Clinical characteristics of lung cancer patients with COVID-19: Retrospective case series.

INTRODUCTION: One of the patient groups adversely affected during the COVID19 pandemic is those suffering with cancer. The aim of this study was to evaluate the clinical characteristics and outcomes of lung cancer (LC) patients with COVID-19. MATERIALS AND METHODS: Three thousand seven-hundred and fifty hospitalized patients with a presumptive diagnosis of COVID-19 in a tertiary referral hospital between March 2020-February 2021 were retrospectively evaluated. Among them, 36 hospitalized COVID-19 patients with a history of primary LC were included in the study. Univariate and multivariate analyses were carried out to assess the risk factors associated with severe disease. RESULT: Of the 36 patients included in the study, 28 (77%) were males and 8 (23%) were females. Median age was 67 years (min-max: 53-81 years). Six patients (17%) had a diagnosis of small cell LC, whereas 30 patients (83%) had a diagnosis of non-small cell LC. The most common symptoms were fever (n= 28, 77%), coughing and myalgia (n= 21, 58%) and dyspnea (n= 18, 50%). The most common radiological finding was ground glass opacity (GGO) (n= 30), of which 13 was bilateral and 17 was unilateral in distribution. Nearly 30% (n= 11) of LC patients with COVID-19 developed severe disease, 5% (n= 2) of the 36 patients were admitted to intensive care unit and all of these patients eventually expired. LC patients with COVID-19 and patchy consolidation on computed tomography of thorax (Th CT) on admission had a higher risk of developing severe disease in univariate (HR 2.41, 95%CI: 1.4- 4.4, p= 0.04) and multivariate Cox regression analysis (HR 0.48, 95%CI: 0.24-0.97, p= 0.03). CONCLUSIONS: Clinical characteristics, laboratory and radiographic findings were similar in LC patients with COVID-19 when compared with the general population, LC patients have a higher mortality rate than the general population, with a 5% mortality rate in our series. Our findings suggest that LC may be a risk factor associated with the prognosis of COVID-19 patients.

COVID-19 pneumonia and pneumothorax: case series.

Barotrauma is a commonly reported complication in critically ill patients with ARDS caused by different etiologies, it's rate is reported to be around %10. Pneumothorax/pneumomediastinum in COVID-19 patients seem to be more common and have different clinical characteristics. Here we report 9 patients who had pneumothorax and/or pneumomediastinum during their stay in the ICU. Patients who were admitted to ICU between March 2020 and December 2020, were reviewed for presence of pneumothorax, pneumomediastinum and subcutaneous emphysema during their ICU stay. Demographic characteristics, mechanical ventilation settings, documented ventilation parameters, outcomes were studied. A total of 161 patients were admitted to ICU during the study period, 96 were invasively ventilated. Nine patients had developed pneumothorax, pneumomediastinum and/or subcutaneous emphysema during their admission. Five of them were men and median age was 66.6 years. All patients were intubated and mechanically ventilated. All patients were managed conservatively. One patient was discharged from ICU, the others were lost due to other complications related to COVID-19. Upon detection of pneumothorax and/or mediastinum all patients were managed conservatively by limiting their PEEP and maximum inspiratory pressures and were followed by daily chest X-rays (CXR) for detection of any progress. None of the patients showed increase in size of their pneumothorax and/or pneumomediastinum. Hemodynamically instability due to pneumothorax and/or pneumomediastinum was not observed in any of the patients. Tension pneumothorax was not observed in any of the patients. Most common reason for death was sepsis due to secondary bacterial infections. Acute deterioration with rapid oxygen desaturation or palpation of crepitation over thorax and neck in a COVID-19 patient should prompt a search for pneumothorax or pneumomediastinum. Conservative management may be an option as long as the patients are stable.

Complete resections of giant thorax masses and experienced difficulties.

INTRODUCTION: Thoracic giant masses do not have a clear definition. In some publications, giant thoracic mass definition is used in tumors whose long axis is> 10 cm and in other publications covering more than 50% of the hemithorax. In this study, demographic data of patients with a massive resectable giant thoracic mass and the difficulties and experiences experienced in the peroperative process were reviewed with a general perspective. MATERIALS AND METHODS: 14 giant intrathoracic masses operated at the department of Thoracic Surgery, School of Medicine, Ankara University were included in the study. The masses occupying more than half of the hemithorax and mediastinal lesions with a long axis of 15 cm or larger radiologically were included and evaluated. RESULT: 9 (64.3%) of our patients were male and 9 (35.7%) were female. The average age was 49.2 ± 17.1(between18-68). The tumor localizations of our patients were determined as 9 (64.2%) hemithorax and 5 (35.8%) mediastinal. When the radiological and intraoperative dimensions were examined separately, it was observed that the mean of long axis of CT image is average 18 ± 3.8 cm (between 12 cm and 26 cm), and the mean of long axis of specimen is average 18.14 ± 3.6 cm (between 15 cm and 23 cm). The heaviest mass was average 844 ± 473 g (350 g-2204 g). CONCLUSIONS: The surgical maneuvers and hence the excision of giant masses become difficult to operate due to the narrow localization of the masses and the frequent invasions of adjacent vascular structures and nerve tissues. However, complete resection of these slowly growing and generally encapsulated masses can provide the cure.

[The pulmonary complications related lymphoma in the patient with COPD and Non-Hodgkin Lymphoma]. / KOAH ve Non-Hodgkin Lenfomali bir olguda yeni baslangiçli nefes darligi; Non-Hodgkin Lenfoma ile iliskili pulmoner komplikasyonlar nedeniyle.

Non-Hodgkin lymphoma (NHL) is a clonal proliferative disease of B or T cell progenitors originating from lymph nodes or extranodal lymphatic tissue. There are several pulmonary complications associated with NHL. We aimed to discuss two pulmonary complications with high morbidity and mortality associated with lymphoma in our patient followed up with COPD and NHL. Seventy one years old male patient was admitted to the emergency department with sudden onset of dyspnea and chest pain. He had a history of bronchodilator use for COPD for 18 years and chemotherapy and local radiotherapy because of NHL 8 years ago. In terms of pulmonary thromboembolism (PTE), it was evaluated as clinically low-medium risk group. Pulmonary CT angiography was performed to diagnose PTE. Unilateral subcutaneous pleural fluid was detected in the chest radiography performed in the emergency room where he was admitted to the hospital due to increased dyspnea under low molecular weight heparin (LMWH) treatment. Triglyceride level > 110 mg/dL was observed in pleural fluid sampled by thoracentesis and diagnosed as chylothorax. He was followed by a pleuroken stool diet and received only one course of chemotherapy because of relapse NHL. Her general condition deteriorated and the patient died. The incidence of thrombosis in hematological oncology varies between 2% and 58%. PTE is a complication that must be considered in case of sudden onset of shortness of breath in hematologic oncologies. Increased shortness of breath under effective PTE treatment was considered as a secondary event and chylothorax, another pulmonary complication, was detected especially in lymphoma. Our patient with lymphoma was presented because of pulmonary complications associated with lymphoma.

High serum YKL-40 level is associated with poor prognosis in patients with lung cancer.

INTRODUCTION: YKL-40 is a glycoprotein that plays role in inflammation and malignant processes. High serum YKL-40 levels are associated with short survive in cancer and chronic obstructive pulmonary disease (COPD) is another reason to increase its' level. However, limited knowledges are known in YKL-40 along with lung cancer and COPD. MATERIALS AND METHODS: One hundred patients were involved to study with lung cancer (84 men, 16 women, and median age 62). Results were compared with 30 healthy volunteers. Thirteen patients were small cell lung cancer (SCLC), 87 patients were non-small cell lung cancer (NSCLC). 62% of patients were inoperable. RESULT: Median YKL-40 level was 222.7 ± 114.1 ng/mL in patients and was 144.5 ± 105.7 ng/mL in controls (p< 0.001). Stage, tumour size, lymph node involvement and distant metastasis weren't associated with serum YKL-40 level. Above all cut-off values (133.159 and 162 ng/mL) survival was shorter (p> 0.05). Patients with COPD had worse survive above all cut-off values (p< 0.05), especially according to 133 ng/mL (p= 0.01). CONCLUSIONS: YKL-40 level is useful in lung cancer however it's not related to cell type and prognosis. It is associated with poor prognosis in lung cancer patients with COPD.

Prognostic significance of serum vascular endothelial growth factor and Angiopoietin-2 in patients with lung cancer.

INTRODUCTION: Vascular endothelial growth factor (VEGF) and Angiopoietin-2 (Ang-2) are major angiogenic mediators in neovascularization process. In current literature both biomarkers are discussed separately and only for non-small cell lung cancer (NSCLC). So in this study we aimed to examine them together for both cell types NSCLC and small cell lung cancer (SCLC). PATIENTS AND METHODS: 100 patients with lung cancer were enrolled to this single center study. 87 of patients were diagnosed with NSCLC including 28 adenocarcinomas and 59 squamous cell cancers and 13 were SCLC. Results were compared with 30 healthy volunteers. Pre-treatment serum VEGF and Ang-2 levels were measured by using ELISA method. RESULTS: While serum Ang-2 levels were higher in patients than healthy controls (23395 pg/mL vs. 4025 pg/mL, p< 0.001), VEGF levels didn't differ (2308 pg/mL vs. 2433 pg/mL, p> 0.05). There was no difference between cases with SCLC and NSCLC in terms of Ang-2. But serum VEGF values were significantly lower in SCLC than NSCLC and control groups. None of these mediators were correlated with cell type, tumor size, TNM staging, performance status and operability. VEGF levels were higher in patients with chronic obstructive pulmonary disease (COPD), but it was not significant. Three cut of values were determined according to sensitivity and specificity by using youden index. They were 8515.73 pg/mL (sensitivity 78%, specificity 76%), 7097 pg/mL (sensitivity 80%, specificity 70%) and 11063.48 pg/mL (sensitivity 76%, specificity 70%). Patients with SCLC had shorter survival time above cut-off values (p> 0.05). VEGF and Ang-2 showed a weak positive correlation (p= 0.1 and r= 0.638). CONCLUSION: In conclusion, serum VEGF wasn't useful to predict lung cancer, prognosis or cell type. Albeit Ang-2 was higher in patients with lung cancer without any effect on survival. Due to the heterogeneity of the studies done with serum measurement Ang-2 on tumor tissue should be more meaningful.

The outcome of bifocal surgical resection in non-small cell lung cancer with synchronous brain metastases: results of a single center retrospective study.

BACKGROUND: The reported median survival in patients with non-small cell lung cancer (NSCLC) metastases to the brain varies from 3 to 12 months with combined treatment modalities. Bifocal surgical resection of synchronous brain metastasis and primary NSCLC has not been reported widely, and there have been only a small number of articles published in the literature. The aim of this retrospective study was to evaluate the prognostic factors among patients undergoing bifocal surgical resection. MATERIALS AND METHODS: We retrospectively analyzed 28 patients who had a solitary metastatic brain lesion at the time of diagnosis, and underwent synchronous surgical resection of the brain metastasis and primary lung tumor. Survival time was measured in all the patients from the date of craniotomy until death or the most recent date of follow-up for those still surviving. RESULTS: Mean age was 53 years. The mean length of follow-up was 23.6 (4-69) months. The overall survival rates were 79, 42, and 8% at the 1st, 2nd, and 5th years, respectively. The median length of survival was 24 ± 3.8 months. The median survival was found to be statistically significantly lower for the stage T3 tumors when compared with both stage T1 and T2 tumors (p = 0.037). CONCLUSION: NSCLC patients with resectable solitary cranial metastasis, low locoregional stage (stages IA, IB, IIA) in which T3 status is counted out, with no mediastinal lymph node involvement or any other extrathoracic spread will mostly benefit from consecutive complete resection of both tumors and are supposed to have a better survival.

Combination of grade and spread through air spaces (STAS) predicts recurrence in early stage lung adenocarcinoma: a retrospective cohort study.

Adenocarcinomas, a common subtype of lung cancer, exhibit diverse histological patterns. In 2020, The International Association for the Study of Lung Cancer (IASLC) introduced a grading system emphasizing high-grade components, which has shown prognostic value. Spread through air spaces (STAS) is recognized as a prognostic feature increasing the risk of recurrence in lung cancer. This study evaluates the combination of STAS status and the IASLC-grading system in surgically resected Stage I lung adenocarcinomas. This study is a retrospective analysis of 123 patients with Stage I lung adenocarcinoma who underwent lobectomy between 2011 and 2019. Histological patterns were assessed according to the IASLC criteria, and STAS status was documented. Patients were categorized based on their IASLC Grade and STAS status. Statistical analyses included Kaplan-Meier survival estimates, Cox proportional hazards models, and comparisons using Chi-square and t-tests. The cohort comprised 43 females and 80 males with a mean age of 61.8 ± 7.6 years. STAS positivity was noted in 52.8% of patients. STAS positivity correlated significantly with Grade 3 tumors (p < 0.001). The 5-year recurrence-free survival was significantly lower in STAS-positive patients (70.7% vs. 88.7%, p = 0.026). Patients with Grade 3 and STAS positivity had significantly lower recurrence-free survival compared to other groups (p = 0.002). Grade 3 and STAS positivity were independent predictors of poor recurrence-free survival in multivariate analysis. IASLC Grade 3 tumors and STAS positivity are independent prognostic factors for poor recurrence-free survival in Stage I lung adenocarcinomas. Adjuvant treatment strategies should be considered for patients with these characteristics to improve outcomes.

Oncological results in primary and secondary malignant chest wall tumors.

Background: This study aims to evaluate the oncological results of primary and secondary chest wall tumors treated with curative resections and to investigate possible prognostic factors. Methods: Between January 2010 and December 2021, a total of 77 patients (53 males, 24 females; median age: 59 years; range, 3 to 87 years) who underwent curative resection for malignant chest wall tumors were retrospectively analyzed. Each tumor was staged according to its histological type. Age, sex, tumor diameter, tumor type (primary/secondary), histological tumor type, grade, stage, complete resection, rib resection, reconstruction, neoadjuvant and adjuvant therapy, recurrence, and survival data were recorded. Results: Of the chest wall tumors, 33 (42.9%) were primary and 44 (57.1%) were secondary (local invasion, metastasis). Nine (11.7%) patients had positive surgical margins. Chest wall resection was most commonly performed due to lung cancer invasion (46.8%), followed by Ewing sarcoma (13%). Recurrence was observed in 34 (44.2%) patients. The five-year recurrence-free survival rate was 42.7% and the five-year overall survival rate was 58.6%. There was no significant difference between the primary and secondary tumors in terms of recurrence-free and overall survival (p=0.663 and p=0.313, respectively). In the multivariate analysis, tumor grade and rib resection were found to be independent prognostic factors for both recurrence-free survival (p=0.005 and p<0.001, respectively) and overall survival (p=0.048 and p=0.007, respectively). Conclusion: Successful oncological results can be achieved in wellselected patients with primary and secondary chest wall tumors. The grade of the tumor should be taken into account while determining the neoadjuvant or adjuvant treatment approach and surgical margin width. Rib resection should not be avoided when necessary.

Oesophageal achalasia misdiagnosed as uncontrolled asthma.

Achalasia is characterized by incomplete lower oesophageal sphincter relaxation and aperistalsis of the oesophagus. It may present with dyspnea symptom. An 18-years-old male patient applied to a clinic with the complaints of cough, dyspnea, wheezing and diagnosed as asthma. Although his asthma treatment was increased in time while he did not recover, he was reffered to our hospital with the diagnosis of uncontrolled asthma. On chest X-ray there was a mild upper mediastinal enlargement and chest computed tomography revealed an over-dilated oesophagus constricting the trachea. The patient was referred to chest surgery clinic with a suspected diagnosis of achalasia. Barium-oesophagogram and endoscopic evaluation of the oesophagus confirmed the diagnosis of achalasia. The patient underwent Heller myotomy and oesophagogastrostomy. He was recovered in one week after the surgery without any complaint of dyspnea. Spirometry tests and chest X-ray resulted normal in one year. With this case of achalasia who used asthma treatment unnecessarily,we wanted to emphasize the importance of differential diagnosis of difficult asthma.

Pulmonary sleeve resection complications and management.

In tumors involving the central airway or vascular structures, achieving local control and preserving pulmonary function can be possible with a pulmonary sleeve resection. In this section, complications and management of pulmonary sleeve resections are discussed.

Benign localized fibrous tumor of the pleura: report of 25 new cases.

OBJECTIVE: Benign localized fibrous tumors (BLFT) of the pleura are very rare slow-growing neoplasms that generally have a favorable prognosis. The aim of this manuscript is to evaluate the predictors of outcome with the review of the literature in a series of 25 patients with BLFT. METHODS: Between January 1985 and November 2009, 25 patients underwent an operation due to BLFT. Of these patients, 14 (56%) were male; mean age was 41.1 (25 to 64) years. All patients underwent thoracotomy. Left thoracotomy approach was used in 16 patients. The mass lesions were totally excised. The histopathological examinations were performed with hematoxylin-eosin and immunohistochemical staining methods. RESULTS: Of the patients, 18 (72%) were symptomatic. Symptoms were cough in 36%, shortness of breath in 32%, and chest pain in 20% of the patients. One patient (4%) appeared to have some symptoms (pain and swelling of the joints) associated with pulmonary osteoarthropathy. Seven patients (28%) underwent an operation due to mass lesion detected at routine control visits. None of the patients had a history of exposure to asbestos. Radiological investigations revealed 16 (64%) mass lesions in the left. Of the lesions found on exploration, 5 (20%) were intrapulmonary localized lesion without pedicle and 20 were pedicled. Of the pedicled masses, 5 were connected to parietal pleura and 15 to visceral pleura and all were intrathoracic extrapulmonary localized lesions. Eight (32%) lesions connected to left lower lobe. Additionally, three pedicled lesions were located in the lung fissure. Pedicled lesions were totally excised together with their pedicles. Intraparenchymal mass lesions were resected using wedge resection. The diameter of the resected masses was ranging between 3 and 22 cm (mean: 8.7). Macroscopically, all were encapsulated with a homogeneous cut surface. Intraoperative mortality and morbidity was not observed. The average hospitalization duration for all patients was 8.6 days (5 to 12). The mean follow-up was 33.6 (9 to 142) months with no recurrence. CONCLUSIONS: Benign localized fibrous tumors are uncommon and treated by surgical means. According to our data obtained from literature review, clinicians should be aware of recurrence possibility even after complete resection of benign localized fibrous tumor and the risk of malign transformation.

[A rare complication of oral anticoagulant treatment: hemothorax]. / Oral antikoagülan tedavinin nadir bir komplikasyonu: Hemotoraks.

Although bleeding is the most serious complication of oral anticoagulant treatment, hemothorax is extremely rare. Herein, a case with localized pleural plaques and spontaneous hemothorax due to warfarin treatment which was improved with medical treatment is presented because of its rarity. The patients recieving oral anticoagulant treatment should be monitorized for effective anticoagulation and adverse effects, if pleural effusion occurs, hemothorax should be kept in mind in the differential diagnosis. Pleural pathologies such as pleural plaques or thickening may be risk factors for hemothorax.

Comparison of outcomes between neoadjuvant treatment followed by surgery and surgical treatment alone in patients with locally advanced esophageal cancer: Our single-center experience.

Background: This study aims to investigate the effect of neoadjuvant therapy on overall survival and recurrence-free survival in locally advanced esophageal cancer patients. Methods: Between January 2010 and December 2019, a total of 143 patients (84 males, 59 females; mean age: 58.8±11.5 years; range, 26 to 87 years) operated for esophageal cancer were retrospectively analyzed. A comparison was made between the groups of 42 patients who underwent direct surgery and 42 patients who underwent surgery after neoadjuvant therapy. The patients were selected by matching one to one with propensity score with a sensitivty of 0.054. Results: Pathological complete response was observed in 21 (50%) of 42 patients who received neoadjuvant therapy. No progression was detected in any of the patients. While the five-year overall survival rate was 58.3% in patients with a pathologic complete response, this rate was 52.8% in patients without a complete response (p=0.709). The five-year overall survival rate was 8% (median 22.3 months) in patients who did not receive neoadjuvant therapy and it was 52.9% (median 62.5 months) in those who received neoadjuvant therapy (p<0.001). The five-year recurrence-free survival rate for patients who did not receive neoadjuvant therapy was 26.2% (median 14.5 months), whereas this rate was 41.3% (median 35 months) for patients who received neoadjuvant therapy (p=0.025). Conclusion: In patients with locally advanced esophageal cancer, the overall survival and disease-free survival rates are significantly better with surgical treatment after neoadjuvant chemotherapy/ neoadjuvant chemoradiotherapy compared to surgery alone.

Operated pulmonary inflammatory myofibroblastic tumors: Our experience with 17 cases.

Background: In this study, we aimed to evaluate the clinicopathological features of pulmonary inflammatory myofibroblastic tumor cases operated in our clinic. Methods: A total of 17 inflammatory myofibroblastic tumor patients (5 males, 12 females; median age: 46 years) who were operated in our clinic between February 2000 and July 2019 were included. Data including sex, age, symptoms, accompanying diseases, tumor localization, tumor diameter, endobronchial extension, maximum standard uptake value of the tumors, surgery type, recurrence, and survival data were analyzed. Results: Two patients were diagnosed preoperatively and two patients were diagnosed during surgery using frozen-section method before resection. Three (17.7%) patients underwent pneumonectomy, five (29.4%) patients lobectomy, three (17.7%) patients segmentectomy, five (29.4%) patients wedge resection, and one (5.8%) patient bronchial sleeve resection. All patients had complete resection with negative margins. None of them had lymph node metastasis. Median follow-up was 122 (range, 8 to 245 months) months. None of the patients received adjuvant therapy, there was no tumor recurrence or tumor-related death. Conclusion: It is difficult to make a preoperative diagnosis of inflammatory myofibroblastic tumor patients. Systematic lymph node dissection is not required in diagnosed patients. Complete resection is the most important prognostic factor, and it is critical to achieve this with the smallest resection possible.

[Pulmonary arteriovenous malformation: two sibling cases]. / Pulmoner arteriyovenöz malformasyon: Iki kardes olgu.

Pulmonary arteriovenous malformations, are abnormal connections between pulmonary arteries and veins. However it can be presented as an isolated single anomaly, also may be multiple when accompanying with autosomal dominant hereditary hemorrhagic telengiectasia (Rendu-Osler-Weber Syndrome; ROWS). In this case report, two patients operated with the diagnosis of multiple pulmonary arteriovenous malformation familial screening done with the possibility of ROWS and pulmonary arteriovenous malformation found in her sister, are presented.

Pulmonary artery sarcoma mimicking pulmonary thromboembolism.

A 30 years old male patient was referred to our hospital with a diagnosis of pulmonary thromboembolism due to thorax-computerized tomography (CT) angiography, revealing a thrombus totally occluding left main pulmonary artery. The lesion was evaluated as tumoural mass. Positron emission tomography (PET)-CT revealed pathologic uptake at pulmonary artery mass. Due to localization of tumour, left pneumonectomy was performed. The pathological diagnosis revealed to be pulmonary artery sarcoma. The patient was presented because pulmonary artery sarcomas are very rare tumors and can mimick pulmonary thromboembolism. The true prevalence is underestimated as many pulmonary artery sarcomas are misdiagnosed as pulmonary thromboembolism. PET-CT may help to make a differential diagnosis.

The management of postoperative COVID-19 pneumonia in a case with right pneumonectomy.

A 61-year-old male patient was hospitalized for the evaluation of a lung mass. The patient underwent right pneumonectomy. Although reverse-transcription polymerase chain reaction tests were negative for COVID-19, the diagnosis was supported by thoracic computed tomography. The patient responded to COVID-19 treatment, as evidenced by thoracic computed tomography. This case report highlights the importance of prompt diagnosis and treatment of COVID-19 in a patient who underwent pneumonectomy, which has high mortality and morbidity rates.

Bronchoscopic electrocautery therapy of a solitary endobronchial extramedullary plasmacytoma.

Extramedullary plasmacytomas are rare tumors. In majority of cases tumors arise in the head and neck region and endobronchial localization is extremely rare. The treatment is usually resection alone or combination of surgery with radiotherapy. Herein we present a case of solitary endobronchial plasmacytoma which was resected with bronchoscopic electrocautery, because of extremely rare occurrence of solitary endobronchial plasmacytoma and also the successful outcome of bronchoscopic electrocautery therapy.

Effectiveness of intraoperative bimanual palpation in metastatic tumors of lung.

BACKGROUND: In this study, we aimed to compare effectiveness of thoracic computed tomography versus intraoperative bimanual palpation in the detection of number of nodules in patients undergoing thoracotomy. METHODS: Between January 2011 and January 2019, a total of 157 patients (63 males, 94 females; mean age: 46.6±11.2 years; range, 13 to 77 years) who underwent pulmonary metastasectomy in our institution were retrospectively analyzed. Metastatic nodules evaluated using thoracic computed tomography were compared with nodules detected by intraoperative palpation. RESULTS: A total of 226 muscle-sparing thoracotomy was performed in 157 patients. The time between the preoperative thoracic computed tomography and operation ranged from 3 to 24 days. Metastasectomy with muscle-sparing thoracotomy was performed in 41 (26%) patients two times, in eight (5%) patients three times, and in four (2.5%) patients four times due to bilateral lung metastasis or re-metastasectomy. The thoracic computed tomography could detect 476 metastatic nodules, while 1,218 nodules were palpated and resected intraoperatively. Of these nodules, 920 were pathologically evaluated as metastatic. CONCLUSION: Our study results showed that the number of nodules reported as pathologically malignant after resection was 1.9 times higher than those reported by thoracic computed tomography. This finding indicates that intraoperative bimanual examination significantly increases the possibility of complete resection. This situation raises the need for more caution for the thoracoscopic metastasectomy procedure in which there is no possibility of intraoperative bimanual palpation.