Journal of thoracic disease最新文献

Background: Esophagectomy following neoadjuvant chemoradiotherapy (nCRT) is a curative treatment for locally advanced esophageal cancer. However, pulmonary complications are the most common postoperative issues and can adversely affect survival. While numerous studies have investigated predictors for these complications and survival, morphomic predictors, derived from body composition measurements on computed tomography scans, have been rarely reported. Our study aims to delineate morphomic predictors for post-esophagectomy pulmonary complications and overall survival.

Methods: We retrospectively analyzed esophageal cancer patients who received nCRT followed by esophagectomy between 2004 and 2016. Preoperative clinical and morphomic variables were collected to evaluate post-esophagectomy pulmonary complications and overall survival. Multivariable logistic regression and Cox's proportional hazard model were used for analysis.

Results: The study involved 221 esophageal cancer patients who received nCRT followed by surgery. Factors such as increased blood loss (P=0.01), more harvested nodes (P<0.001), advanced pT stage (P=0.01), elevated visceral adipose tissue (VAT) density (P=0.04), and reduced skeletal muscle (SM) area (P=0.01) were linked to pulmonary complications. Additionally, being male (P=0.01), increased blood loss (P<0.001), non-R0 resection margin (P=0.001), advanced pStage (P<0.001), advanced pT stage (P=0.02), and decreased SM density (P=0.045) were associated with poorer overall survival.

Conclusions: Increased VAT density and decreased SM area were associated with pulmonary complications, while decreased SM density was linked to poorer overall survival. Preoperative analytic morphomics aids in predicting both postoperative pulmonary complications and survival.

Background: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is an effective lung protection strategy that avoids ventilator-induced lung injury. However, appropriate respiratory settings for VV-ECMO are yet to be established. This study aimed to elucidate the effects of ventilation under VV-ECMO using a newly developed rat VV-ECMO model and analyzed gene expression profiles.

Methods: Rats were assigned to three groups of five rats each: spontaneous breathing, conventional-protective ventilation, and ultra-protective ventilation. The conventional protective and ultraprotective ventilation groups received volume-controlled ventilation at a frequency of 60 and 20 beats/min, with tidal volumes of 6 and 3 mL/kg, respectively. VV-ECMO was performed at a pump flow rate of 20-30 mL/kg/min. At 120 min post initiation of VV-ECMO, rats were euthanized, and their lungs were harvested. Changes in gene expression were assessed using microarray analysis.

Results: Gene expression profile analyses revealed lowest expression of inflammation/immune promotion, cytotoxicity, and cell proliferation related genes (Defa5, Prg2, Siglec8, Atf3, Rnd1, Ctsg, and Gc), and the highest expression of inflammation/immune suppression related genes (Pp2d1) in the spontaneous breathing group as compared to that in the other two mechanical ventilation groups.

Conclusions: The findings of this study demonstrated that spontaneous breathing was the least invasive respiratory setting under VV-ECMO. Further, mechanical ventilation may be associated with lung injury even at low ventilation frequency and tidal volume.

Background: Video-assisted thoracoscopic surgery (VATS) lobectomy serves as a standard surgical approach for the management of resectable lung cancer. The double micro-portal VATS lobectomy technique, a viable surgical procedure, has gained widespread acceptance in clinical settings within our center. In this study, we present a retrospective analysis of our institutional experience with the double micro-portal VATS lobectomy, including an assessment of the learning curve.

Methods: The cumulative sum (CUSUM) analysis method was used to analyze the learning curve of 106 cases of double micro-portal VATS lobectomy for resectable lung cancer, all belonging to the same treatment group within the Department of Thoracic Surgery, the 2nd Affiliated Hospital of Air Force Medical University of Chinese People's Liberation Army, from March 2015 to December 2016. The learning curve was derived through accumulating and fitting the operation time and intraoperative bleeding, enabling a comprehensive comparison and analysis of perioperative data across distinct learning phases.

Results: With the gradual increase in the number of operations, the operation time gradually shortened. Through the application of CUSUM analysis, the goodness-of-fit coefficient peaked at R²=0.878, corresponding to the formula y=134.6 + 15.84×n - 0.1397×n² - 0.000215×n³. Notably, a vertex crossing occurred when the number of operations reached 51 cases. Similarly, intraoperative bleeding also exhibited a decreasing trend with the increasing number of operations. The goodness-of-fit coefficient attained its maximum value of R²=0.858 using CUSUM analysis, with the formula expressed as y=-238.89 + 81.87×x - 0.9912×x² + 0.002161×x³. A vertex crossing was achieved when the number of operations reached 49 cases. Based on these findings, 106 surgical patients were categorized into two distinct stages: the learning stage and the proficiency stage, with 51 cases serving as the dividing line. Statistically significant differences were observed in both operation time and intraoperative blood loss (IBL) between these two stages (P<0.05).

Conclusions: The learning curve of double micro-portal VATS lobectomy is fitted by CUSUM analysis. When the cumulative number of operation cases reaches 51 cases, the operation can achieve a relatively stable level.

Background: Chronic pulmonary aspergillosis (CPA) complicates post-tuberculosis lung disease (PTLD), causing significant morbidity and mortality. Predictors for Aspergillus seropositivity and CPA in a PTLD population remain unclear. The objective of this study was to identify the clinical, radiological, physiological, and biochemical characteristics of patients presenting to an adult PTLD clinical service, who met full criteria for CPA, and to compare them to those who did not, as well as compare those with positive Aspergillus serology to those without.

Methods: This retrospective cross-sectional study, performed in a tertiary adult PTLD clinical service in South Africa, investigated the clinical, radiological, physiological and biochemical characteristics of patients who had Aspergillus serology performed and compared those with positive and negative serology, as well as those meeting CPA diagnostic criteria with those who did not.

Results: Over a 2-year period, 238 patients were seen in the PTLD clinic, of which 79 had registered Aspergillus immunoglobulin G (IgG) serology testing and computed tomography (CT) chest imaging performed. Twenty-six (32.9%) patients had positive Aspergillus serology and 20 (25.3%) met criteria for CPA. Current radiological definitions for CPA when applied in a blinded fashion, had a sensitivity of 80.8% and a specificity of 58.5% for Aspergillus seropositivity, with a positive predictive value of 48.8%. Having ≥4 episodes of previous pulmonary tuberculosis (PTB) was significantly associated with both Aspergillus seropositivity [odds ratio (OR) =10.9; 95% confidence interval (CI): 2.1-84.9] and CPA diagnosis (OR =15.5; 95% CI: 2.8-125.6). Haemoptysis was significantly more common in those with positive Aspergillus serology (OR =2.7; 95% CI: 1.4-5.2) and in those with CPA (OR =2.7; 95% CI: 1.4-5.4). Total immunoglobulin E (IgE) levels were significantly higher in those with Aspergillus seropositivity (P value =0.006) and in those with CPA (P value =0.03). Other symptoms, spirometric and laboratory findings were similar between groups.

Conclusions: Current radiological criteria are not sufficiently specific for the diagnosis of CPA in PTLD populations, necessitating wider use of Aspergillus serology. The significant overlap in clinical syndromes highlights a complicated yet poorly understood relationship between CPA and PTLD, with increased frequency of haemoptysis requiring further research.

Background: Thymic epithelial tumors (TETs) represent the predominant primary malignancy of the anterior mediastinum, often necessitating complex surgical interventions due to their invasive nature. The prognosis of advanced TET relies significantly on achieving complete resection with microscopically clear margins (R0). This frequently entails resection and reconstruction of major vascular structures like the superior vena cava (SVC) and brachiocephalic veins, and in some cases, extra pleural pneumonectomy (EPP). The aim of the study is to interrogate our series of advanced TET resections.

Methods: We analysed our experience with vascular resection and reconstruction in 14 patients with advanced stage III/IV TET undergoing extensive resection post-neoadjuvant chemotherapy. A comprehensive preoperative evaluation was performed, including computed tomography (CT), positron emission tomography (PET), biopsy, and exercise testing. We describe our surgical approach and the details of our series.

Results: From 2015 to 2023, 31 patients underwent surgery for advanced TET at our centre, with major vessel reconstruction performed in 14 cases. This included resection of SVC and innominate veins with subsequent reconstruction using polytetrafluoroethylene (PTFE) grafts. The median operative time was 350 minutes, with a median blood loss of 1,300 mL. Cardiopulmonary bypass (CPB) was required in 2 cases. The rate of R0 resection was 78.6%, with a recurrence rate of 14.3% at a median follow-up of 1,700 days. Postoperative complications occurred in 42.9% of patients, with an in-hospital mortality rate of 7.1%.

Conclusions: Multi-disciplinary management, meticulous preoperative planning, and advanced surgical techniques are essential for the successful treatment of advanced TET. Complex vascular resections should be reserved for high-volume centres to optimize outcomes.

Background: Prompt initiation of antibiotics and drainage of infection source is essential in the management of pleural cavity infection. Although surgical drainage is considered a gold standard of treatment for unresolved parapneumonic infection, optimal timing for surgical intervention is still under debate. Thus, we seek to analyze the clinical outcomes of urgent thoracoscopic surgery for complicated parapneumonic effusion regarding the duration of preoperative antibiotic usage.

Methods: Medical records were retrospectively reviewed for patients who received thoracoscopic surgery for complicated parapneumonic effusion or empyema. Patients were grouped according to the preoperative antibiotic durations and compared. Group A consists of the patients with less than 3 days of preoperative antibiotics usage and Group B consists of those with more than 3 days of preoperative antibiotic coverage. Basic demographics, preoperative chest computed tomography (CT) findings, antibiotics usage, duration until surgery and treatment outcomes were evaluated.

Results: From February 2008 to November 2018, a total of 180 patients underwent video-assisted thoracoscopic surgery (VATS) for pleural drainage or decortication of lung. Group A patients had higher C-reactive protein value (240 vs. 192 mg/L, P=0.003) and were given significantly shorter duration of total antibiotics (9 vs. 14 days, P<0.001). The median duration of postoperative chest tube indwelling time (5 vs. 5 days, P=0.38), postoperative hospital stays (8 vs. 8 days, P=0.56), operation time (105 vs. 105 min, P=0.88) showed no significant difference between the groups. CT images of Group A patients showed a significantly higher rate of multi-loculation (83 vs. 59, P=0.008) and interlobar effusions (64 vs. 42, P=0.02). There were two postoperative mortalities and four recurrences.

Conclusions: Faster and relatively safe and successful clinical outcomes can be achieved with urgent thoracoscopic surgery on patients with complicated parapneumonic effusion despite limited duration of antibiotics coverage.

Background: CD276 is an immune checkpoint, and immune checkpoint inhibitors (ICIs) targeting CD276 have been tested against various cancers. However, the precise role of CD276 in mesothelioma subtypes is unknown. This study aimed to reveal the prognostic significance of CD276 in various cancers and explore CD276 as a target for ICIs in different mesothelioma subtypes.

Methods: We evaluated data from The Cancer Genome Atlas (TCGA) database retrospectively. The Wilcoxon rank-sum test was used to assess CD276 mRNA expression between cancer tissues and the adjacent normal tissues in the context of various cancers. The study involved 86 patients with mesothelioma. The mean number of patients was set as the cutoff value for comparing CD276 mRNA expression. The overall survival (OS) of patients with each mesothelioma subtype was estimated using the Kaplan-Meier method with CD276 mRNA expression. The factors affecting the correlation between OS and high/low CD276 expression in combination with/without a current existing molecular targets of programmed cell death 1 (PD-1), cytotoxic T-lymphocyte-associated protein 4 (CTLA4), and vascular endothelial growth factor A (VEGFA) were assessed using a multivariate Cox proportional hazards model. The correlation between the mRNA expression of CD276 and expression of gene markers of tumor-infiltrating immune cells and those of different pathways was evaluated using Spearman's correlation. The factors affecting correlations of CD276 mRNA expression were confirmed using a multivariate linear regression model.

Results: Upregulated CD276 mRNA expression was associated with a poor prognosis in various cancers, including epithelioid mesothelioma. The multivariate Cox proportional hazards model demonstrated that upregulated CD276 mRNA expression indicated the worst prognosis, including the combination of CD276 and PD-1, CTLA4, and VEGFA. In addition, using a multivariate linear regression model, CD276 mRNA expression was found to correlate with multiple glycolytic pathway mRNAs in epithelioid mesothelioma, especially PKM2.

Conclusions: CD276 is an independent prognostic biomarker in patients with epithelioid mesothelioma. It is associated with the glycolytic pathway and may contribute to ATP generation in epithelioid mesothelioma. CD276 inhibitors might contribute to better prognosis in patients with epithelioid mesothelioma.

Background: Postoperative delirium (POD) is a common neurocognitive complication after type A aortic dissection (TAAD), which seriously affects the recovery of patients, and the current intervention timing and treatment methods are still uncertain. This prospective observational cohort study aimed to discuss the effect of dexmedetomidine on POD in patients undergoing TAAD surgery.

Methods: Between February 2022 and March 2023, 167 eligible patients aged 18 to 85 years who underwent TAAD surgery participated in this study. The patients were assigned to either the dexmedetomidine or the control group, which did not receive dexmedetomidine treatment. The primary outcome of interest was the incidence of delirium within five days following surgery. Secondary outcomes included intubation duration, length of stay in the intensive care unit (ICU), total postoperative hospital stay, incidence of non-delirium complications, and all-cause mortality within seven days. To account for differences in baseline characteristics between the groups, propensity score matching (PSM) was utilized.

Results: Before PSM, the dexmedetomidine group was made up of 120 patients, whereas the control group comprised 47. The occurrence rate of POD increased from 35.0% in the dexmedetomidine group to 42.6% in the control group, but there was no significant difference [odds ratio (OR) 0.73; 95% confidence interval (CI): 0.37-1.45; P=0.36]. After 1:1 PSM, there were 42 patients in each of the dexmedetomidine and control groups. The occurrence of POD was 28.6% and 45.2% in the dexmedetomidine and control groups, respectively, with no statistically significant difference observed (OR 0.48; 95% CI: 0.20-1.20; P=0.12). The dexmedetomidine group showed a shorter ICU hospitalization time and postoperative hospital stay than the control group, but the differences were not statistically significant. Furthermore, the two groups had no statistical differences in other secondary outcomes.

Conclusions: Intraoperative dexmedetomidine did not decrease the occurrence rate of POD in TAAD patients. Additionally, no significant differences were observed between the dexmedetomidine and control groups regarding the occurrence of non-delirium complications, intubation time, ICU hospitalization time, and postoperative hospital stay.

Background: Computed tomography (CT) plays an important role in the diagnosis of lung nodules and early screening of lung cancer. The purpose of this study was to compare the efficacy of 1,024×1,024 matrix and 512×512 matrix in an artificial intelligence-based computer-aided diagnosis (AI-CAD) for evaluating lung nodules based on CT images.

Methods: This retrospective analysis included 344 patients from two hospitals between January 2020 and November 2023. CT images presenting lung nodules smaller than 30 mm were reconstructed using the 512×512 and 1,024×1,024 matrix. We evaluated image quality and AI-CAD detection of lung nodules. Image quality was subjectively scored using a 5-point Likert method and objectively assessed using image noise and signal-to-noise ratio (SNR). For lung nodules detection, we recorded the accuracy, precision, and recall of AI-CAD for detecting of different types and sizes of lung nodules.

Results: The 512×512 matrix's overall image subjective evaluation score was 3.63, whereas the 1,024×1,024 matrix's was 4.18, among 344 individuals with 4,319 lung nodules. The detection accuracy, precision, and recall of 512×512 and 1,024×1,024 for AI-CAD in all lung nodules were 91.63% vs. 98.32%, 95.68% vs. 98.32%, and 95.59% vs. 100% respectively. Solid, part-solid, and nonsolid nodule identification accuracy on 512 and 1,024 matrix were 91.30% vs. 98.34%, 94.63% vs. 98.50%, and 94.71% vs. 97.74%, respectively, and of <6 mm, 6-8 mm, and >8 mm nodules were 90.58% vs. 97.87%, 96.64% vs. 99.04% and 93.68% vs. 99.36%, respectively.

Conclusions: The 1,024 matrix performed significantly better than the 512 matrix in terms of overall subjective image quality and lung nodule AI-CAD detection rate.