The impact of dissection of station 9 on survival and the necessity of pulmonary ligament division during upper lobectomy for lung cancer.

BACKGROUND: We conducted this study to investigate the need for dissection of station 9 lymph nodes during upper lobectomy for non-small-cell lung cancer (NSCLC) and to find out the operative results of inferior pulmonary ligament division. METHODS: A total of 840 patients who underwent upper lobectomy for NSCLC between January 2007 and June 2020 were evaluated retrospectively. The patients were separated into two groups - those having undergone lymph node dissection of station 9 and inferior pulmonary ligament dissection (Group I) and those who did not (Group II). In these groups, the prognostic value of station 9 lymph nodes and postoperative effects (drainage time, prolonged air leak, dead space and length of hospital stay) of ligament division or preservation were analyzed. RESULTS: The number of patients with station 9 lymph node metastasis was only one (0.1%) and that was multi-station pN2 disease. Station 9 lymph nodes were found in 675 (80.4%) patients, while 22 (2.6%) patients had no lymph nodes in the dissected material. In the other 143 (17%) patients, the inferior pulmonary ligament and station 9 were not dissected. While 5-year survival was 64.9% in 697 patients of Group I, it was 61.3% in 143 patients of Group II (p = 0.56). There was no statistically significant difference between the groups in postoperative effects of ligament division or preservation. CONCLUSIONS: In upper lobectomies, status of station 9 does not have a significant impact on patients' survival and lymph node staging. Additionally, preservation or division of the inferior pulmonary ligament has no significant advantage or disadvantage.

Comparison of Brock University, Mayo Clinic and Herder models for pretest probability of cancer in solid pulmonary nodules.

OBJECTIVE: Risk analysis models, which are used in the diagnostic algorithm of incidental pulmonary nodules, are based on patient data from developed countries. Mayo Clinic, Brock University and Herder are among the most known models. We aim to compare the reliability of these models in patients with indeterminate solid nodules and to investigate the contribution of the predictors used to the model. METHODS: We analysed 305 patients who performed transthoracic needle biopsy and positron emission tomography/computed tomography for solid nodules, retrospectively. For all three models, the malignancy risk probabilities of patients were calculated, and patients were classified as low (<5%), moderate (60%) and high (<60%) risk groups. Later, the malignancy rates of each model in three different risk groups were compared within each other and among the models. RESULTS: The malignancy rate is 73% in 305 patients. In the Mayo Clinic and Herder models, the difference in the low-, medium- and high-risk groups is significant (p < 0.001). In the medium-risk group, the rate of malignancy is 96.8% in the Brock model. In the high-risk group, the rate of malignancy in Herder is 88.3% and the rate of malignancy in Mayo Clinic is 28.8%. The optimal cutoff values for the Mayo Clinic, Brock University, and Herder were 29.6, 13.4 and 70 (AUC, respectively; 0.71, 0.67 and 0.73). Age, smoking, gender, size, emphysema and spiculation increase the likelihood of malignancy. CONCLUSION: Close results were obtained in all three models. In the high-risk group, the Herder model has the highest reliability rate (odds ratio 3.3, confidence interval [1.1, 10.2]). Upper lobe predilection is not a reliable predictor.

FDG PET/CT signs of proven pulmonary hydatid cyst: is there any clue?

PURPOSE: Pulmonary hydatid cyst (PHC) can imitate many diseases. Sometimes, positron emission tomography/computed tomography (PET/CT) is performed in terms of malignancy exclusion for complicated cysts. Although some specific findings (doughnut sign) have been identified in hydatid cyst of the liver, there is no specific sign described for PHC. The aim of this study is to investigate the presence of a common finding in PHC patients scanned with PET/CT inadvertently. MATERIALS AND METHODS: From January 2015 to 2020, patients proven to have PHC were analyzed retrospectively. From all the patients, only 17, having a previous PET/CT, were included the study. Lesions were evaluated in three groups according to FDG uptake: A, negative; B, focal; C, doughnut sign. RESULTS: The total number of patients was 17. Nine of the patients were male and the median age was 41.94 + 14.68 (16-65) years. SUV max of the lesions ranged from 0.5 to 15.8 (mean ± SE: 4.68). According to the FDG uptake of the lesions, five were in Group A, two in Group B, and the remaining ten (58.8%) in Group C with doughnut sign. To correlate the CT findings with PET/CT findings, doughnut sign, which is a typical finding of hydatid cysts of liver, is seen in only four patients in Group 1-classified cysts which are non-complicated. But in Group 2 (n = 3) and 3(n = 4), the finding of doughnut sign is three in both groups. CONCLUSIONS: PET/CT is not a recommended imaging technique for PHC, but in cases where a definitive diagnosis is difficult, interpreting PET/CT findings is significant. This study demonstrates that previously described doughnut sign for liver hydatid cysts is also common for perforated pulmonary cysts. According to our knowledge, this is the first largest series of determining PET/CT findings of PHC. Further larger series will contribute to the literature.

Video-assisted thoracoscopic lobectomy and bilobectomy versus open thoracotomy for non-small cell lung cancer: Mortality and survival.

Background: In this study, we aimed to evaluate patients who had non-small cell lung cancer and underwent resection, to investigate our tendency to prefer video-assisted thoracic surgery or open thoracotomy, and to compare 30- and 90-day mortalities and survival rates. Methods: Between January 2013 and January 2019, a total of 706 patients (577 males, 129 females; mean age: 61.9±8.6 years; range, 17 to 84 years) who underwent lobectomy or bilobectomy due to primary non-small cell lung cancer were retrospectively analyzed. The patients were divided into two groups as operated on through video-assisted thoracic surgery and through open thoracotomy. The 30- and 90-day mortality rates and survival rates were compared. Results: Of the patients, 202 (28.6%) underwent video-assisted thoracic surgery and 504 (71.4%) underwent open thoracotomy. Lobectomy was performed in 632 patients (89.5%) and bilobectomy was performed in 74 patients (10.5%). Patients who were chosen for video-assisted thoracic surgery were statistically significantly older, did not require any procedure other than lobectomy, did not receive neoadjuvant therapy, had a small tumor, and did not have lymph node metastases. The 30- and 90-day mortality rates in the video-assisted thoracic surgery and open thoracotomy groups were 1.8% vs. 2% and 2.6% vs. 2.5%, respectively. The five-year survival rates of video-assisted thoracic surgery and open thoracotomy groups were 74.1% and 65.2%, respectively (p>0.05). The 30- and 90-day mortality and five-year survival rates were 2.1%, 2.6%, and 73.5% in the video-assisted thoracic surgery group and 2.1%, 2.1%, and 68.5% in the open thoracotomy group, respectively, indicating no statistically significant difference between the two groups. Conclusion: Throughout the study period, video-assisted thoracic surgery was more preferred in patients with advanced age, in those who had a small tumor, who did not receive neoadjuvant therapy, did not have lymph node metastasis, and did not require any procedure other than lobectomy. In the video-assisted thoracic surgery and open thoracotomy groups, 30- and 90-day mortality and five-year survival rates were similar. Based on these findings, both procedures seem to be acceptable in this patient population.

Correlation of preoperative PET/computer tomography 18F-fluorodeoxyglucose uptake (maximum standardized uptake value) with prognosis in patients with operated lung cancer.

PURPOSE: The aim of this study was to investigate the correlation of preoperative 18F-fluorodeoxyglucose PET/computed tomography maximum standardized uptake value (SUVmax) in operated non-small cell lung cancer (NSCLC) cases with other prognostic parameters and survival. PATIENTS AND METHODS: NSCLC patients treated by surgical resection were imaged with PET within 60 days before surgery. RESULTS: Overall, 525 cases consecutive patients were retrospectively reviewed. The median value of SUVmax in a total of 525 cases was 12.1, and the mean was 13.3 ± 7.13. Logistic regression analysis performed to identify the variables that have an impact on SUVmax revealed that histology [hazard ratio (HR: 1.893; 95% CI; P = 0.001) and T status (HR: 8.991; 95% CI; P = 0.000) are correlated with SUVmax. Kaplan-Meier analysis revealed a mean survival of 73.7 ± 1.95 months and a median survival of 85.6 ± 6.03 months. In the group with an SUVmax value of less than 10, the mean survival was 81.9 ± 3.02 months (76.0-87.8), and in the group with SUVmax greater than 10.1, the mean survival was 68.6 ± 2.4 months (63.9-73.3) (P = 0.000). In the multivariate analysis, SUVmax, age, tumor histology, lymph node metastasis, comorbid diseases and complete/incomplete status of the resection were identified as the factors predictive of prognosis. CONCLUSION: It is seen that preoperative SUVmax is a parameter with prognostic significance at least as much as histopathology, age, complete/incomplete status of resection and lymph node involvement.

Surgery in congenital lung malformations: the evolution from thoracotomy to VATS, 10-year experience in a single center.

BACKGROUND: Congenital lung malformation is an umbrella term and consist of various kind of parenchymal and mediastinal pathologies. Surgical resection is often required for diagnosis and curative treatment. We aimed to review our experience in surgical treatment for congenital lung disease and present the role of minimally invasive surgery. METHODS: Surgical resections performed for benign lesions of the lung and mediastinum between January 2009 and May 2019 were retrospectively analyzed. Patients who were found to have congenital lung malformation as a result of pathological examination were included in our study. Distribution characteristics of the patients according to congenital lung malformation subtypes, differences in surgical approach and postoperative results were investigated. RESULTS: A total of 94 patients who underwent surgical resection and were diagnosed with the bronchogenic cyst, sequestration, bronchial atresia, congenital cystic adenomatoid malformation (CCAM), or enteric cyst as a result of pathological examination were included the study. There were no significant differences between pathological subtypes in the postoperative length of hospital stay and drainage duration however, perioperative complication rate was higher in the sequestration group. In addition, in the first three days postoperatively, the mean pain score was found to be lower in the VATS group compared to thoracotomy. CONCLUSIONS: Congenital lung malformations consist of a heterogeneous group of diseases and the surgical treatment in these patients can range from a simple cyst excision to pneumonectomy. Video-assisted thoracoscopic surgery should be considered as the first choice in the surgical treatment of these patients in experienced centers.

Iterative surgical resections in non-small cell lung cancer.

INTRODUCTION: We reviewed our surgical preferences and the prognosis for recurrent and second primary tumors in patients who underwent surgical treatment for non-small cell lung carcinoma (NSCLC). AIM: We report our experience with patients undergoing iterative pulmonary resection for lung cancer. MATERIAL AND METHODS: Among patients who underwent anatomical resection for primary NSCLC, those who underwent a second surgical resection between 2010 and 2020 due to recurrent or second primary tumor were included in the study. Operative mortality, survival, and prognostic factors were investigated. RESULTS: In total, 77 cases were included: 31 (40.3%) underwent the second resection for the recurrent disease and 46 (59.7%) underwent the second resection for the second primary tumor. Postoperative mortality occurred in 8 (10.4%) patients. All patients with postoperative mortality were in the group that underwent thoracotomy in both surgical procedures. The 5-year survival rate was 46.5%. The 5-year survival of those operated on for recurrent or second primary tumor was 32.8% and 51.1%, respectively (p = 0.81). The 5-year survival rate was 68.8% in patients under the age of 60 years, while it was 27.5% in patients aged 60 years and above (p = 0.004). The 5-year survival was 21.8% in patients with an interval of 36 months or less between two operations and 72.2% in those with a longer interval (p = 0.028). CONCLUSIONS: Our study shows that survival results similar to or better than primary NSCLC surgery can be obtained with lower mortality if more limited resections are performed via video-assisted thoracic surgery, especially in young patients. In addition, the prognosis is better in patients with an interval of more than 36 months between two operations.

Surgical Experience of Video-Assisted Mediastinoscopy for Nonlung Cancer Diseases.

BACKGROUND: Video-assisted mediastinoscopy (VAM) is a valuable method in the investigation of diseases with mediastinal lymphadenopathy or those localized in the mediastinum. The aim of this study was to determine the diagnostic value of VAM in the investigation of mediastinal involvement of nonlung cancer diseases and to describe our institutional surgical experience. METHODS: Clinical parameters such as age, sex, histological diagnosis, morbidity, and mortality of all patients who underwent VAM for the investigation of mediastinal involvement of diseases except lung cancer between January 2006 and July 2018 were retrospectively reviewed, and the diagnostic efficacy of VAM was determined statistically. RESULTS: During the study period, 388 patients underwent VAM, and 536 lymph nodes were sampled for histopathological evaluation of mediastinum due to mediastinal lymphadenopathy or paratracheal lesions. The most common diagnoses were sarcoidosis (n = 178 [45.9%]), tuberculous lymphadenitis (n = 108 [27.8%]), lymphadenitis with anthracosis (n = 72 [18.6%]), and lymphoma (n = 15 [3.9%]). CONCLUSION: The results of the study show that VAM should be used because of its high diagnostic benefit in mediastinal lymphadenopathies, which are difficult to diagnose, or mediastinal lesions located in the paratracheal region. Despite the increase in the number of new diagnostic modalities, VAM is still the most effective method and a gold standard.

Pleural complications in patients with coronavirus disease 2019 (COVID-19): how to safely apply and follow-up with a chest tube during the pandemic?

OBJECTIVES: Severe acute respiratory syndrome coronavirus 2, a novel coronavirus, affects mainly the pulmonary parenchyma and produces significant morbidity and mortality. During the pandemic, several complications have been shown to be associated with coronavirus disease 2019 (COVID-19). Our goal was to present a series of patients with COVID-19 who underwent chest tube placements due to the development of pleural complications and to make suggestions for the insertion and follow-up management of the chest tube. METHODS: We retrospectively collected and analysed data on patients with laboratory-confirmed COVID-19 in our hospital between 11 March and 15 May 2020. Patients from this patient group who developed pleural complications requiring chest tube insertion were included in the study. RESULTS: A total of 542 patients who were suspected of having COVID-19 were hospitalized. The presence of severe acute respiratory syndrome coronavirus 2 was confirmed with laboratory tests in 342 patients between 11 March and 15 May 2020 in our centre. A chest tube was used in 13 (3.8%) of these patients. A high-efficiency particulate air filter mounted double-bottle technique was used to prevent viral transmission. CONCLUSIONS: In patients with COVID-19, the chest tube can be applied in cases with disease or treatment-related pleural complications. Our case series comprised a small group of patients, which is one of its limitations. Still, our main goal was to present our experience with patients with pleural complications and describe a new drainage technique to prevent viral transmission during chest tube application and follow-up.

The Role of Sublobar Resection in T1 N0 Non-Small-Cell Pulmonary Carcinoma.

OBJECTIVES: In this study, we aimed to investigate the effect of resection type on survival in patients with stage IA non-small-cell lung cancer (NSCLC) and other factors affecting the prognosis. MATERIALS AND METHODS: Between January 2005 and December 2016, we retrospectively screened 269 patients who were resected and were having T1N0M0 non-small-cell pulmonary carcinoma. The survival time after surgery was obtained from the National Population Registration System (MERNIS) system. Patients were classified according to the extent of resection. Additionally, age, sex, smoking, concomitant disease, histological type, pathological stage (T1a-T1b-T1c), and the presence of postoperative complications were evaluated to determine whether they are prognostic factors or not. RESULTS: A lobectomy was performed in 257 cases (95.5%), and a sublobar resection was performed in 12 patients (4.5%). The 5-year survival was 62.5% for lobectomies and 73.3% for sublobar resections. Although 5-year survival was better in patients with a limited resection, it was not statistically significant (p=0.301). Histopathological evaluation revealed that 130 patients (48.3%) had adenocarcinoma, 113 (42.0%) had squamous cell carcinoma, and 26 (9.7%) had the other types. The 5-year survival rate was 69.9% in patients with adenocarcinoma and 53.2% in squamous cell carcinoma, and this was statistically significant (p=0.036). The overall 5- and 10-year survival rates in all patients were 65.0% and 47.2%, respectively. CONCLUSION: Although lobectomy is the standard type of resection in the early stage of lung cancer cases in the Thoracic Surgery Department of Dr. Suat Seren Chest Diseases and Thoracic Surgery Training and Research Hospital patients who underwent sublobar resection were found to be having partially better survival, but it was not statistically significant. Owing to the small number of cases, we think that sublobar resections should be prospectively investigated with more extensive series in patients with T1 NSCLC.

Changes in the Surgical Treatment Strategies for Nonsmall Cell Lung Cancer in the Past 20 Years: A Single-Center Experience.

OBJECTIVES: Nonsmall cell lung cancer (NSCLC) is a multifactorial disease, and differences in the characteristics of surgical patients may develop over the years. This study aimed to evaluate the patients who underwent curative surgical resection for NSCLC in the past 20 years at our center and analyze the changes in the treatment strategies based on demographics, surgical strategies, and histopathology. MATERIALS AND METHODS: In this retrospective single-center cohort study, 1995 patients who had undergone lobectomy, bilobectomy, or pneumonectomy for primary NSCLC from January 1997 to January 2017 were analyzed. Patients were divided into two groups: Group I included patients operated in the first 10 years and Group II included patients operated in the last 10 years. RESULTS: Overall, 77% of patients were operated in the last 10 years (458 vs. 1537 patients). Sleeve lobectomies performed in Group II reduced the rate of pneumonectomy from 37% to 20% (p<0.001). The operation rates for adenocarcinomas increased significantly during the study period, increasing from 31.4% to 36.2% (p=0.049). The 30- and 90-day postoperative mortality rates were 4.6% and 8.5% in Group I and 4.1% and 5.7% in Group II, respectively (p=0.69 and p=0.037, respectively). When the groups were compared, the median and 5-year survival rates were 44.1 months (95% confidence interval [CI], 35.6-52.6) and 42.9% in Group I and 73.6 months (95% CI, 63.3-83.9) and 53.9% in Group II, respectively (p<0.001). CONCLUSION: This study demonstrates an improvement in long-term outcomes following lung cancer surgery with an increasing rate of surgical procedures in the last 10 years. There was an increase in the proportion of females affected and the rate of adenocarcinoma. However, the pneumonectomy and postoperative N2 disease rates have decreased with advancing preoperative evaluation techniques and parenchyma-saving surgical methods. Postoperative mortality has decreased, and the survival rate has increased.

Diagnostic success of transthoracic needle biopsy and PET-CT for 1 to 2 cm solid indeterminate pulmonary nodules.

OBJECTIVES: Among the nodule types, the most controversial group are indeterminate solid nodules from 1 to 2 cm in size with the first choice being transthoracic needle biopsy (TTNB) or positron emission tomography (PET-CT) or both methods together. However, no single diagnostic algorithm could be applied to all cases. This research discusses the diagnostic success of PET-CT and TTNB. MATERIALS AND METHODS: 407 Patients who referred to our hospital for any reason, with solid nodules with the size from 1 to 2 cmincidentally identified on the thoracic CT tests were investigated. Among the patients who underwent biopsy, 312 cases had PET-CT, and maximum SUV (SUVmax) values of the nodules were examined. Values of ≥2.5 were accepted as hypermetabolic. RESULTS: The mean age of the patients was 61 ± 10.8 years. 84 patients were female (20.6%) and 323 were male (79.4%). For TTNB; sensitivity, specificity and accuracy rates of all cases, who were correctly diagnosed, were 76.9%, 83.3% and 78.9%, respectively (P < .001). The 2.5 SUVmax cutoff value had sensitivity of 91%, specificity of 35.6%, accuracy of 75% (P = .034). The cutoff value of 49 years of age, nodule size of 16.4 mm, gender and 2.5 SUVmax value had high accuracy for benign-malignant differentiation. No statistically significant difference was found in the upper lobe localization of nodule. CONCLUSION: A positive result from TTNB is a reliable finding; however, a negative result is not definitive. The high negative predictive value of PET-CT is effective in preventing the unnecessary biopsies and surgical procedures.

Prognosis of Resected Non-small Cell Lung Cancer with Ipsilateral Pulmonary Metastasis.

BACKGROUND: Ipsilateral pulmonary metastasis (PM) in the same lobe (T3Satell) or different lobe (T4Ipsi Nod) constitutes a small proportion of patients with non-small cell lung cancer (NSCLC). In our study, we aimed to determine prognostic factors and to evaluate long-term survival outcomes in the patients who underwent complete resection due to NSCLC. METHODS: Data of 1,502 surgically treated patients with NSCLC from January 2007 to December 2016 were retrospectively reviewed. Fifty (3.3%) patients diagnosed with PM were the basis of the study. Demographic and histopathological characteristics, surgical procedures, and prognostic factors for survival were analyzed, categorizing patients according to the presence of PM in the same lobe or different lobe. RESULTS: Among the 50 patients, 23 (46%) had PM in the same lobe as the primary tumor and 27 (54%) had PM in different ipsilateral lobes. The mean size of nodules was 11.5 mm. While T3Satell was detected mostly in squamous cell carcinoma (SCC) (65.2%), T4Ipsi Nod was more common in adenocarcinoma (AC) (70.4%), and the difference was statistically significant (p = 0.022). Survival was significantly better in the SCC-T3Satell group than the AC-T3Satell group (64 and 58.3%, respectively; p = 0.043). Although the overall 5-year survival was better in the T3Satell group, the difference between survival outcomes of both groups was not statistically significant (61.2 and 37.2%, respectively; p = 0.27). In the T3Satell group, nodule size was found to be a negative prognostic factor in survival (p = 0.042), whereas the number of nodules was found to be a negative prognostic factor in the T4Ipsi Nod group (p = 0.046). In multivariate analysis, advanced age was a poor prognostic factor for PM (p = 0.03). CONCLUSION: There was no significant difference in survival between T3Satell and T4Ipsi Nod patients. Among surgically treated patients due to NSCLC, poor prognostic factors were advanced age for the patients with PM, nodule size and AC for T3Satell patients, and the number of nodules for T4Ipsi Nod patients.

Prognostic Effects of Predominant Histologic Subtypes in Resected Pulmonary Adenocarcinomas

Background: Predominant histologic subtypes have been reported as predictors of survival of patients with pulmonary adenocarcinoma. Aims: To evaluate the predictive value of histologic classification in resected lung adenocarcinoma using the classification systems proposed by the International Association for the Study of Lung Cancer, American Thoracic Society, European Respiratory Society, and World Health Organization (2015). Study Design: Cross-sectional study. Methods: The histologic classification of a large cohort of 491 patients with resected lung adenocarcinoma (stages I-III) was retrospectively analyzed. The tumors were classified according to their predominant component (lepidic, acinar, papillary, solid, micropapillary, and mucinous), and their predictive values were assessed for clinicopathologic characteristics and overall survival. Results: The patient cohort comprised 158 (32.2%) patients with solid predominant, 150 (30.5%) with acinar predominant, 80 (16.3%) with papillary predominant, 75 (15.3%) with lepidic predominant, 22 (4.5%) with mucinous, and 5 (1.0%) with micropapillary subtype, and 1 (0.2%) with adenocarcinoma in situ. Overall 5-year survival of 491 patients was found to be 51.8%. Patients with lepidic, acinar, and mucinous adenocarcinoma had 70.9%, 59.0%, and 66.6% 5-year survival, respectively, and there was no statistically significant difference between them. Whereas patients with solid, papillary, and micropapillary predominant adenocarcinoma had 41.0%, 40.5%, and 0.0% 5-year survival, respectively. Compared to other histologic subtypes, patients with solid and papillary predominant adenocarcinoma had significantly lower survival than those with lepidic (p<0.001, p=0.002), acinar (p<0.001, p=0.008), and mucinous (p=0.048, p=0.048) subtypes, respectively. The survival difference between patients with solid subtype and those with papillary subtype was not statistically significant (p=0.67). Conclusion: Solid and papillary histologic subtypes are poor prognostic factors in resected invasive lung adenocarcinoma.

Long-term results of sleeve lobectomy with continuous suture technique in non-small cell lung cancer.

BACKGROUND: This study aims to investigate the operation-related complications, recurrence frequency, morbidity, mortality and survival rates as well as variables effective on survival of patients undergoing bronchial sleeve lobectomy due to primary non-small cell lung cancer. METHODS: A total of 85 patients ( 80 males, 5 females; mean age 59.9±8.4 years; range, 35 to 77 years) of bronchial sleeve lobectomy operated with the same surgical technique by the same team in our clinic between May 2007 and November 2015 were analyzed retrospectively. Survival and 30- and 90-day mortality rates were analyzed. Variables effective on survival rate were evaluated statistically. Complications related to bronchial anastomosis and the frequency of local recurrence in postoperative period were investigated. RESULTS: Twenty-five patients (29.4%) received neoadjuvant therapy and two of these patients (8%) developed complication in the anastomosis line. Local recurrence rate in the postoperative follow-up was 16.5%. Mean duration of follow-up was 35±29.9 months, median survival was 65.2 months, and five-year survival rate was 50.9%. Thirty- and 90-day mortality rates were 1.2% and 2.4%, respectively. In univariate analysis, patients with larger tumors, N2 disease, or those who underwent extended surgery had statistically significantly worse survival rates (p=0.001, p=0.002, and p=0.0001, respectively). In the Cox regression analysis, variables effective on survival were presence of extended surgery and node status (p=0.03 and p=0.012, respectively). CONCLUSION: Sleeve lobectomy can be achieved with acceptable anastomotic complications, good survival and low mortality rates using continuous suture technique. When performed due to oncological reasons, its long-term results are not different from pneumonectomy.

Papillary predominant histological subtype predicts poor survival in lung adenocarcinoma.

BACKGROUND: This study aims to investigate whether papillary predominant histological subtype can predict poor survival in lung adenocarcinoma. METHODS: Between January 2005 and December 2016, a total of 80 patients with papillary predominant subtype lung adenocarcinoma (70 males, 10 females; mean age 60.7 years; range, 42 to 79 years) operated in our clinic were included in the study. These patients were compared with those having lepidic, acinar, and mucinous subtypes. Overall and five-year survival rates were evaluated. RESULTS: Five-year survival was 40.5% in papillary predominant histological subtype, while this rate was 70.9%, 59.0%, and 66.6% in lepidic, acinar, and mucinous subtypes, respectively. Papillary subtype showed significantly poor survival compared to lepidic (p=0.002), acinar (p=0.008), and mucinous subtypes (p=0.048). In Stage 1 disease, it was more evident (papillary, 47.5%, lepidic 86.9% [p=0.001], acinar 69.3% [p=0.040], and mucinous 90.0% [p=0.050]). CONCLUSION: Our study results suggest that papillary predominant subtype predicts poor survival in lung adenocarcinoma and these cases may be candidates for adjuvant treatment modalities even in the earlier stages of disease.

Single-station skip-N2 disease: good prognosis in resected non-small-cell lung cancer (long-term results in skip-N2 disease).

OBJECTIVES: Pathological N2 (pN2) involvement has a negative impact on prognosis in patients operated on due to non-small-cell lung cancer (NSCLC). pN2 disease may cause skip (pN0N2) or non-skip (pN1N2) metastases with pathological N1 (pN1) involvement. The effect of pN2 subgroups on prognosis is still controversial. We analysed the effect of pN1 disease and single-station pN2 disease subgroups on survival outcomes. METHODS: The medical records of patients who underwent anatomical lung resection due to NSCLC at a single centre between January 2007 and January 2017 were prospectively collected and retrospectively analysed. Operative mortality, sublobar resection, Stage IV disease, incomplete resection and carcinoid tumour were considered exclusion criteria. After histopathological examination, the prognosis of patients with pN1, pN0N2 and pN1N2 was compared statistically. Univariable and multivariable analyses were made to define independent risk factors for overall survival rates. RESULTS: The mean follow-up time for 358 patients with 228 pN1 disease (63.7%), 59 pN0N2 disease (16.5%) and 71 pN1N2 disease (19.8%) was 40.4 ± 30.4 months. Median and 5-year overall survival rates for pN1, pN0N2 and pN1N2 diseases were 73.6 months [95% confidence interval (CI) 55.5-91.7] and 54.1%, 60.3 months (95% CI 26.8-93.8) and 51.2%, 20.8 months (95% CI 16.1-25.5) and 21.5%, respectively. The survival CIs of pN1 and pN0N2 diseases were similar, and the survival rates of these 2 groups were significantly better than those with pN1N2 (P < 0.001, P = 0.001, respectively). In multivariable analysis, patients over the age of 60 [hazard ratio (HR) 2.13, P < 0.001], patients not receiving adjuvant therapy (HR 1.52, P = 0.01) and patients with pN1N2 disease (HR 2.91, P < 0.001) had a poor prognosis. CONCLUSIONS: Advanced age, not receiving adjuvant therapy and having pN1N2 disease are negative prognostic factors in patients with nodal involvement who underwent curative resection due to NSCLC. The overall survival and recurrence-free survival rates of pN1 disease and single-station pN0N2 disease are similar, and they have significantly better survival rates than pN1N2 disease. Based on these results, surgical treatment may be considered an appropriate choice in patients with histopathologically diagnosed single-station skip-N2 disease.

Conjunction of a Fungus Ball and a Pulmonary Tumourlet in a Bronchiectatic Cavity.

Herein, we describe the case of a 67-year-old female patient who presented with cough and haemoptysis. Chest computed tomography revealed destruction of the left lower lobe and multiple fungus balls in a bronchiectatic cavity. A left lower lobectomy was performed via thoracotomy. Histopathological examination of the lung showed a concomitant aspergilloma and multiple tumourlets in the large bronchiectatic cavity. Pulmonary intracavitary aspergilloma and concomitant tumourlets are quite rare. Our report presents this interesting case that manifested with haemoptysis.

Postpneumonectomy bronchopleural fistula in non-small cell lung cancer patients: incidence, survival, mortality, and treatment analysis.

PURPOSE: Bronchopleural fistula (BPF) is a catastrophic complication after pneumonectomy, still associated with high mortality. We reviewed our recent experience of managing BPF, particularly after right pneumonectomy for non-small cell lung cancer (NSCLC), and analyzed our findings. METHODS: A total of 436 patients underwent pneumonectomy for NSCLC in our department between January 2000 and June 2017. BPF developed during follow-up in 47 of these patients, who are the subjects of this retrospective analysis. RESULTS: The overall incidence of BPF was 10.8% (47/436), being 22.8% (33/145) after right pneumonectomy and 4.8% (14/291) after left pneumonectomy (P = 0.0001). The incidence of BPF in patients with a history of tuberculosis was 33.3% (6/18; P = 0.008). The fistula healed in 48.9% (23/47) of the patients and the rate of mortality caused by the fistula was 19.1% (9/47). CONCLUSIONS: The side of the pneumonectomy and previous tuberculosis were the two most important risk factors independent of the bronchial closure methods. The incidence of BPF was much higher after right pneumonectomy than after left pneumonectomy. The high mortality and morbidity rates show that the treatment of BPF is still not satisfactory.

Rethoracotomy for early complications: A marker for increased morbidity and mortality.

BACKGROUND: This study aims to examine the indications, timing and risk factors of rethoracotomy, analyze the postoperative results, and give suggestions to reduce the risks. METHODS: A total of 3,292 patients operated via thoracotomy between January 2006 and January 2017 were evaluated retrospectively. Demographic data, initial operative indications, surgical procedures, indications for rethoracotomy and preoperative risk factors, intraoperative findings and surgical methods, timing of rethoracotomy, morbidity and mortality results were analyzed of 66 patients (60 males, 6 females; mean age 59.4±12.4 years; range, 17 to 80 years) who were performed rethoracotomy before being discharged. Rethoracotomies performed within 72 hours after the first operation constituted the early and those performed after 72 hours constituted the late rethoracotomy group. RESULTS: Rethoracotomy was performed in average 4.7 days (range, 1 to 17 days). Early rethoracotomy was performed on 42 patients (1.3%) and 38 (90.4%) of these were due to hemorrhage. The most frequent indication for rethoracotomy was hemorrhage (n=41, 1.2%), followed by bronchopleural fistula (n=17, 0.5%). The other indications were chylothorax, lobe torsion, parenchymal air leak and collapse, and diaphragmatic laceration. Eight patients had rib fractures and all of these patients were over the age of 60. Eight patients who were performed rethoracotomy due to hemorrhage were using antiaggregant drugs. The postoperative morbidity and mortality rates were 33.3% (n=22) and 24.2% (n=16), respectively. CONCLUSION: Rethoracotomy still has high morbidity and mortality rates. The main cause of rethoracotomy performed due to hemorrhage may be rib fractures or antiaggregant drugs. The most remarkable indications of rethoracotomy are hemorrhage and bronchopleural fistula.