Impact of surgical approach on 90-day mortality after lung resection for nonsmall cell lung cancer in high-risk operable patients

Introduction

Non-small cell lung cancer (NSCLC) is often associated with compromised lung function. Real-world data on the impact of surgical approach in NSCLC patients with compromised lung function are still lacking. The objective of this study is to assess the potential impact of minimally invasive surgery (MIS) on 90-day post-operative mortality after anatomic lung resection in high-risk operable NSCLC patients.

Methods

We conducted a retrospective multicentre study including all patients who underwent anatomic lung resection between January 2010 and October 2021 and registered in the Epithor database. High-risk patients were defined as those with a forced expiratory volume in 1 s (FEV1) or diffusing capacity of the lung for carbon monoxide (DLCO) value below 50%. Co-primary end-points were the impact of risk status on 90-day mortality and the impact of MIS on 90-day mortality in high-risk patients.

Results

Of the 46 909 patients who met the inclusion criteria, 42 214 patients (90%) with both preoperative FEV1 and DLCO above 50% were included in the low-risk group, and 4695 patients (10%) with preoperative FEV1 and/or preoperative DLCO below 50% were included in the high-risk group. The 90-day mortality rate was significantly higher in the high-risk group compared to the low-risk group (280 (5.96%) versus 1301 (3.18%); p<0.0001). In high-risk patients, MIS was associated with lower 90-day mortality compared to open surgery in univariate analysis (OR=0.04 (0.02-0.05), p<0.001) and in multivariable analysis after propensity score matching (OR=0.46 (0.30-0.69), p<0.001). High-risk patients operated through MIS had a similar 90-day mortality rate compared to low-risk patients in general (3.10% versus 3.18% respectively).

Conclusion

By examining the impact of surgical approaches on 90-day mortality using a nationwide database, we found that either preoperative FEV1 or DLCO below 50% is associated with higher 90-day mortality, which can be reduced by using minimally invasive surgical approaches. High-risk patients operated through MIS have a similar 90-day mortality rate as low-risk patients.

Survival Impact of Stations of Pathological Lymph Nodes in N2 Non-small Cell Lung Cancer in a French Hospital

BACKGROUND

The prognosis of lung cancer remains poor; only 20% of patients can undergo surgery. N2 non-small cell lung cancer (NSCLC) is a heterogeneous disease. We conducted a retrospective study to analyze the impact of N2 location on survival.

METHODS

This study included 342 NSCLC with N2 involvement between 1988 and 2014. Patient-related data were collected through the CRB biobank and included demographic, therapeutic, and survival data. Survival was analyzed according to Kaplan-Maier method. Cox's regression analysis and analysis of variance (ANOVA) were used to determine factors significantly associated with survival.

RESULTS

The population average age was 61.6 years; 82.2% were men, a majority were former smokers (87.1%), and 45.3% had adenocarcinoma. The main prognostic factors were male gender (p = 0.01), number of nodes (p < 0.0001), and tumor size (p < 0.0001). N2 disease had a poor survival (16 months) compared with N0 (32 months) and N1 (21.1 months) disease (p < 0.0001). The patients with involvement of station 4 (survival = 17.8 months) seemed to have a prognosis between those with station 7 (survival = 10.5 months) and N1 (survival = 22.6 months), p = 0.0005.

CONCLUSIONS

N2 location has a prognostic impact in surgically NSCLC, and station 4 involvement has a better prognostic than station 7.

Large thoracomyoplasty and negative pressure therapy for late postpneumonectomy empyema with a retrosternal abscess: a modern version of the Clagett procedure

A 63-year-old male with a history of cancer, and who had undergone a left pneumonectomy seven years before, presented with deterioration in his general status and recent dyspnea [stage III (New York Heart Association) NYHA]. Imaging revealed a contralateral mediastinal shift and cardiac compression caused by pneumonectomy cavity enlargement and a retrosternal liquid mass. Late empyema associated with a retrosternal abscess caused by Propionibacterium acnes was diagnosed after thoracoscopy and an anterior mediastinotomy. Surgical treatment included an axillary open-window thoracostomy associated with negative pressure therapy (NPT), followed by a large thoracomyoplasty where part of the latissimus dorsi was harvested, and then guided healing. The chest was closed after eight months. This case is an unusual observation of a late post-pneumonectomy empyema with Propionibacterium acnes presenting like recurring cancer, but that was treated effectively using traditional (Clagett procedure) and newer (NPT) strategies.

A uniform strain criterion for trabecular bone adaptation: do continuum-level strain gradients drive adaptation?

In this paper, it is postulated that the apparent density of trabecular bone adapts so that continuum-level strains within the bone are uniform and, as a consequence, spatial strain gradients within the bone/marrow continuum are minimized. The feasibility of a uniform strain criterion was tested using computational finite-element analysis of the proximal femur. We demonstrated that (1) this criterion produced a realistic apparent density distribution in the proximal femur, (2) the solutions for apparent density were convergent and unique, (3) predicted apparent densities compared well to experimental measurements, and (4) strain gradients within the bone/marrow continuum were reduced substantially. Thus, a possible goal of trabecular bone adaptation may be the reduction of strain gradients within the bone/marrow continuum. Osteocytes within the bone tissue and bone cells on the surface of a trabeculum are mechanosensitive and play a role in bone adaptation. In addition, the bone marrow is rich in osteoprogenitor cells near the bone surface that are mechanosensitive. Strain gradients within bone/marrow continuum cause pressure gradients in the marrow, causing extracellular fluid flow which could stimulate osteoprogenitor cells and contribute to bone adaptation.

Development of esophageal epithelium in the fetal and neonatal mouse

Development of the fetal mouse esophageal epithelium was followed using light microscopy, transmission electron microscopy (TEM), scanning electron microscopy (SEM) and radioautography. At 15 days of gestation in the cervical (C), mediastinal (M), and abdominal (A) segments of the esophagus, the epithelium was two or three cells thick, and only cells located in the basal (germinal) layer incorporated tritiated thymidine. Ciliated cells were sparse in all three segments. At 17 days of gestation, longitudinal mesenchymal ridges became more differentiated in the distal segment. Labeling indices were lower than at preceding stages in each segment. Ciliated cells had increased in number and appeared to be evenly distributed along the whole esophagus. In periodic acid-Schiff (PAS)-stained sections, an increasing proximodistal distribution of glycogen stores was observed, with greatest concentrations found in segment A. At 18 days of gestation, labeling indices were comparable in segments C and M (11.7% +/- 2.9% and 12.8% +/- 1.9%, respectively) but remained higher in segment A (17.9% +/- 2.0%). Ciliated cells were still present. At this stage, transverse circular furrows and ridges started to appear. They increased in number at 4 days after birth and were very closely distributed in the adult. In longitudinal sections, these ridges corresponded to projections of stratum granulosum and of the overlying stratum corneum. After birth, ciliated cells desquamated rapidly but some patches were still present at 4 days. At 8 days, the esophageal epithelium was not yet keratinized.