and pN2 patients were determined using the best sensitivity and specificity scores, calculated using receiver operating characteristic analysis. RESULTS: The difference in survival between N1a and N1b patients was statistically significant (P = 0.001), but there was no significant difference in the survival rates of N1b and N2a1 (P = 0.52). The survival curves for N2a1 and N2a2 patients almost overlapped (P = 0.143). N2a2 patients showed a better survival rate than N2b patients, with no significant difference (P = 0.132). The cut-off points for LNR were 0.10 and 0.25 for pN1 and pN2 patients, respectively, according to receiver operating characteristic analysis for survival. Based on receiver operating characteristic analysis, pN patients were categorized into the N1-lowLNR (n = 232), N1-highLNR (n = 231), N2-lowLNR (n = 266) and N2-highLNR (n = 232) groups. The 5-year survival rate was 62.9%, 49.8%, 41.1% and 27.1% for N1-lowLNR, N1-highLNR, N2-lowLNR and N2-highLNR, respectively (P < 0.001). CONCLUSIONS: LowLNR is associated with better survival than highLNR in resected lung cancer patients. Anatomic-LNR shows a high discriminatory power for prognosis.

Is the Yedikule-solitary pulmonary nodule malignancy risk score sufficient to predict malignancy? An internal validation study.

OBJECTIVES: We aimed to develop a malignancy risk score model for solitary pulmonary nodules (SPNs) using the demographic, radiological and clinical characteristics of patients in our centre. The model was then internally validated for malignancy risk estimation. METHODS: A total of 270 consecutive patients who underwent surgery for SPN between June 2017 and May 2019 were retrospectively analysed. Using the receiver operating characteristic curve analysis, cut-off values were determined for radiological tumour diameter, maximum standardized uptake value and the Brock University probability of malignancy (BU-PM) model. The Yedikule-SPN malignancy risk model was developed using these cut-off values and demographic, radiological and clinical criteria in the first 180 patients (study cohort) and internally validated with the next 90 patients (validation cohort). The Yedikule-SPN model was then compared with the BU-PM model in terms of malignancy prediction. RESULTS: Malignancy was reported in 171 patients (63.3%). Maximum standardized uptake value and BU-PM scores were sufficient to predict malignancy (P < 0.001 for both), while the effectiveness of nodule size determined on thoracic computed tomography did not reach statistical significance (P = 0.09). When the Yedikule-SPN model developed with the study cohort was applied to the validation cohort, it significantly predicted malignancy (area under the receiver operating characteristic curve: 0.883, 95% confidence interval: 0.827-0.957, P < 0.001). Comparison of patients in the validation group with Yedikule-SPN scores above (n = 53) and below (n = 37) the cut-off value of 65.75 showed that the malignancy rate was significantly higher among patients with Yedikule-SPN score over 65.75 (86.8% vs 21.6%, P < 0.001, odds ratio = 23.821, 95% confidence interval: 7.805-72.701). When compared with the BU-PM model in all patients, the Yedikule-SPN model tended to be a better predictor of malignancy (P = 0.06). CONCLUSIONS: The internally validated Yedikule-SPN model is also a good predictor of the malignancy of SPN(s). Prospective and multicentre external validation studies with large patients' cohorts are needed.

Subnormothermic Ex Vivo Lung Perfusion Temperature Improves Graft Preservation in Lung Transplantation.

Normothermic machine perfusion is clinically used to assess the quality of marginal donor lungs. Although subnormothermic temperatures have proven beneficial for other solid organ transplants, subnormothermia-related benefits of ex vivo lung perfusion (EVLP) still need to be investigated. Material and Methods: In a rat model, we evaluated the effects of 28 °C temperature on 4-h EVLPs with subsequent left lung transplantation. The recipients were observed for 2 h postoperatively. Lung physiology data were recorded and metabolic parameters were assessed. Results: During the 4-h subnormothermic EVLP, the lung oxygenation was significantly higher (p < 0.001), pulmonary vascular resistance (PVR) lower and dynamic compliance (Cdyn) higher when compared to the 37 °C EVLP. During an end-of-EVLP stress test, we recorded significantly higher flow (p < 0.05), lower PVR (p < 0.05) and higher Cdyn (p < 0.01) in the 28 °C group when compared to the 37 °C group. After the left lung transplantation, Cdyn and oxygenation improved in the 28 °C group, which were comparable to the 37 °C group. Chemokines RANTES, MIP-3α, MIP-1α MCP-1 GRO/KC and pro-inflammatory mediators GM-CSF, G-CSF and TNFα were significantly lower after the 28 °C EVLP and remained low in the plasma of the recipient rats after transplantation. The lungs of the 28 °C group showed significantly lowered myeloperoxidase activity and lowered levels of TNFα and IL-1ß. Conclusions: Compared to the normothermic perfusion, the 28 °C EVLP improved Cdyn and PVR and reduced both the release of pro-inflammatory cytokines and myeloperoxidase activity in lung tissue. These observations were also observed after the left lung transplantation in the subnormothermic group. The 28 °C EVLP significantly improved biochemical, physiological and inflammatory parameters in lung donors.

COVID-19 Screening Program Should be Performed in Healthcare Workers.

The screening test for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) disease 2019 (COVID-19) has not been performed in healthcare workers (HCWs) yet, although HCWs are at a high risk of infection. COVID-19 is detected in 5%-15% of HCWs according to published studies. Nevertheless, it may be higher than the rates indicated in published studies. Based on this fact, the current recommendation of studies in the literature is to screen COVID-19 in HCWs. In this review, studies on SARS-CoV-2 screening in HCWs will be reconsidered, and the frequency and target group in whom screening should be performed will be emphasized.

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.

Survival analysis of pathological complete response of locally advanced lung cancer after neoadjuvant treatment.

AIM: The first aim is to determine the clinical and pathological characteristics and factors affecting survival in patients with pathological complete response (pCR) after neoadjuvant therapy, and the secondary aim is to investigate the effect of adjuvant therapy on survival in these patients. METHODS: Between 2003 and 2015, there was 372 patients who underwent lung resection after neoadjuvant therapy with a diagnosis of locally advanced lung cancer. Sixty-eight patients who had pCRwere retrospectively analyzed. The odds ratios (OR) were calculated in regards of recurrence. RESULTS: Overall 5-year survival rate was 65.1%. Recurrence was the risk factor affecting survival (78.2% vs 19.3%, p = 0.001) while neoadjuvant treatment type (p = 0.766), the reason of neodjuvant treatment (p = 0.581), and the type of operation (p = 0.860) did not affect survival. Postoperative adjuvant treatment had a positive effect on survival (71.1% versus 62.7%), although this difference was not significant (p = 0.561). Local or distant recurrence was detected in 15 patients (22%). In multivariate analysis, the independent risk factors affecting the recurrence were the time from the end of the neoadjuvant therapy to the surgery being less than eight weeks (OR = 6.49, p = 0.03), the type of neoadjuvant treatment (OR = 0.203, p = 0.03). In patients with a squamous cell carcinoma, there was a decreased trend toward in terms of recurrence (p = 0.06). CONCLUSIONS: pCR after neoadjuvant therapy positively affects survival. Better survival may be detected in patients receiving adjuvant therapy. Due to unexpected the high recurrence rate, patients should be followed in the postoperative period closely.