Lung cancer resection in patients with underlying usual interstitial pneumonia:a meta-analysis

Objective Patients with lung cancer with underlying idiopathic pulmonary fibrosis and usual interstitial pneumonia (UIP) pattern on CT represent a very high-risk group in terms of postoperative UIP acute exacerbations (AEs) and in-hospital mortality. We sought to investigate the outcomes in these patients.Methods We carried out a meta-analysis, searching four international databases from 1 January 1947 to 27 April 2022, for studies in any language reporting on the acute postoperative outcomes of patients with lung cancer undergoing surgical resection with underlying UIP (the primary outcome). Random effects meta-analyses (DerSimonian and Laird) were conducted. We analysed the difference in incidence of postoperative AE as well as the difference in long-term overall survival among subpopulations. These were stratified by the extent of surgical resection, with meta-regression testing (uniivariate and multivariate) according to the stage of disease, operative decision making and country of origin. This study was registered with PROSPERO (CRD42022319245).Results The overall incidence of AE of UIP postoperatively from 10 studies (2202 patients) was 14.6% (random effects model, 95% CI 9.8 to 20.1, I2=74%). Sublobar resection was significantly associated with a reduced odds of postoperative AE (OR 0.521 (fixed effects model), 95% CI 0.339 to 0.803, p=0.0031, I2=0%). The extent of resection was not significantly associated with overall survival following lung cancer resection in UIP patients (HR for sublobar resection 0.978 (random effects model), 95% CI 0.521 to 1.833, p=0.9351, I2=71%).Conclusions With appropriate implementation of perioperative measures such as screening for high-risk cases, appropriate use of steroids, antifibrotics and employing sublobar resection in select cases, the risk of local recurrence versus in-hospital mortality from AEUIP can be balanced and long-term survival can be achieved in a super-selected group of patients. Further investigation in the form of a randomised study is warranted

Does the revised cardiac risk index predict cardiac complications following elective lung resection?

Background: Revised Cardiac Risk Index (RCRI) score and Thoracic Revised Cardiac Risk Index (ThRCRI) score were developed to predict the risks of postoperative major cardiac complications in generic surgical population and thoracic surgery respectively. This study aims to determine the accuracy of these scores in predicting the risk of developing cardiac complications including atrial arrhythmias after lung resection surgery in adults. Methods: We studied 703 patients undergoing lung resection surgery in a tertiary thoracic surgery centre. Observed outcome measures of postoperative cardiac morbidity and mortality were compared against those predicted by risk. Results: Postoperative major cardiac complications and supraventricular arrhythmias occurred in 4.8% of patients. Both index scores had poor discriminative ability for predicting postoperative cardiac complications with an area under receiver operating characteristic (ROC) curve of 0.59 (95% CI 0.51-0.67) for the RCRI score and 0.57 (95% CI 0.49-0.66) for the ThRCRI score. Conclusions: In our cohort, RCRI and ThRCRI scores failed to accurately predict the risk of cardiac complications in patients undergoing elective resection of lung cancer. The British Thoracic Society (BTS) recommendation to seek a cardiology referral for all asymptomatic pre-operative lung resection patients with > 3 RCRI risk factors is thus unlikely to be of clinical benefit

UK pneumonectomy outcome study (UKPOS): a prospective observational study of pneumonectomy outcome

<p>Abstract</p> <p>Background</p> <p>In order to assess the short term risks of pneumonectomy for lung cancer in contemporary practice a one year prospective observational study of pneumonectomy outcome was made. Current UK practice for pneumonectomy was observed to note patient and treatment factors associated with major complications.</p> <p>Methods</p> <p>A multicentre, prospective, observational cohort study was performed. All 35 UK thoracic surgical centres were invited to submit data to the study. All adult patients undergoing pneumonectomy for lung cancer between 1 January and 31 December 2005 were included. Patients undergoing pleuropneumonectomy, extended pneumonectomy, completion pneumonectomy following previous lobectomy and pneumonectomy for benign disease, were excluded from the study.</p> <p>The main outcome measure was suffering a major complication. Major complications were defined as: death within 30 days of surgery; treated cardiac arrhythmia or hypotension; unplanned intensive care admission; further surgery or inotrope usage.</p> <p>Results</p> <p>312 pneumonectomies from 28 participating centres were entered. The major complication incidence was: 30-day mortality 5.4%; treated cardiac arrhythmia 19.9%; unplanned intensive care unit admission 9.3%; further surgery 4.8%; inotrope usage 3.5%. Age, American Society of Anesthesiologists physical status ≥ P3, pre-operative diffusing capacity for carbon monoxide (DLCO) and epidural analgesia were collectively the strongest risk factors for major complications. Major complications prolonged median hospital stay by 2 days.</p> <p>Conclusion</p> <p>The 30 day mortality rate was less than 8%, in agreement with the British Thoracic Society guidelines. Pneumonectomy was associated with a high rate of major complications. Age, ASA physical status, DLCO and epidural analgesia appeared collectively most associated with major complications.</p

Trichoptysis: a hairy presentation of a rare tumour.

We describe the case of a 17-year-old hairdresser who presented with haemoptysis and trichoptysis due to benign intrapulmonary teratoma and her surgical management. The clinical and radiological features of this rare tumour are reviewed and the symptom of trichoptysis discussed

Chest Wall Mechanics In Vivo With a New Custom-Made Three-Dimensional-Printed Sternal Prosthesis.

PURPOSE Reconstruction after sternal resection is performed according to surgeon intuition; physiologic evidence for selection of prostheses is lacking. We present our experience of the in vivo function of a novel device for sternal reconstruction. DESCRIPTION A three-dimensional-printed titanium and porous polyethylene sternal prosthesis was made according to the patient's computed tomographic scan. The titanium arms slot over adjacent ribs and are fixed in place with screws. The porous element allows ingrowth of native tissue while preventing lung herniation around the narrow titanium bars. EVALUATION We performed optoelectronic plethysmography to assess the physiologic function of the device compared with a muscle flap reconstruction. Asynchronous and paradoxical movements of the thoracoabdominal surface were apparent with the muscle flap reconstruction but not with the new device. Considerably higher tidal volumes and a lower respiratory rate achieved the same minute volume with the new device compared with the muscle flap. CONCLUSIONS Rigid sternal reconstruction with a three-dimensional-printed prosthesis demonstrated superior respiratory mechanics compared with reconstruction with an autologous muscle flap

The significance of microvascular invasion after complete resection of early-stage non-small-cell lung cancer.

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'in patients with non-small-cell lung cancer who have undergone complete resection, does the presence of microvascular invasion (MVI) significantly impact long-term survival or prognosis?' Altogether, more than 250 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. Outcome parameters that were used in the assessment include 5-year overall survival, event-free or recurrence-free survival (RFS) and incidence of metastatic relapse. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. The majority of the data collected were retrospective. Meta-analysis of data of over 16 000 patients showed that when considering RFS, MVI positivity was associated with a significantly reduced period of RFS; pooled hazard ratio estimates by univariate and multivariate analyses were 3.28 (95% CI 2.14-5.05; P < 0.0001) and 3.98 (95% CI 2.24-7.06; P < 0.0001), respectively. Eight of the studies showed a significantly worse 5-year survival in the presence of MVI, whereas a further study found a reduced median survival with MVI. One study showed no difference, but concurred with five other studies that MVI was associated with a significantly shorter event-free or RFS. Multivariate analyses have furthermore demonstrated that MVI positivity correlates with larger tumour size, an increased risk of distant metastases, visceral pleural involvement, lymphovascular invasion, higher tumour grade and nodal status. We conclude that the presence of microvascular invasion in resected early-stage non-small-cell lung cancer is a negative prognostic factor