Journal of thoracic disease最新文献

Background: Does efficacy differ among first-line treatment strategies that include maintenance therapy (MT) in patients with advanced driver-gene wild-type non-small cell lung cancer (NSCLC)? Few studies have directly compared these MT-containing strategies, and the optimal regimen for this population remains uncertain. In this Bayesian network meta-analysis (NMA), we aimed (I) to compare the efficacy and safety of available first-line regimens incorporating MT and to rate the certainty of evidence, and (II) to compare outcomes across chemotherapy (CT) backbones when combined with MT.

Methods: We systematically searched PubMed, Embase and the Cochrane Library. We included randomized controlled trials (RCTs) that randomized patients before first-line treatment initiation and included MT in at least one study arm. We assessed risk of bias for each RCT and used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to rate certainty of evidence. We performed a Bayesian NMA and compared MT-containing regimens across CT backbones using prespecified subgroup analyses. This review was registered in PROSPERO (CRD42021215862).

Results: We included 61 RCTs. Certainty of evidence for primary outcomes was mostly moderate to low. Continuous dual immunotherapy [DI; anti-PD-(L)1 plus anti-CTLA-4] ranked highest for overall survival (OS) in the overall population. In patients with programmed cell death ligand 1 (PD-L1) <1%, DI remained preferred because it was associated with improved OS, regardless of histology. In non-squamous (NSQ) NSCLC with PD-L1 ≥1%, pemetrexed-platinum plus single immunotherapy (SI), with maintenance pemetrexed plus anti-PD-(L)1, may be the most appropriate option. By contrast, in squamous (SQ) NSCLC with PD-L1 ≥1%, platinum-based CT plus SI, with maintenance anti-PD-(L)-1, may be optimal.

Conclusions: Among all available first-line therapies incorporating MT for advanced driver-gene wild-type NSCLC, immunotherapies play a central role. DI was associated with an OS advantage over CT in patients with PD-L1 <1%. With increasing PD-L1 expression, chemo-immunotherapy [CT plus a single anti-PD-(L)1 antibody] was associated with durable clinical benefit. However, additional evidence is needed to compare continuous DI with other MT-containing strategies, particularly for progression-free survival in key subgroups.

Background: Immune checkpoint inhibitors (ICIs) have markedly improved the outcome of patients with non-small cell lung cancer (NSCLC), but the prognostic significance of different immune-related adverse events (irAEs) types has not been fully elucidated, particularly in Japanese patients who have a higher susceptibility to interstitial lung disease (ILD). This study aimed to clarify the relationship between the occurrence and severity of irAEs and clinical outcomes.

Methods: We conducted a retrospective cohort study including 144 consecutive Japanese patients with advanced NSCLC treated with ICIs between 2015 and 2022. Clinicopathological factors, including performance status (PS), histology, programmed cell death ligand 1 (PD-L1) expression, the presence of driver mutations, lines of treatment, and response to treatment, were recorded. Treatments comprised pembrolizumab, nivolumab, and atezolizumab administered as monotherapy or in combination regimens. irAEs were defined and graded following the Common Terminology Criteria for Adverse Events version 5.0. Overall survival (OS) was analyzed using the Kaplan-Meier method and Cox proportional hazards models.

Results: irAEs occurred in 35 patients (24%), with a significantly higher incidence in patients with PD-L1 expression ≥50%. Patients with irAEs showed significantly higher response rates (56% vs. 24%) and longer OS (median not reached vs. 9.7 months; P<0.001). Multivariate analysis identified the occurrence of irAEs as an independent prognostic factor for better OS [hazard ratio 0.39, 95% confidence interval (CI): 0.22-0.70, P=0.002]. Subtype-specific analysis revealed that endocrine and rash-type irAEs were associated with favorable survival, whereas ILD-type irAEs did not confer similar prognostic benefit.

Conclusions: The occurrence of irAEs is associated with improved response and survival, whereas ILD may not reflect antitumor immunity. These findings emphasize the need for detailed toxicity profiling when interpreting irAEs as potential biomarkers in immunotherapy.

Background: For elderly patients, when weighing the benefits and risks associated with surgery, the treatment strategy remains controversial. Our objective was to compare clinical outcomes between surgical and non-surgical management of rib fractures in patients aged ≥60 years.

Methods: PubMed, Embase, Cochrane Library, and Web of Science were searched for studies comparing surgical intervention with non-surgical treatment in elderly patients of rib fractures over the past decade. The mean differences (MDs) for continuous outcomes, the risk ratios (RRs) for binary outcomes, and the 95% confidence intervals (CIs) were calculated. Meta-analysis was performed using Review Manager (RevMan) version 5.4.

Results: Ten studies were included with a total of 98,004 patients, of whom 2,478 underwent surgical intervention. Compared with non-surgical treatment, surgical intervention was associated with lower mortality (RR =0.61, 95% CI: 0.49, 0.75, P<0.001), longer hospital stay (MD =5.75, 95% CI: 4.50, 7.01, P<0.001), longer intensive care unit (ICU) stay (MD =2.16, 95% CI: 0.21, 4.11, P=0.03), and lower readmission risk (RR =0.30, 95% CI: 0.11, 0.79, P=0.01). No significant differences were noted in the incidence of pneumonia (RR =1.21, 95% CI: 0.50, 2.92, P=0.67), pleural effusion (RR =0.32, 95% CI: 0.03, 3.60, P=0.36), pneumothorax (RR =0.43, 95% CI: 0.04, 5.15, P=0.51), respiratory failure (RR =1.10, 95% CI: 0.50, 2.43, P=0.81) and duration of mechanical ventilation (DMV) (MD =-0.22, 95% CI: -1.25, 0.81, P=0.68). Subgroup analysis showed no significant difference in mortality among patients aged ≥80 years (RR =0.87, 95% CI: 0.59, 1.29, P=0.49).

Conclusions: Elderly patients of rib fractures may benefit from surgical intervention, particularly those aged under 80 years. For super-elderly patients aged ≥80 years, the value of surgical intervention is not obvious. For this population, high-quality prospective studies are needed to further clarify the clinical value of surgery.

Background: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a major cause of hospitalization and is associated with high in-hospital mortality; consequently, early identification of high-risk patients is crucial. This study aimed to develop and validate a clinical prediction model for in-hospital mortality among patients with AECOPD using readily available admission indicators to aid in risk stratification.

Methods: A retrospective analysis was conducted on 287 patients with AECOPD admitted to the Emergency Department and Respiratory and Critical Care Medicine Department of The Sixth People's Hospital of Nantong between February 2022 and February 2025. The complete patient dataset was randomly and equally divided into five mutually exclusive subsets (or folds). Each subset was sequentially used as the validation set, while the remaining four served as the training set. The training datasets were used for variable screening and model construction, and this process was repeated five times. Ultimately, the model's performance metrics were calculated as the average of the five validation results.

Results: In the mortality group, parameters such as partial pressure of carbon dioxide (PaCO₂) (mmHg) (P<0.001), lactate (mmol/L) (P<0.001), creatinine (μmol/L) (P<0.001), high-sensitivity troponin T (hscTnT) (ng/mL) (P<0.001), and heart rate (beats/min) (P<0.001) were significantly higher in the AECOPD patients compared to the improvement group. Although diastolic blood pressure (P=0.07), gender (P>0.99), and age (P=0.38) showed no statistical significance in univariate analysis, they were included in the multivariate model for adjustment based on their known clinical importance and to control for potential confounding effects. Subsequently, these parameters were incorporated as independent variables in the multivariate analysis, and a predictive model was constructed using Firth penalized logistic regression. According to the Youden index, the optimal cutoff value for this model was determined to be 0.080, corresponding to a sensitivity of 87.5% and specificity of 90.1%.

Conclusions: Using prognosis (in-hospital outcome) as the dependent variable (death =1 and improvement =0), we ultimately identified eight variables-age, sex, PaCO₂ (mmHg), lactate (mmol/L), creatinine (μmol/L), hscTnT (ng/mL), heart rate (beats/min), and diastolic blood pressure (mmHg)-that can serve as valuable prognostic predictors for patients with AECOPD.

Background: Due to anatomical complexities, the surgical resection of middle mediastinal tumors located beneath the carina is particularly challenging. This real-world study aimed to evaluate a novel bronchoplasty-based approach for the resection of such tumors and to assess its safety and feasibility based on a retrospective cohort.

Methods: We retrospectively reviewed patients with middle mediastinal tumors located beneath the carina who underwent a novel bronchoplasty-based approach at Shanghai Chest Hospital between January 2016 and December 2023. Perioperative outcomes and survival rates were assessed.

Results: A total of 9 patients were included, and complete tumor resection was achieved in all cases. The median operative duration was 125 minutes [interquartile range (IQR), 107-184 minutes], and the median intraoperative blood loss was 100 mL (IQR, 100-200 mL). The median postoperative chest tube drainage duration and hospitalization were 4.0 days (IQR, 3.0-5.0 days) and 5.0 days (IQR, 5.0-7.0 days), respectively, while the incidence rate of postoperative complications was 22.2%. No perioperative mortality was observed. Over a median follow-up of 5.6 years, the 5-year cancer-specific survival and overall survival rates were 100.0% and 83.3%, respectively.

Conclusions: The novel bronchoplasty-based approach appears to be safe and feasible for the resection of middle mediastinal tumors located beneath the carina.

Background and objective: Artificial intelligence (AI) is transforming surgical care by enhancing clinical decision-making and providing intraoperative guidance. As its applications expand, ethical challenges arise, including algorithmic bias, transparency in AI reasoning, informed consent regarding AI involvement, and accountability surrounding AI-guided decisions. This review explores the readiness of the surgical community to address these issues at both the institutional and individual levels.

Methods: A PubMed search identified literature on AI in surgery published between 2018-2025. Fourteen key studies were selected and reviewed to assess AI applications across the surgical continuum, with attention to ethical considerations and barriers to integration.

Key content and findings: AI now supports surgical care from the preoperative diagnosis through postoperative recovery. AI can outperform or match clinician performance in tumor detection, disease diagnosis, and surgical risk stratification. Predictive models using deep learning can outperform traditional scoring systems for perioperative and postoperative complication risk. Intraoperatively, AI enables surgical phase recognition, augmented reality guidance, and detection of technical errors. Despite these benefits, ethical concerns remain. Algorithmic bias may underestimate the needs of marginalized populations. Furthermore, questions of legal liability arise when AI-guided decisions cause harm. Informed consent must now address AI's role, limitations, and potential consequences if declined. Surgeons must guard against "automation bias" to preserve human judgment and patient trust. Institutional readiness remains unsatisfactory, as many healthcare systems lack infrastructure for real-time data integration and governance over data ownership. Surgeon skepticism and the "black box" nature of models also hinder adoption of the technology. Education on AI's design, validation, and biases is essential for safe integration.

Conclusions: While AI holds immense potential to enhance surgical care, its use should be grounded in ethical principles to ensure non-maleficence and justice. Adoption should aim to maximize beneficence while preserving patient autonomy through transparent consent and promoting equity in access and implementation. At the same time, surgeons must remain vigilant against automation bias such that AI supports, not replaces, clinical intuition and trust, which lies at the core of the surgeon-patient relationship.

Background: Low-dose computed tomography (LDCT) screening reduces lung cancer mortality among high-risk smokers, but data from Southeast Asia remain limited. This study evaluated the detection yield and risk factors of lung cancer among adults undergoing LDCT health screening in Thailand.

Methods: We retrospectively reviewed 4,478 adults aged 18-85 years who underwent LDCT between January 2019 and December 2023 at a tertiary private hospital in Bangkok. Scans were performed using a Philips IQon Spectral CT (256-slice, 120 kV, 30 mA, 1 mm slice thickness, radiation dose <1.5 mSv) and interpreted according to Lung Imaging Reporting and Data System (Lung-RADS) version 1.1. Lung-RADS 3-4X were confirmed histopathologically. Multivariable logistic regression identified predictors of lung cancer.

Results: Among all participants, 1,980 (44.2%) were female and 84.0% were never-smokers, with a mean age of 56.9 years [standard deviation (SD) 12.5]. LDCT positivity was 55.8%, and 53 cancers (1.2%) were detected. Most were stage 0-IB (69.8%), with adenocarcinoma as the predominant histology (85%) and solid morphology (77.4%). Incidental findings occurred in 65.2%, most commonly coronary artery calcification (CAC) (39.8%). Independent predictors included age ≥55 years [adjusted odds ratio (OR) 4.82, 95% confidence interval (CI): 1.68-13.86], smoking history (P<0.001), CAC (adjusted OR 23.63, 95% CI: 2.09-266.98), and extrapulmonary malignancy (adjusted OR 173.54, 95% CI: 42.73-704.77).

Conclusions: LDCT health screening in an unselected Thai population detected a meaningful burden of early-stage lung cancer. The findings support age-based screening beginning at 55 years, highlighting the potential role of chronic inflammation and environmental injury, such as PM_2.5 exposure and prior tuberculosis.

Background and objective: Pediatric pericardiectomies are rare operations used to treat recurrent, purulent, or constrictive pericarditis. Given the lack of pediatric-specific guidelines, we conducted a review to summarize the current literature on pediatric pericardiectomies including: etiology, diagnosis, timing of operation, surgical methods, and outcomes.

Methods: We conducted a PubMed literature review including articles in English from 2000-2025. To ensure completeness, we utilized a systematic search with "pediatric" and "pericardiectomy" as medical subject heading or text words. We identified 92 articles and included 58 relevant publications.

Key content and findings: The most common etiology of pericarditis in pediatric patients requiring a pericardiectomy is idiopathic. The second most common etiology is prior cardiac surgery in the United States and bacterial infections in India. The majority of pediatric patients (i.e., >80%) treated with a pericardiectomy present with dyspnea, chest pain, or heart failure symptoms. Transthoracic echocardiogram (TTE) is the first line imaging test. Adult guidelines for the treatment of pericarditis can be utilized to inform individualized care decisions, including timing of operation, for pediatric patients potentially requiring a pericardiectomy. Specifically for constrictive pericarditis, pericardiectomy is the mainstay treatment for chronic constriction. In addition, there is concern that delaying surgery in cases of constrictive pericarditis could result in deteriorating patient status and irreversible myocardial damage. Most pediatric pericardiectomies (~90%) are performed without the use of cardiopulmonary bypass. Complete pericardiectomies are more common than partial pericardiectomies, and a median sternotomy is the most utilized approach. Among patients in the United States, the mortality rate is ~2% (1/45, range 0-4%) compared to ~11% (8/70, range 0-22%) in lower-resourced countries. The increased mortality rate in lower-resourced countries could be due to the predominance of tubercular etiology or delayed patient presentation, emphasizing the potential importance of identifying patients requiring pericardiectomy and intervening early.

Conclusions: Pediatric pericardiectomies are rare and generally safe operations, especially in the United States. There is a need to further investigate and delineate outcomes in relation to timing for pediatric pericardiectomies.

Background: Treatment of multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) faces severe challenges, including prolonged courses, marked drug toxicity, and poor patient compliance. While regimens containing new drugs (bedaquiline, delamanid) have substantially improved MDR/RR-TB outcomes, systematic research on the epidemiological characteristics and risk control of adverse drug reactions (ADRs) remains insufficient. This study, based on a national multi-center clinical cohort, retrospectively analyzed data from 2,151 patients, aiming to explore the characteristics and risk factors related to ADR and provide a basis for individualized treatment.

Methods: This study retrospectively included 2,151 patients with MDR/RR-TB from two national multicenter clinical cohorts in China (including the bedaquiline cohort and the delamanid cohort) from 2017 to 2022. Clinical data were extracted using a standardized process, and patients with missing key data that could not be traced were excluded from the study. Adverse reactions were defined and graded. Potential risk factors were screened through univariate analysis (Chi-squared test), and independent risk factors for ADRs were identified using a multivariate logistic regression model. The association between different types of ADRs and treatment drugs was also analyzed.

Results: Overall ADR incidence was 56.2% (62.2% in bedaquiline cohort vs. 45.7% in delamanid cohort). The most common ADRs were cardiovascular [29.1%, mainly corrected QT interval (QTc) prolongation], hepatic (20.9%), and hematological (12.6%). Independent risk factors included female sex [odds ratio (OR) =1.26], age ≥35 years (OR =1.31), body mass index <18.5 kg/m² (OR =1.22), diabetes (OR =1.28), retreatment (OR =1.28), extrapulmonary TB (OR =1.62), cavitation (OR =1.24), and pre-extensively drug-resistant (XDR)/XDR-TB (OR =1.14/1.29). Both drugs were linked to QTc prolongation.

Conclusions: New MDR/RR-TB regimens are effective but carry a high ADR burden. Enhanced monitoring of high-risk groups and QTc/liver function is essential.

Background: Lung cancer ablation treatment is to insert an antenna into the tumor under imaging guidance, resulting in tumor coagulation necrosis through extreme energy changes. It is one of the main local treatments for lung cancer and has become a prominent research area in recent years. The objective of this bibliometric study is to introduce research trends in lung cancer ablation therapy.

Methods: Publications on ablative treatment for lung cancer are downloaded from the Web of Science core collection. This analysis includes 919 original English-language articles published between 2002 and 2025. VOSviewer, CiteSpace, and R software are employed to visualize the collected data.

Results: In total, 919 original articles were examined. The number of publications is increasing year by year. China ranks first by publication volume. The United States leads in total citations and breadth of international collaboration. The document "Pulmonary radiofrequency ablation: long-term safety and efficacy in 153 patients", published by Simon in 2007, is the most influential paper (447 citations). This study demonstrates that radiofrequency ablation (RFA) provides favorable tumor control rates and long-term survival outcomes, particularly for lung tumors smaller than 3 cm. RFA is the most prominent research area. Microwave ablation (MWA) and pulmonary nodules have been research hotspots since 2019. Percutaneous cryoablation has gained significant attention since 2023.

Conclusions: This bibliometric study provides a comprehensive and quantitative analysis and summary of research in lung cancer ablation, offering researchers insights into the research history, current hotspots, and future directions, aiming at advancing the development of lung cancer ablation therapy.