Journal of thoracic disease最新文献

Background: Local consolidative therapy (LCT) can improve survival outcomes for select patients with oligometastatic non-small cell lung cancer (NSCLC). While genetic alterations affect prognosis in NSCLC, their impact in oligometastatic patients undergoing lung resection as part of comprehensive LCT (cLCT) remains unclear. We sought to evaluate outcomes based on genetic alteration status in this population.

Methods: We identified oligometastatic (≤3 synchronous sites) NSCLC patients from 2 centers who underwent cLCT to all disease sites from 1996-2023. Patients were stratified by genetic alteration status. Survival outcomes were evaluated with Kaplan-Meier and multivariable Cox regression models.

Results: We identified 87 patients with the following genetic alterations: TP53 (1.2%, n=1), EGFR (13.8%, n=12), KRAS (12.6%, n=11), ALK (5.7%, n=5), multiple alterations (6.9%, n=6), and no alterations (59.8%, n=52). The median overall survival (OS) was 88.9 months for patients with EGFR alteration [95% confidence interval (CI): 48.46-121.28], and 30.8 months for those with other alteration statuses (95% CI: 12.25-49.36, P=0.20). The median progression-free survival (PFS) for EGFR patients was 43.1 months (95% CI: 22.14-64.07) and 19.1 months for the other alteration status group (95% CI: 16.46-31.74, P=0.58). Multivariate Cox regression analysis failed to demonstrate any alteration status as an independent predictor of OS or PFS.

Conclusions: EGFR mutation demonstrated a promising trend toward better outcomes among oligometastatic NSCLC patients undergoing lung resection. Whether these differences reflect dissimilarities in disease biology, targeted agent availability and/or efficacy, patient-related factors, or other elements remains unknown. Further efforts to understand the interplay among these variables are needed to advance multimodal treatment for oligometastatic NSCLC.

Background: Sleeve lobectomy is widely used for the treatment of centrally located non-small cell lung cancer (NSCLC), aiming to preserve lung function while achieving complete tumor resection. Reinforcement of the bronchial anastomosis with autologous tissues, such as pericardium, has been proposed to reduce postoperative complications. However, the clinical necessity and prognostic significance of this technique remain controversial. This study aimed to evaluate whether wrapping of the bronchial anastomosis with autologous pericardium influences perioperative complications and long-term survival in patients undergoing sleeve lobectomy, thereby providing evidence for optimizing surgical decision-making and individualized management strategies.

Methods: In this retrospective study, 91 patients with NSCLC who underwent sleeve lobectomy were included between 2012 and 2017. Group A (29 patients) did not undergo wrapping and group B (62 patients) underwent bronchial wrapping. After propensity score matching, 20 patients were included in each group. Overall survival (OS) was estimated using the Kaplan-Meier method and compared using the Log-rank test.

Results: Wrapping of the bronchial anastomosis did not improve the 30- and 90-day mortality (3.45% and 3.45% vs. 9.68% and 12.9%, P=0.54 and P=0.30, respectively, before matching; 5% and 5% vs. 5% and 5%; P>0.99 and P>0.99, after matching), and there was no significant difference in 5-year OS (55.17% vs. 48.39%, P=0.79, before matching; 60% vs. 65%, P=0.58, after matching) between the two groups.

Conclusions: This study concludes no evidence that bronchial anastomotic wrapping improves either short-term or long-term outcomes. Therefore, routine wrapping is not recommended; however, an individualized surgical strategy based on patient selection should still be considered.

Background: Anastomotic leak (AL) remains one of the most severe complications following esophagectomy. Malnutrition is a risk factor for postoperative complications, and many nutritional indicators are also associated with postoperative stress and inflammatory responses. This study aimed to evaluate the relationship between AL and three nutritional risk indices: the Prognostic Nutritional Index (PNI), Geriatric Nutritional Risk Index (GNRI), and Controlling Nutritional Status (CONUT) score.

Methods: We retrospectively analyzed 1,749 patients who underwent esophagectomy from August 2018 to January 2023. Preoperative and postoperative day 1 (POD1) PNI, GNRI, and CONUT scores were calculated, along with their perioperative changes. The association between these indices and AL development was assessed. Univariate and multivariate analyses were performed to screen for prognostic factors.

Results: Among 1,749 patients, 145 (8.3%) developed AL. No significant differences were observed in PNI changes (-13.6±6.2 vs. -13.2±6.2, P=0.42) or GNRI changes (-1.9±0.8 vs. -1.9±0.8, P=0.46) between AL and non-AL groups. However, CONUT score changes showed significant intergroup difference (3.9±2.2 vs. 3.4±1.9, P=0.01). Among CONUT components, only cholesterol changes demonstrated a significant difference between AL and non-AL groups (-41.3±30.6 vs. -33.6±26.0 mg/dL, P=0.001) and can serve as an independent risk factor for AL [odds ratio (OR) =1.01, 95% confidence interval (CI): 1.003-1.02].

Conclusions: The cholesterol depletion was significantly associated with AL occurrence and can serve as an independent risk factor. This association suggests that acute cholesterol depletion may be a biomarker of a more profound systemic stress response, which in turn, critically impairs anastomotic healing.

Background: Atrial functional mitral regurgitation (AFMR) can cause mitral regurgitation (MR) and tricuspid regurgitation (TR) without structural valve abnormalities, due to atrial enlargement and annular dilatation. On the other hand, atrial fibrillation (Af) is one of the primary causes of AFMR, and increasing in the elderly population residing in industrialized countries. In addition, in recent years, flow energy loss (EL) assessed by four-dimensional (4D) flow magnetic resonance imaging (MRI) is expected to be a novel parameter of cardiac workload. This study aimed to evaluate the pathophysiology of AFMR by comparing parameters between AFMR with Af and structural MR (StMR) with prolapse from a viewpoint of hemodynamic.

Methods: This study was a prospective study. Preoperative 4D flow MRI studies were performed in 10 AFMR for Af and 10 StMR for prolapse surgical candidates. Study results were segmented to visualize flow patterns, quantify hemodynamics, and energy dynamics [EL and cardiac output (CO), among other parameters], using iTFlow2 (Cardio Flow Design Inc., Tokyo, Japan). Statistical analysis the Mann-Whitney U test was used to compare the differences between the two groups, and Spearman's correlation coefficient by the Mann-Whitney U test, and Spearman's correlation coefficient was performed.

Results: In AFMR, CO and cardiac index (CI) were significantly lower [CO: 5.01 (4.53-6.13) vs. 8.54 (7.51-11.11) L/min, P<0.001; CI: 3.54 (3.17-3.98) vs. 5.47 (4.37-6.09) L/min/m²; P=0.007], with lower systemic (left side) EL (ltEL) [3.34 (1.96-6.46) vs. 7.13 (4.75-9.72) mW, P=0.08] and higher pulmonary (right side) EL (rtEL) [2.43 (1.87-4.03) vs. 1.70 (1.18-2.13) mW, P=0.17]. TR fraction was higher [56.1% (39.5-69.2%) vs. 29.0% (20.9-37.9%), P=0.01], while the left ventricular end-diastolic volume (LVEDV) was significantly lower [134.6 (114.1-177.3) vs. 209.0 (190.1-255.6) mL, P=0.01]. EL densities [defined as EL/each chamber volume (mW/mL)] and CO ratios [defined as EL/CO (mW·min·m²/L)] were significantly reduced compared to those of StMR (all P<0.05). In the AFMR group, a positive relationship was observed between ltEL and both ventricular volumes, rtEL, and right ventricular volume (P<0.05). Af duration showed a non-significant but positive correlation with rtEL/CO (P=0.056).

Conclusions: 4D flow MRI revealed that AFMR is associated with lower CO, higher pulmonary load and right ventricular enlargement, compressing the left ventricle, and increasing systemic EL. Longer Af duration correlates with higher EL in smaller left ventricles.

Background: Non-small cell lung cancer (NSCLC) is a leading cause of cancer-related mortality worldwide. Beyond clinical prognostic factors, psychosocial determinants such as marital status may influence outcomes. However, its impact on cancer-specific death (CSD) and other-cause death (OCD) within a competing risk framework remains unclear. This study aimed to comprehensively evaluate the effect of marital status on CSD and OCD in patients with NSCLC using a large Surveillance, Epidemiology, and End Results (SEER)-based cohort, and to develop a competing risk nomogram for individualized prognostic prediction.

Methods: We identified NSCLC patients from the SEER between 2010 and 2015. Baseline characteristics were balanced between married and unmarried groups using propensity score matching (PSM). Fine-Gray competing risk models were applied to estimate the effect of marital status on CSD and OCD. A competing risk nomogram was constructed and validated to predict individualized 1-, 3-, and 5-year CSD probabilities.

Results: Among 47,170 patients, 54.8% were married. Married patients had consistently lower cumulative incidences of CSD and OCD before and after PSM (all P<0.001). In multivariable models, unmarried patients had a significantly higher CSD risk (subdistribution hazard ratio =1.11; 95% confidence interval: 1.08-1.14; P<0.001). The nomogram showed strong discrimination (area under the curve ranging from 0.81 to 0.84) and good calibration in both training and validation cohorts.

Conclusions: Marital status independently influences NSCLC prognosis, with married patients showing lower cancer-specific and non-cancer mortality. These findings underscore the importance of incorporating marital and broader social support factors into survivorship care. Prospective studies are needed to confirm these findings and develop supportive strategies to improve survival and quality of life.

Background: Spray cryotherapy (SCT) has been used as a bronchoscopic tool within the large airways for over a decade. SCT is unique in its non-contact method of flash freezing (up to -196 ℃) tissue versus a contact cryoprobe (up to -50 ℃). Techniques for venting nitrogen gas formed from liquid nitrogen during SCT are essential for safe use. Prospective data on SCT in bronchoscopy are lacking. The objective of this study was to evaluate the safety, dosimetry, and clinical outcomes of the trūFreeze SCT system in a prospective multicenter registry of patients with benign and malignant central airway disease.

Methods: This was a prospective observational registry of patients undergoing SCT enrolled at 4 participating institutions for up to 5-year follow-up (2013-2021). Data focusing on patient safety, diseases treated, dosimetry and selected efficacy measures were collected in a standardized electronic report form and central database.

Results: A total of 64 patients (47 with malignant disease and 17 with benign disease) were enrolled in the registry. A total of 114 SCT procedures were performed and 472 SCT freeze/thaw cycles delivered. The median observed follow-up for the malignant cohort was 520 days [interquartile range (IQR), 153-1,818 days]. The median observed follow-up for the benign cohort was 1,803 days (IQR, 1,769-1,832 days). Malignant disease included 14 different cancer types. Subglottic stenosis was the most common benign disease treated and only 3 patients needed more than 2 serial SCT treatments. SCT was used to treat endobronchial bleeding in 30% of cases, with complete success reported in 91%. Adverse events included one death which was unrelated to SCT and one small asymptomatic pneumothorax which did not require a chest tube.

Conclusions: SCT can be safely used within the central airways, adding the unique capability of delivering flash-freezing temperatures to tissue. This approach shows potential utility in treatment strategies for a wide range of benign and malignant conditions, though further controlled studies would better define these roles.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is considered an essential modality for mediastinal and hilar lymph node evaluation in lung cancer and other thoracic diseases. When compared with surgical staging, EBUS-TBNA yields high sensitivity and specificity with a favorable safety profile. It now serves as the first-line approach for invasive mediastinal staging in most guidelines. In this review, we provide a comprehensive overview of EBUS-TBNA, with a focus on mediastinal staging in the era of the 9th edition of the TNM (Tumor, Node, Metastasis) classification, technical considerations, and emerging applications. We outline the limitations of noninvasive imaging and summarize current indications for invasive staging while emphasizing the prognostic importance of accurate nodal assessment in non-small cell lung cancer including the role of N1 and N2 subcategories. Then, we discuss practical aspects of systematic nodal staging such as which stations to sample, the debate around routine evaluation of station 10 and N3 nodes, and the implications of the updated TNM nodal descriptors for decision making. We also review bronchoscope and needle options and examine the role of rapid on-site evaluation (ROSE), needle gauge, needle design, and sampling techniques in optimizing diagnostic yield and tissue adequacy for immunohistochemistry and next-generation sequencing. Finally, we highlight advanced strategies for challenging non-malignant and lymphoproliferative conditions.

Background and objective: Air pollution, particularly fine particulate matter ≤2.5 µm (PM_2.5), has emerged as a significant public health concern with established carcinogenic properties. Lung cancer incidence among patients who have never smoked cigarettes has doubled from 8% to 15% of cases since the 1990s, with stronger correlations observed between poor air quality and cancer development. This review synthesizes epidemiological evidence linking PM_2.5 exposure to lung cancer development, focusing on molecular mechanisms and clinical outcomes in those who have never smoked.

Methods: A systematic literature search was conducted in PubMed and Scopus using search terms related to PM_2.5 epidemiology and lung cancer in never-smokers. Articles were limited to original research, reviews, and meta-analyses published in English between 2004 and 2024. Of 198 articles identified, 45 were selected as relevant.

Key content and findings: PM_2.5 particles penetrate into alveoli, triggering inflammatory pathways including PI3K/Akt, NF-κB, JAK/STAT, and MAPK signaling, leading to oxidative stress, DNA damage, and oncogenic mutations. Non-tobacco user lung cancers demonstrate higher rates of epidermal growth factor receptor (EGFR) mutations, with PM_2.5 promoting carcinogenesis by acting on cells with pre-existing EGFR mutations through interleukin-1β release and macrophage activation. Post-treatment outcomes are significantly impacted by continued PM_2.5 exposure, particularly in populations with higher proportions of non-white patients, with higher exposure levels associated with increased mortality risk following surgical resection.

Conclusions: There has been an increased incidence of lung cancer in patients who have never smoked and can be associated with the increase in air pollution, particularly PM_2.5. Furthermore, PM_2.5 exposure is associated with worse outcomes after treatment of lung cancer. Because of this linkage between PM_2.5 and lung cancer, further research is needed to identify PM_2.5 exposure reduction strategies and improve post-treatment outcomes.

Multiple rib fractures are the most frequently encountered traumatic chest injury. Randomised control trials have shown superiority of surgical stabilisation of rib fractures (SSRF) for reduction of displaced fractures in comparison to non-operative management. As SSRF techniques continue to evolve, new technologies have enabled less invasive approaches, including intrathoracic rib fixation, which can achieve chest wall stability while allowing for a less invasive approach. This article reports our initial experience with intrathoracic SSRF (I-SSRF), our operative technique, case series description, and learning points when implementing this technique. We present our operative technique alongside a single-centre, prospective case series, representing the first reported European experience with intrathoracic SSRF using the RibFix Advantage™ system. This includes the first fifteen patients with multiple rib fractures who were treated with SSRF using an intrathoracic fixation system from May 2025 to August 2025 at our major trauma centre in the United Kingdom. The majority of these patients sustained associated intrathoracic injuries requiring intervention, including haemothorax, lung lacerations, and 20% with diaphragmatic defects. The average length of stay for patients subjected to I-SSRF was 5 days (range, 3-9 days). The only reported complication was with one patient treated for wound infection with antibiotics. This early experience has highlighted a safe and effective implementation of this technique at a major trauma centre. This technique of I-SSRF in chest trauma offers benefits such as thoracoscopic assessment and repair of other intrathoracic injuries, less invasive incisions for access, and a short length of hospital stay with good pain relief for patients.