High-Risk Features Associated with Recurrence in Stage I Lung Adenocarcinoma

OBJECTIVE

There is a lack of knowledge regarding the use of prognostic features in stage I lung adenocarcinoma (LUAD). Thus, we investigated clinicopathologic features associated with recurrence after complete resection for stage I LUAD.

METHODS

We performed a retrospective analysis of patients with pathologic stage I LUAD who underwent R0 resection from 2010 to 2020. Exclusion criteria included history of lung cancer, induction or adjuvant therapy, noninvasive or mucinous LUAD, and death within 90 days of surgery. Fine and Gray competing-risk regression assessed associations between clinicopathologic features and disease recurrence.

RESULTS

In total, 1912 patients met inclusion criteria. Most patients (1565 [82%]) had stage IA LUAD, and 250 developed recurrence: 141 (56%) distant and 109 (44%) locoregional only. The 5-year cumulative incidence of recurrence was 12% (95% confidence interval, 11%-14%). Higher maximum standardized uptake value of the primary tumor (hazard ratio [HR]=1.04), sublobar resection (HR=2.04), higher IASLC grade (HR=5.32 [grade 2]; HR=7.93 [grade 3]), lymphovascular invasion (HR=1.70), visceral pleural invasion (HR=1.54), and tumor size (HR=1.30) were independently associated with hazard of recurrence. Tumors with 3-4 high-risk features had a higher cumulative incidence of recurrence at 5 years than tumors without these features (30% vs. 4%; p<0.001).

CONCLUSIONS

Recurrence after resection for stage I LUAD remains an issue for select patients. Commonly reported clinicopathologic features can be used to define patients at high risk of recurrence and should be considered when assessing the prognosis of patients with stage I disease.

A real-world assessment of stage I lung cancer through electronic nose technology

INTRODUCTION

Electronic nose (E-nose) technology has demonstrated excellent sensitivity and specificity in the setting of lung cancer screening. However, the performance of E-nose specifically for early-stage tumors remains unclear. Therefore, the aim of our study was to assess the diagnostic performance of E-nose technology in clinical stage I lung cancer.

METHODS

This Phase-IIc trial (NCT04734145) included patients diagnosed with a single ≥50% solid stage I nodule. Exhalates were prospectively collected from January 2020 to August 2023. Blinded bioengineers analyzed the exhalates, using E-nose technology to determine the probability of malignancy. Patients were stratified into 3 risk groups (low-risk, <0.2; moderate-risk, ≥0.2 to 0.7; high-risk, ≥0.7). The primary outcome was the diagnostic performance of E-nose versus histopathology (accuracy and F1 score). The secondary outcome was the clinical performance of the E-nose versus clinicoradiological prediction models.

RESULTS

Based on the predefined cut-off (<0.20), E-nose agreed with histopathological results in 86% of cases, achieving an F1 score of 92.5%, based on 86 true positives, 2 false negatives, and 12 false positives (n=100). Compared with Swensen and Brock models, E-nose would refer fewer patients with malignant nodules to observation (Low-risk: 2 vs. 9 and 11; respectively; p=0.028 and p=0.011) and more patients with malignant nodules to treatment without biopsy (High-risk: 27 vs. 19 and 6; respectively; p=0.057 and p<0.001).

CONCLUSIONS

In the setting of clinical stage I lung cancer, E-nose has good agreement with histopathology. Accordingly, E-nose technology can be used in addition to imaging or as part of a "multiomics" platform.

Diagnosis and Management of Esophageal Fistulas After Lung Transplantation: A Case Series

Background

Lung transplantations are highly complex procedures, often conducted in frail patients. Through the addition of immunosuppressants, healing can be compromised, primarily leading to the development of bronchopleural fistulas. Although esophageal fistulas (EFs) after lung transplantation remain rare, they are associated with significant morbidity. We aimed to investigate the clinical presentation, diagnostic approaches, and treatment strategies of EF after lung transplantation.

Methods

All patients who developed EF after lung transplantation at the University Hospitals Leuven between January 2019 and March 2022 were retrospectively reviewed and the clinical presentations, diagnostic approaches, and treatment strategies were summarized.

Results

Among 212 lung transplantation patients, 5 patients (2.4%) developed EF. Three patients were male and median age was 39 y (range, 34-63). Intraoperative circulatory support was required in 3 patients, with 2 needing continued support postoperatively. Bipolar energy devices were consistently used for mediastinal hemostasis. All EFs were right-sided. Median time to diagnosis was 28 d (range, 12-48) and 80% of EFs presented as recurrent respiratory infections or empyema. Diagnosis was made through computed tomography (n = 3) or esophagogastroscopy (n = 2). Surgical repair with muscle flap covering achieved an 80% success rate. All patients achieved complete resolution, with only 1 patient experiencing a fatal outcome during a complicated EF-related recovery.

Conclusion

Although EF after lung transplantation remains rare, vigilance is crucial, particularly in cases of right-sided intrathoracic infection. Moreover, caution must be exercised when applying thermal energy in the mediastinal area to prevent EF development and mitigate the risk of major morbidity. Timely diagnosis and surgical intervention can yield favorable outcomes.

Biologic versus synthetic prosthesis for chest wall reconstruction: a matched analysis

OBJECTIVES

The aim of this study was to compare postoperative outcomes between biologic and synthetic reconstructions after chest wall resection in a matched cohort.

METHODS

All patients who underwent reconstruction after full-thickness chest wall resection from 2000 to 2022 were reviewed and stratified by prosthesis type (biologic or synthetic). Biologic prostheses were of biologic origin or were fully absorbable and incorporable. Integer matching was performed to reduce confounding. The study end point was surgical site complications requiring reoperation. Multivariable analysis was performed to identify associated risk factors.

RESULTS

In total, 438 patients underwent prosthetic chest wall reconstruction (unmatched: biologic, n = 49; synthetic, n = 389; matched: biologic, n = 46; synthetic, n = 46). After matching, the median (interquartile range) defect size was 83 cm2 (50-142) for the biologic group and 90 cm2 (48-146) for the synthetic group (P = 0.97). Myocutaneous flaps were used in 33% of biologic reconstructions (n = 15) and 33% of synthetic reconstructions (n = 15) in the matched cohort (P = 0.99). The incidence of surgical site complications requiring reoperation was not significantly different between biologic and synthetic reconstructions in the unmatched (3 [6%] vs 29 [7%]; P = 0.99) and matched (2 [4%] vs 4 [9%]; P = 0.68) cohorts. On the multivariable analysis, operative time [adjusted odds ratio (aOR) = 1.01, 95% confidence interval (CI), 1.00-1.01; P = 0.006] and operative blood loss (aOR = 1.00, 95% CI, 1.00-1.00]; P = 0.012) were associated with higher rates of surgical site complications requiring reoperation; microvascular free flaps (aOR = 0.03, 95% CI, 0.00-0.42; P = 0.024) were associated with lower rates.

CONCLUSIONS

The incidence of surgical site complications requiring reoperation was not significantly different between biologic and synthetic prostheses in chest wall reconstructions.

The contribution of microvascular free flaps and pedicled flaps to successful chest wall surgery

OBJECTIVE

Pedicled flaps (PFs) have historically served as the preferred option for reconstruction of large chest wall defects. More recently, the indications for microvascular-free flaps (MVFFs) have increased, particularly for defects in which PFs are inadequate or unavailable. We sought to compare oncologic and surgical outcomes between MVFFs and PFs in reconstructions of full-thickness chest wall defects.

METHODS

We retrospectively identified all patients who underwent chest wall resection at our institution from 2000 to 2022. Patients were stratified by flap reconstruction. End points were defect size, rate of complete resection, rate of local recurrence, and postoperative outcomes. Multivariable analysis was performed to identify factors associated with complications at 30 days.

RESULTS

In total, 536 patients underwent chest wall resection, of whom 133 had flap reconstruction (MVFF, n = 28; PF, n = 105). The median (interquartile range) covered defect size was 172 cm2 (100-216 cm2) for patients receiving MVFF versus 109 cm2 (75-148 cm2) for patients receiving PF (P = .004). The rate of R0 resection was high in both groups (MVFF, 93% [n = 26]; PF, 86% [n = 90]; P = .5). The rate of local recurrence was 4% in MVFF patients (n = 1) versus 12% in PF patients (n = 13, P = .3). Postoperative complications were not statistically different between groups (odds ratio for PF, 1.37; 95% confidence interval, 0.39-5.14]; P = .6). Operative time >400 minutes was associated with 30-day complications (odds ratio, 3.22; 95% confidence interval, 1.10-9.93; P = .033).

CONCLUSIONS

Patients with MVFFs had larger defects, a high rate of complete resection, and a low rate of local recurrence. MVFFs are a valid option for chest wall reconstructions.

How to handle brain tumors after esophagectomy with curative intent: A single center 20-year experience

BACKGROUND

Brain metastases after esophagectomy are rare. Moreover, a diagnostic uncertainty remains as pathology is rarely obtained and radiological features can show similarities to primary brain tumors. Our aim was to demonstrate the diagnostic uncertainty and identify risk factors associated with brain tumors (BT) after esophagectomy with curative intent.

METHODS

All patients who underwent an esophagectomy with curative intent from 2000 to 2019 were reviewed. Diagnostics and characteristics of BT were analyzed. Multivariable logistic and cox regression were performed to determine factors associated with development of BT and survival, respectively.

RESULTS

In total, 2131 patients underwent esophagectomy with curative intent, of which 72 patients (3.4%) developed BT. Pathological diagnosis was obtained in 26 patients (1.2%), of which 2 patients were diagnosed with glioblastoma. On multivariate analysis, radiotherapy (OR, 7.71; 95%CI: 2.66-22.34, p < 0.001) was associated with an increased risk of BT and early-stage tumors (OR, 0.29; 95%CI: 0.10-0.90, p = 0.004) with a decreased risk of BT. Median overall survival was 7.4 months (95%CI: 4.80-9.96). BT treated with curative intent (surgery or stereotactic radiation) had a significantly better median overall survival (16 months; 95%CI: 11.3-20.7) compared to those without (3.7 months; 95%CI: 0.9-6.6, p < 0.001) CONCLUSIONS: Advanced stage tumors and radiotherapy seem related to the development of brain tumors after esophagectomy with curative intent. However, an important diagnostic uncertainty remains in these patients as pathological diagnosis is only obtained in a minority of cases. Tissue confirmation can be useful to inform a patient-tailored multimodality treatment strategy in select patient.

Real-life introduction of powered circular stapler for esophagogastric anastomosis: cohort and propensity matched score study

Anastomotic leakage after esophagectomy is one of the most feared complications, which results in increased morbidity and mortality. Our aim was to evaluate the impact of a powered circular stapler on complications after esophagectomy with intrathoracic anastomosis for esophageal cancer. Between May 2019 and July 2021, all consecutive oesophagectomies for cancer with intrathoracic anastomosis in a high-volume center were included in this retrospective study. Surgeons were free to choose either a manual or a powered circular stapler. Preoperative characteristics and postoperative complications were recorded in a prospective database, according to EsoData. Propensity score matching (age, body mass index, Eastern cooperative oncology group (ECOG) performance and neoadjuvant therapy) was conducted to reduce potential confounding. We included 128 patients. Powered and manual circular staplers were used in 62 and 66 patients, respectively. Fewer anastomotic leakages were observed with the powered stapler group (OR = 7.3 (95%CI: 1.58-33.7); [3.2% (n = 2) vs 19.7% (n = 13), respectively; p = 0.004]). After propensity score matching, this remained statistically significant (OR = 8.5 (95%CI: 1.80-40.1); [4.1% (n = 2) vs 20.4% (n = 10), respectively; p = 0.013]). Additionally, anastomotic diameter was significantly higher with the powered stapler (median: 29 mm (63.3%) vs 25 mm (57.1%), respectively; p < 0.0001). There was no significant difference in comprehensive complication index (p = 0.146). A decreased mean length of stay was observed in the powered stapler group (11.1 vs 18.7 days respectively; p = 0.022). Postoperative anastomotic leakage after esophageal resection was significantly reduced after the introduction of the powered circular stapler, consequently resulting in a reduced length of stay. Further evaluation on long-term strictures and quality of life are warranted to support these results.

Early surgical complications after congenital diaphragmatic hernia repair by thoracotomy vs. laparotomy: A bicentric comparison

PURPOSE

The surgical strategy for congenital diaphragmatic hernia (CDH) repair remains debated and mainly depends on the training and preference of the surgeon. Our aim was to evaluate the occurrence and nature of surgical reinterventions within the first year of life, following repair through thoracotomy as compared to laparotomy.

METHODS

This is a retrospective bi-centric cohort study comparing postero-lateral thoracotomy (n = 55) versus subcostal laparotomy (n = 62) for CDH repair (IRB: MP001882). We included neonates with isolated, left-sided, Bochdalek-type CDH who were operated on between 2000 and 2017, and had a minimum follow-up of 1 year. Excluded were patients treated prenatally and/or had extra-corporeal membrane oxygenation. Outcomes were occurrence and nature of surgical reinterventions and mortality by 1 year of life.

RESULTS

Both groups had comparable neonatal severity risk profiles. The overall surgical reintervention rate by 1 year of age was higher in the thoracotomy group (29.1% vs. 6.5%; p = 0.001), mainly because of a higher prevalence of acute bowel complications (18.1% vs. 3.2%; p = 0.012) requiring surgery, such as perforation, obstruction and volvulus. At 1 year of follow-up, groups were similar in terms of recurrence (5.5% vs. 1.6%; p = 0.341), surgical interventions related to severe gastroesophageal reflux disease (3.6% vs. 1.6%; p = 0.600) and mortality (5.5% vs. 6.6%; p = 1.000).

CONCLUSION

Postnatal CDH repair through thoracotomy was associated with a higher rate of surgical reinterventions within the first year of life, especially for severe acute gastro-intestinal complications. There seemed to be no difference in recurrence and mortality rate.

TYPE OF STUDY

Retrospective Comparative Cohort Study.

LEVEL OF EVIDENCE

Level III.

Video-assisted thoracoscopic sternal adhesiolysis before resternotomy reduces morbidity and improves patient care

BACKGROUND

Resternotomy still carries an important risk for an already high-risk population. Re-entry injuries may lead to massive bleeding, which can be difficult to control due to poor accessibility. The aim of the study was to assess early outcomes of video-assisted thoracoscopic adhesiolysis, as well as safety and feasibility.

METHODS

Forty-five patients received a video-assisted thoracoscopic adhesiolysis before resternotomy between April 1, 2016 and January 1, 2019. Records were reviewed for demographics, perioperative and early postoperative (Postop) outcomes.

RESULTS

The median age of the population was 73 years with a EUROSCORE II of 8.322. Only 1 (2.22%) patient experienced a major and 2 (4.44%) a minor re-entry injury. This resulted in a mean peroperative and 24-hour Postop blood loss of, respectively, 675.72 (range: 5-2862) and 444.71 mL (range: 0-2100). There was no significant difference between the use of minimally invasive and classic extracorporeal circulation (P = .276 and P = .81, respectively). Twenty-nine patients (64%) were not in need of red blood cell transfusion. A survival rate of 93.33% could be achieved. No deaths (n = 3) were related to the video-assisted thoracoscopic adhesiolysis or re-entry injuries. Kidney function remained stale postoperatively with creatinine preoperative and Postop levels of 1.56 (95%confidence interval: 1.07-2.05) and 1.43 (95%CI, 1.05-1.81) mg/dL (P = .264). Despite high-risk surgery, the median length of stay was 8 days.

CONCLUSION

A video-assisted thoracoscopic approach allows for a safe and effective adhesiolysis, due to increased visibility and accuracy. This approach may prevent major and minor re-entry injuries and consequently reduce perioperative morbidity and mortality of high-risk surgery.

Drug Thrombus Resulting in Superior Vena Cava Syndrome: A Case Report

INTRODUCTION

Superior vena cava syndrome is one of the more serious complications of central venous catheter insertion. Drug interactions of administered drugs used in association with these catheters can lead to formation of precipitations and consequently thrombus formation. These interactions can be either anion-cation or acid-base based and more commonly present in clinical practice than expected.

CASE PRESENTATION

The case of a 31-year old female who was admitted to an intensive care unit with an intracranial haemorrhage, is presented. Occlusion of the superior vena cava was caused by a drug-induced thrombus, formed by the precipitation and clotting of total parenteral nutrition and intravenous drugs. Given the nature of the thrombus and a recent intracranial haemorrhage, the patient was treated with a central thrombectomy supported by a heparin-free extracorporeal membrane oxygenation.

CONCLUSION

Knowledge of drug interactions is crucial in order to heighten awareness for the dangers of concomitant drug administration, especially in combination with total parenteral nutrition in critically ill patients.

A comparative linkage map of oilseed rape and its use for QTL analysis of seed oil and erucic acid content

We have developed a new DH mapping population for oilseed rape, named TNDH, using genetically and phenotypically diverse parental lines. We used the population in the construction of a high stringency genetic linkage map, consisting of 277 loci, for use in quantitative genetic analysis. A proportion of the markers had been used previously in the construction of linkage maps for Brassica species, thus permitting the alignment of maps. The map includes 68 newly developed Sequence Tagged Site (STS) markers targeted to the homologues of defined genes of A. thaliana. The use of these markers permits the alignment of our linkage map with the A. thaliana genome sequence. An additional 74 loci (31 newly developed STS markers and 43 loci defined by SSR and RFLP markers that had previously been used in published linkage maps) were added to the map. These markers increased the resolution of alignment of the newly constructed linkage map with existing Brassica linkage maps and the A. thaliana genome sequence. We conducted field trials with the TNDH population at two sites, and over 2 years, and identified reproducible QTL for seed oil content and erucic acid content. The results provide new insights into the genetic control of seed oil and erucic acid content in oilseed rape, and demonstrate the utility of the linkage map and population.

Factors influencing the flow rate through a surgical defect in human fetal membranes

OBJECTIVES

In order to determine factors influencing the flow rate trough a created defect in human fetal membranes, an ex vivo set-up was used with fetal membranes collected from patients undergoing Caesarean section at term.

METHODS

The membranes were secured at the bottom of a plastic tube and traumatised with needles ranging from 14-26 Gauges (Ga), under a hydrostatic pressure of 10 to 20 cm H(2)O and an angle of 45 degrees or 90 degrees. The column was filled with amniotic fluid or Hartmann's solution. The duration of the puncture was 1 s or the time it takes to aspirate 10 ml through the needle. The flow rate through the defect in the fetal membranes and size of the defect were measured.

RESULTS

The flow rate and defect size increased with increasing diameter of the needle. Increasing the pressure in the column resulted in a significant linear increase in the flow rate. Replacing the saline solution with amniotic fluid did not result in significant changes in the measured flow rates, except for the small needle size (24 Ga). Increasing the duration of the puncture did not result in increased flow rates, except for small needle size (24 Ga).

CONCLUSION

These experiments suggest that needle diameter, angle of needle insertion, duration of the procedure, amniotic fluid pressure and composition could influence the incidence of amniotic fluid leakage following amniocentesis.