Journal of thoracic disease最新文献

Background: The rare incidence of small cell carcinoma of the esophagus (SCCE) makes prospective studies difficult to conduct, the efficacy of existing standard treatment regimens for SCCE is therefore highly controversial. This study aimed to explore differences in the efficacy of three different treatment regimens [upfront surgery, neoadjuvant chemotherapy (NCT), and chemoradiotherapy (CRT)] in patients with limited-stage SCCE (LS-SCCE).

Methods: In total, 483 patients with LS-SCCE were screened from five centers from June 2001 to June 2020, and 128 patients with LS-SCCE were screened from the Surveillance, Epidemiology, and End Results (SEER) database. A survival analysis of the patients who underwent upfront surgery, NCT, and CRT was performed. The primary endpoint was overall survival (OS).

Results: Treatment approaches for LS-SCCE differ between China and America. The data from the SEER database showed that aggressive treatment resulted in a significant survival benefit for patients [median OS (mOS), 16.0 vs. 1.0 months]. However, no significant survival difference was observed between the surgical and non-surgical treatments [China: hazard ratio (HR), 0.820; 95% confidence interval (CI): 0.618-1.088, P=0.17; SEER: HR, 0.717; 95% CI: 0.440-1.169, P=0.18]. CRT significantly improved the survival time of the patients aged >60 years (mOS, 20.9 vs. 36.0 months, P=0.007). NCT significantly prolonged the survival time of the patients who underwent esophagectomy (HR, 0.753; 95% CI: 0.569-0.995, P=0.046).

Conclusions: This study suggests that NCT provided a better survival benefit for patients with LS-SCCE than upfront surgery, LS-SCCE patients aged >60 years receiving CRT had survival benefit compared to those undergoing surgery.

Background: Malignant pleural mesothelioma (MPM) is primarily treated with a combination therapy based on lung pleurectomy in the early stage or pemetrexed combined with platinum-based chemotherapy in the late stage. However, these standard therapies do not significantly improve survival and are associated with significant adverse reactions.

Case description: In February 2017, a 63-year-old male patient was admitted to Department of Thoracic Surgery, The Third Affiliated Hospital of Chongqing Medical University coughing for 1 month and experienced chest tightness and chest pain for 2 days. After admission, the patient underwent thoracic puncture drainage and was diagnosed with stage IIIb (c-T4NxM0) MPM. The patient subsequently underwent left pleural biopsy under single-port thoracoscopy, followed by cytoreductive surgery plus hyperthermic intrathoracic chemotherapy as a local treatment for controlling pleural effusion. At a postoperative follow-up in October 2017, we found that he had recurrent MPM with multiple nodules on the left pleura. Despite this, the patient declined further antitumor treatment. In April 2020, the patient was readmitted to The Third Affiliated Hospital of Chongqing Medical University for left-sided chest pain and was observed to have an enlarged tumor in the left pleural according to further imaging examination. Fortunately, no further pleural effusion has been observed since then. Subsequently, the patient was administered a combination of immunotherapy and cisplatin-pemetrexed chemotherapy as systemic therapy for six cycles, along with subsequent mono immunotherapy as maintenance therapy for three additional cycles. Following this, the left pleural tumor shrank significantly, and the patient achieved partial remission. However, due to the patient's irregular treatment adherence, the patient returned for systemic immunotherapy therapy for four cycles in November 2021, and a slight reduction of the pleural tumor was achieved. Once again, the patient discontinued treatment until he experienced left-sided chest pain and partial tumor enlargement in February 2023. Another three cycles of immunotherapy were administered, but the pleural tumor continued to grow. In June 2023, the patient succumbed to respiratory failure caused by a pulmonary infection. Overall, the patient's survival time was 76 months.

Conclusions: Cytoreductive video-assisted thoracic surgery plus hyperthermic intrathoracic chemotherapy followed by systemic chemo-immunotherapy can effectively control pleural effusion, prolong patient survival, and improve the quality of life in patients with MPM.

Background: Segmentectomy has been recognized as the standard procedure for small peripheral lung cancer; however, it has been shown that loco-regional relapse is more common with segmentectomy than with lobectomy. This study aims to investigate the long-term outcomes and loco-regional relapse patterns in patients with clinical stage IA (c-IA) non-small cell lung cancer (NSCLC) after segmentectomy and compare them with those after lobectomy.

Methods: We retrospectively compared the long-term outcomes of 115 patients who underwent segmentectomy for c-IA NSCLC with those of 292 patients who underwent lobectomy between January 2008 and December 2015. Segmentectomy was indicated intentionally or chosen in patients who were considered intolerable to lobectomy. New isolated growing lung lesions were defined as relapses if they were not diagnosed with a second primary lung cancer.

Results: The median observation period was 2,150 days. The 10-year overall survival (OS) rates and relapse-free survival (RFS) rates of the two groups were similar: 79.4% and 68.7% for segmentectomy, and 68.2% and 61.2% for lobectomy. Even after propensity score matching, no significant differences were observed in the OS and RFS rates between the groups. The segmentectomy group had a higher loco-regional relapse rate (14% vs. 8%), including the surgical margin, remnant lobe, ipsilateral lung, mediastinal lymph node, and ipsilateral dissemination; however, no relapse was observed in the ipsilateral hilar lymph node. Loco-regional relapse occurred significantly later after segmentectomy than after lobectomy (median: 1,246 vs. 512 days, P=0.03), especially four years after segmentectomy. Loco-regional relapse occurred even when the tumor diameter was <1.0 cm. Most patients with loco-regional relapse had solid-dominant tumors.

Conclusions: Segmentectomy, both intentional and compromised, showed comparable long-term outcomes to lobectomy; however, loco-regional relapse can develop in a later phase than lobectomy, requiring careful follow-up.

Background: While the relationship between gut microbiota and gastrointestinal cancer has been elucidated, the relationship between lung microbiota and lung cancer remains unclear. Previous study findings are inconclusive due to the possibility of contamination by upper airway microbiota in samples obtained from the oropharynx, such as saliva and sputum, and bronchoalveolar lavage fluid (BALF) collected during bronchoscopy. Therefore, this study aimed to detect pure lung microbiota in patients with lung cancer using BALF samples from resected lung specimens. Additionally, we aimed to evaluate the lung microbiota to clarify their relationship with lung cancer and aid in postoperative pneumonia (POP) prevention and treatment.

Methods: This prospective cohort study enrolled patients with clinically suspected lung cancer who underwent surgical resection at the Department of Thoracic Surgery, Japanese Red Cross Suwa Hospital, between April 2020 and March 2022. BALF from resected lung specimens collected under sterile conditions were used for high-throughput next-generation sequencing (NGS) and bacterial culture analyses. Pure lung microbiota were identified, and their abundance ratio was analyzed. Additionally, we performed α-diversity analysis and explored the relationship between microbiota and POP by comparing our findings with previous literature.

Results: Among samples collected from 54 included cases, bacteria were detected in 13 samples (24.1%) via bacterial culture and in all samples via NGS. Candidate Phylum OD1 bacteria (OD1) was present in a large proportion of samples (phylum level). The major bacteria genera, with a relative abundance ratio (each bacterial read amount/total bacterial read amount) >1% in at least one sample, included Aquabacterium, Acinetobacter, and Ralstonia. Additionally, bacteria widely recognized as pathogens of POP were detected.

Conclusions: Our lung microbiota sampling method eliminated contamination from upper airway microbiota, allowing detection of pure lung microbiota. This study provides baseline data on pure lung microbiota and highlights the need for further research to explore the role of OD1 in lung cancer, which was previously unreported in lung microbiota. Although the pathogens of POP can be aspirated post-hospitalization, they could already exist as lung microbiota pre-hospitalization. Further investigation is needed to substantiate our results and hypothesis.

Background: The inflated balloon of a bronchial blocker (BB) obstructs the mainstem bronchus, allowing controlled ventilation of one lung while collapsing the other for lung isolation during thoracic surgery. We compared the effects of lung isolation using electromagnetic navigation bronchoscopy (ENB)-guided versus fiberoptic bronchoscopy (FOB)-guided BB placement to provide a novel BB positioning method for airway management during thoracic anesthesia.

Methods: We randomly divided 106 patients who underwent elective one-lung ventilation (OLV) with intraoperative ENB usage into ENB and FOB groups. We compared subjective lung collapse scores, time required for correct BB placement, incidence of BB malposition, and frequency of intraoperative BB repositioning with FOB between the groups. Heart rate (HR) and mean arterial pressure were recorded before intubation of single-lumen tracheal tube, and before and after BB positioning. Blood gas levels were measured before and at 10 and 30 min after initiating OLV. Postoperative follow-up indices, including blood cell analysis, C-reactive protein levels, and pulmonary complications, were also recorded.

Results: The subjective lung collapse score was significantly higher in the ENB group than in the FOB group [9.08 (1.36) vs. 8.24 (1.93), P=0.01]. The time required for correct BB placement was significantly shorter in the ENB group than in the FOB group [13.00 (10.00, 20.25) vs. 49.00 (35.00, 75.00), P<0.001]. However, the incidence of BB malposition, frequency of intraoperative BB repositioning with FOB, HR, mean arterial and peak airway pressure before and after BB positioning, arterial blood gas analysis, and postoperative follow-up indices did not differ significantly between the two groups.

Conclusions: ENB-guided BB positioning is an efficient method of lung isolation, demonstrating superior and more rapid lung collapse effects compared with conventional FOB-guided BB placement.

Trial registration: The trial was registered on China Clinical Trial Registry (registration No. ChiCTR2300076133).

Background: Benign airway stenoses are complex disorders that present with progressive dyspnoea, stridor, and significant respiratory distress. These conditions have a high recurrence rate and despite the plethora of endoscopic and open techniques available for treatment, the outcomes are variable. Our primary was to determine the pre-operative factors associated with an increased hazard of cricotracheal resection (CTR)/tracheal resection (TR) and reconstruction in cases of benign subglottic and tracheal strictures.

Methods: We performed a retrospective analysis of a prospectively maintained database of all patients ages 16 years and over with benign subglottic and tracheal stenoses that underwent endoscopic or surgical treatment at our institution between 2008 and 2022.

Results: Ninety-seven patients were included in our series, with a strong female preponderance (n=79; 81%). Forty-one patients underwent formal resection and reconstruction, and 56 patients were managed conservatively. Subglottic stenosis (SGS) was the most common site of disease in the trachea (79%), and the common aetiology of all stenoses was idiopathic (52%). The median interval between first dilatation and formal resection was 5 [interquartile range (IQR), 0-173] months. Pre-operative tracheostomy rate was significantly higher in those who underwent TR (51% vs. 18%, P<0.001) yet the number of dilatations was equivocal between the surgical and non-surgical groups (P=0.30). The most significant independent predictors of TR were pre-operative tracheostomy, advanced Myer-Cotton grading and an increased number of involved airway subsites. Risk modelling using these parameters identified a low and a high-risk group for TR and the latter had a significantly reduced time to resection (P<0.001).

Conclusions: Benign airway stenoses are a heterogeneous group of conditions which respond to both endoscopic and open surgical airway intervention. The underlying aetiology will influence the treatment paradigm. We found that more complex lesions, patients with pre-operative tracheostomy and previous smoking history conferred a higher hazard for resection.

Background: Sepsis-induced skeletal muscle atrophy is accompanied by complex physiological and biochemical changes that negatively affect clinical outcomes, lead to prolonged hospitalization, and even increase mortality. However, few studies have been performed on the mechanisms of the disease, and effective treatments are still lacking. This study is aimed to research the molecular mechanisms of sepsis-induced skeletal muscle atrophy and to develop new therapeutic strategies.

Methods: In this study, we first constructed a mouse model of sepsis after cecal ligation and puncture (CLP). At 12, 24, 48, and 72 hours after modeling, we then analyzed the differentially expressed genes (DEGs) in the tibialis anterior muscle using transcriptome sequencing technology.

Results: The results showed that tibialis anterior muscle atrophy exacerbated with time after CLP and was accompanied by the altered expression of a large number of genes. The expression profiling analysis showed that there were three transcriptional phases within 72 hours of surgery: transcriptional phase I (0-12 hours), transcriptional phase II (24 hours), and transcriptional phase III (48-72 hours), of which 24 hours may be the critical time point for muscle atrophy. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses showed that the upregulated genes were mainly involved in inflammatory immunity, proteolysis, apoptosis, and autophagy, while the downregulated genes were mainly involved in cell proliferation and protein synthesis. These three transcriptional phases were defined as the inflammatory-immune phase, inflammatory-atrophy phase, and atrophy phase, respectively.

Conclusions: These findings not only enrich understandings of the molecular mechanism of sepsis-induced skeletal muscle atrophy, but also provide a scientific basis for its targeted therapy.

Background: With the development of tyrosine kinase inhibitor (TKI) treatment, the prognosis of advanced lung adenocarcinoma (LUAD) patients with epidermal growth factor receptor (EGFR) mutations has been continuously improving. This study aims to propose the utilization of pathological characteristics and imaging features to evaluate the impact of EGFR gene mutations on the prognosis of T1-4N0M0 LUAD.

Methods: Among the cases diagnosed with LUAD between April 2015 and April 2016, 438 patients with T1-4N0M0 LUAD were included, and the clinical characteristics were collected. EGFR mutations were analyzed in these patients who underwent lobectomy with different radiological and pathological types for the relation to patient prognosis.

Results: Patients with EGFR mutation had longer recurrence-free survival (RFS) in part-solid nodules cohort (P=0.03), which was in contrast to purely solid nodules (P=0.06). Positive EGFR mutations significantly prolonged RFS in nodules consolidation-to-tumor ratio (CTR) values of 0-0.5. In the International Association for the Study of Lung Cancer (IASLC) grade I patients with EGFR mutations, there was a trend towards longer RFS but with no effect on overall survival (OS) (P=0.08; P=0.71); in IASLC grade II patients with EGFR mutations, there was a tendency of longer OS (P=0.06); in IASLC grade III patients with EGFR mutations, both RFS and OS were significantly shorter (P=0.02; P=0.005). EGFR mutation state was not an independent risk factors for both RFS and OS.

Conclusions: EGFR mutations are associated with a favorable prognosis in nodules with lower IASLC grading or more ground glass opacity (GGO) components. The results were reversed in patients with higher IASLC grading or no GGO component.

Background and objective: The global prevalence of diabetes mellitus has markedly risen in recent years. Consequently, there has been a rise in the number of patients with diabetes undergoing cardiac surgery. Despite the existence of national and international guidelines to improve surgical outcomes in patients with diabetes, perioperative diabetes management optimisation remains inadequate resulting in these patients experiencing increased rates of surgical morbidity and mortality. This review aims to evaluate outcomes following cardiac surgery in patients with diabetes and assess strategies to enhance preoperative and perioperative optimization and postoperative outcomes.

Methods: A comprehensive literature search was performed for articles concerning perioperative management of diabetes in patients undergoing cardiac surgery as well as postoperative complications related to diabetes in addition to interventions utilised to optimize outcomes.

Key content and findings: Principle findings were extracted and synthesized. Patients with diabetes undergoing cardiac surgery exhibit increased perioperative complications, higher in-hospital mortality rates and inferior long-term survival. A key facilitator is specifically poor glycemic control, with glycated haemoglobin (HbA1c) serving as a predictive marker. However, measuring preoperative HbA1c is not routine, and there is no established threshold for deferring elective surgery. Preoperatively, emphasis should be placed on lowering the patient's HbA1c through optimized medical management and continuous glucose monitoring. Intraoperatively, continuous insulin infusion therapy is recommended alongside postoperative continuation for critically ill patients. Prompt resumption of the patient's routine medications post-surgery is also necessary.

Conclusions: Optimal glycemic control, both pre-, intra- and perioperatively, correlates with improved outcomes that are comparable to those without diabetes. Targeted efforts are warranted for patients with diabetes undergoing cardiac surgery to ensure long-term benefits for the patients and healthcare systems.