Surgical resection for synchronous multiple pulmonary nodules identified difficultly in clinics / 中国胸心血管外科临床杂志

@#Objective 　To evaluate the role of surgical resection on synchronous multiple pulmonary nodules identified difficultly in clinics. Methods 　The clinical data of 97 patients with synchronous multiple pulmonary nodules who received surgical resection between 2012 and 2019 in Hunan Cancer Hospital were retrospectively analyzed. There were 72 males and 25 females, aged 58.1卤9.0 years. Among these patients, there were 78 patients with ipsilateral and 19 patients with bilateral pulmonary nodules. Clinicopathological parameters between main nodules and secondary nodules were evaluated. Perioperative morbidity was also assessed. Results 　The operation was successfully completed on all patients for the ipsilateral and bilateral lesions. Totally, 71.1% of mian lesions was mostly removed by lobectomy, and the completion rate of video-assisted thoracoscopic surgery (VATS) was 69.1% (67/97); 80.4% of secondary lesions were mostly removed by wedge resection, and the completion rate of VATS was 71.1% (69/97). The incidence of grade 3 or higher complications after unilateral or bilateral surgery was 12.8% and 5.3%, respectively. Postoperative pathology confirmed that the main lesions were malignant in 65 patients (67.0%), mainly adenocarcinoma (63.1%), of which 43.1%were in the stage Ⅰ; 32 patients were benign, mainly tuberculoma (56.3%). There were 29 patients of malignant secondary lesions, 67 benign, and 1 both benign and malignant; the pathological agreement rate of primary and secondary lesions was 54.6% (lung cancer metastases in the lung and all the benign). When the primary lesion was malignant with its diameters of <3 cm, 3-<5 cm, 5-7 cm, >7 cm, the metastatic rate of secondary lesions was 42.5%, 15.8%, 20.0%, 0, respectively. When the primary lesion was malignant with lymph node metastasis, the probability of the secondary lesion being a metastatic tumor was higher than that without lymph node metastasis (46.7% vs. 30.0%, P>0.05). When the primary lesion was malignant and the primary and secondary lesions were located in the same lobe, the secondary lesions were more likely to metastasize (54.5%), while when they were located on different lobes on the same side or different sides, the secondary lesions were more likely to be benign (58.1%, 72.7%), and the possibility of metastasis was small ( 32.6%, 9.1%). When the primary lesion was benign and clinical differential diagnosis was difficult, the secondary lesion was benign. Conclusion    For synchronous multiple pulmonary nodules, the diameter of the primary lesion is large, the metastatic rate of secondary lesions tends to decrease. In ipsilateral synchronous multiple pulmonary nodules, especially with node metastasis, the risk of metastatic nodule increases. Bilateral surgical resection does not significantly increase the perioperative morbidity.

The learning curve of video-assisted thoracoscopic sleeve lobectomy in patients with central lung cancer / 中华胸心血管外科杂志

Objective To evaluate the learning curve of video-assisted thoracoscopic sleeve lobectomy in patients with central lung cancer.Methods A total of 86 consecutive patients with resected central lung cancer in the second department of thoracic surgery of Hunan Cancer Hospital between Apirl 2016 and July 2018 were retrospectively enrolled.Video-assisted tho-racoscopic tracheoplasty with sleeve resection and lobectomy were performed in 56 patients, video-assisted thoracoscopic tra-cheoplasty with wedge resection and lobectomy were performed in 20 patients, and 10 patients transit to thoracotomy.Surgical parameter of patients who underwent video-assisted thoracoscopic sleeve lobectomy were investigated to assess the learning curve, including operation duration, bleeding volume, amount of lymph nodes examined(medianstinal and intrapulmonary). Lowess smoothing method was performed to fit curve to evaluate the variation tendency of surgical parameters .Cut-off point, as well as the confidence interval, were identified using piecewise regression analysis.Results Surgical duration tend to be stable (almost 200 min) when the cumulative case amount of video-assisted thoracoscopic sleeve lobectomy reach 40.Surgical bleed-ing tend to be stable( almost 200 ml) when the cumulative case amount of video-assisted thoracoscopic sleeve lobectomy reach 20.There is no significant correlation between the amount of lymph node harvest and surgical volume .Conclusion The cut-off point for video-assisted thoracoscopic sleeve lobectomy is approximately 40 cases.

Research progress on PD-1/PD-L1 in the treatment of non-small cell lung cancer / 中国肿瘤临床

In recent years, immune therapy for the treatment of cancer has made remarkable progress. The monoclonal antibodies of programmed death-1 (PD-1) and programmed death-ligand 1 (PD-L1) have shown considerable responses and good tolerance in the treatment of non-small cell lung cancer (NSCLC). In this review, we summarized the current clinical status and future direction of PD-1/PD-L1 in NSCLC.

Analysis of the delay diagnosis and treatment of lung cancer initially expressed as solitary pulmonary nodules diagnosed by physical examination——162 cases report / 中华胸心血管外科杂志

Objective To analyze the delay in diagnosis and treatment lung cancer expressed as solitary pulmonary nodules (SPN) found by physical examination,and to discover the relative reasons and consequence for future improvement.Methods From January 2000 to August 2011,162 patients (93 males,69 females,ranging 33-82 years,median age 63.9 years) with SPN found by physical examination and diagnosed lung cancer by surgical pathology subsequently were enrolled to this study.Depending on the interval between the date when finding SPN and the date of surgery,these cases were divided into 6 groups,including the group with interval less than 1 month (74 patients),1-3 months (48 patients),3-6 months (10 patients),6-12 months (7 patients),12-24 months (8 patients),and more than 24 months (15 patients).Factors which impact the delay interval between SNP finding and surgery were discussed.The change of tumor' s diameter during observation period,and the pathological characters were also analyzed among each group.Results Of all the delay cases,30.2％ were attributed to doctor,30.9％ attributed to patients themselves,and 38.9％ attributed to hospitals.51.0％ (25/49) of the cases delayed by doctors were misdiagnosed as inflammation,16.3％ (8/49) misdiagnosed as tuberculosis,and 16.3％ (8/49)misdiagnosed as old lesions,which were three common reasons.Patients delayed more than 3 months were more likely to be related to doctor's misdiagnosis than those delayed less than 3 months[70.0％ (28/40) vs.36.8％ (21/57),x2 =10.338.P =0.001].Moreover,the possibility of SPN enlargement was positively correlated with the delay interval.In groups with delay interval more than 24 months or between 12 and 24 months,the percentage of SPN enlargement were 73.3％ (11/15) and 87.5％ (7/8) separately.The proportion of patients with stage IV disease in groups whose delay interval exceeded 12 months (13.3％ for more than 24 months and 12.5％ for 12-24 months) also significantly surpassed others groups with shorter delay interval.Conclusion There exists obvious delayed diagnosis and treatment in lung cancer initially expressed as solitary pulmonary nodules (SPN) during physical examination.Nearly 1/3 patients were delayed by doctors and half of them were misdiagnosed as inflammation.Increase of observation time could result in enlargement of SPN and advancement of disease staging.Thus,patients and doctors should pay more attention and clarify the diagnosis through surgery in less than 3 months after finding SPN,which could remarkably benefit early treatment.

Analysis of clinical and radiologic features of intrapulmonary lymph nodes / 中华胸心血管外科杂志

Objective To analysis the clinical radiologic features of intrapulmonary lymph nodes,and to improve the diagnostic rate of intrapulmonary lymph nodes.Methods From May 2008 to September 2011,16 cases of pulmonary nodules were proved pathologically as intrapulmonary lymph nodes,including 9 males and 7 females,with an average age of 58.2 years (39-73 years).All patients accepted chest X-ray and HR CT scan prior to operation,identified of 11 solitary nodules,3 multiple nodules,and other 2 cases of multiple nodules with synchronous ipsilateral lung cancer.We retrospectively review the data as follows:the population and clinical characters,the subjective imaging diagnosis,the imaging characters of the nodule location,size,texture,shape,border,distance from the nearest pleural surface,and the appearance of the surrounding pulmonary parenchyma et al.Results Clinically,six of all the 16 patients are or were cigarette smokers or had an exposure history of inhaled particles,three patients else were all from a same oilfield area although they denied having the Aforementioned history of smoke or exposure.Lung cancer,metastatic tumor,lung cancer intrapulmonary metastasis were the common subjective imaging diagnosis,with a misdiagnosis rate of 56.3％.Radiologically,these intrapulmonary nodules could be seen in the chest X-ray in half of the 16 patients,with a discovery rate of 50％ in chest X- ray screening.The median size of the intrapulmonary lymph nodes was 7.1 mm (4 - 11 mm),all nodules located below the level of the carina,87.5％ ( 14/16 cases) were solid nodules,68.75％ ( 11/16 cases) were round or ovate in shape with a sharp border.87.5％ ( 14/16 cases) were attached to the pleura or within 1 cm from the nearest pleural surface,87.5％ ( 14/16 cases) appeared linear densities extending from the intrapulmonary lymph nodes.The linear denshy referred to the CT imaging feature that a linear soft-tissue density extended from the intrapulmonary lymph nodes,distinct from the normal lung marking like interlobular septa and bronchovascular bundles,with a diameter less than 5 mm; spiculation were detected in only 2 of the 16 patients ; no calcification and mediestinal lymphadenopathy was detect in all the nodules.Pathologically,All nodules contained anthracotic pigment,and follicular hyperplasia were seen in 8 cases.Conclusion Intrapulmonary lymph nodes are rare benign pulmonary nodules possessing certain clinical and radiologic features.Intrapulmonary lymph nodes should be suspected for small subpleural nodules below the level of the carina.

The Value of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for the Diagnosis of Intrapulmonary Lesions / 中华胸心血管外科杂志

Objective To determine the value of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the diagnosis of intrapulmonary tumors located adjacent to the central airway.MethodsThe study was retrospective,from September 2009 to September 2011,33 patients with pulmonary masses located close to the central airways suspected to be lung cancer were accessed by EBUS-TBNA.Conventional bronchoscopic biopsy before EBUSTBNA was nondiagnostic in all cases.If EBUS-TBNA did not result in a formal pathological diagnosis of malignancy,patients were subsequently referred for a surgical procedure.ResultsOf the 33 patients,EBUS-TBNA confirmed lung cancer in 29 cases (4 small cell lung cancer,25 non-small cell lung cancer).Four patients were not confirmed by EBUS-TBNA,3 cases were diagnosed as squamous cell carcinoma by thoracoscoopy or thoracotomy,the other one was a pulmonary inflammatory lesion diagnosed by thoracoscopy.The sensitivity,specificity,accuracy,negative predictive value and positive predictive value of EBUS-TBNA for the diagnosis of intrapulmonary lesions was 90.2％,100％,90.9％,25％,and 100％,respectively.The procedure was uneventful,and there were no complications.ConclusionEBUS-TBNA is an effective tool with a high yield for the diagnosis of intrapulmonary lesions located adjacent to the central airway.

Clinical verification and application of mathematical models for predicting the probability of malignant or benign in patients with solitary pulmonary nodules / 中华胸心血管外科杂志

Objective Based on the mathematical models established in Department of Thoracic Surgery of Peking University People's Hospital for predicting malignant probability for solitary pulmonary nodules ( SPN),another continuous 145 patients with SPN were assessed to verify the accuracy of the model comparing with foreign models (Mayo model and VA model).Methods A retrospective cohort study in our institution included 145 patients with definite pathological diagnosis of SPN from Oct 2009 to Aug 2011,72 males and 73 females,average age (59.4 ± 12.2 ) years old.Clinical data included age,gender,course of disease,symptoms,history and quantity of smoking,time of smoking cessation,history of tumor,family history of tumor,tumor site,diameter,calcification,speculation,border,lobulation,traction of pleural,vascular convergence sign,and cavity.These raw data were incorporated into our model,Mayo model and VA model,the probability of malignant in every patient was calculated separately according to methods described before.The sensitivity and specificity of these 3 models were evaluated then.Afterwards,calibration of the 3 models was assessed by the Hosmer-Lemeshow (H-L) test.Discrimination was tested by calculating the area under curve ( AUC ) after the receiver operating characteristic (ROC) curve was drawn.Results 32.4％ (47 in 145 patients) of the nodules were malignant,and 67.6％ (98 in 145 patients) were benign in this group.Verified the accuracy of our model with sensitivity of 94.9％,specificity of 66.0％,positive predictive value of 85.3％ and negative predictive value of 86.1％.The H-L test showed good fitting in all models ( P ＞0.05 ).The AUC for our model was 0.874 ±0.035,and 0.784 ± 0.041 in Mayo model (P =0.004 compared to our model),0.754 ± 0.041 in VA model (P =0.002 compare to our model).And,there was not significant statistical difference between Mayo model and VA model (P ＞0.05 ).Our model has the best precision indexed by AUC,which were statistically significant differential compared with Mayo model and VA model.Conclusion The model established by our center has superior value than foreign counterparts in predicting the probability of malignant or benign in patients with SPN.

Endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of thoracic sarcoidosis / 中华胸心血管外科杂志

Objective To evaluated the role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of thoracic sarcoidosis.Methods The study was retrospective,from September 2009 to June 2011,35 patients with suspected sarcoidosis,with enlarged hilar or mediastinal lymph nodes on computed tomography ( ≥1.0 cm),underwent EBUS-TBNA.Patients in whom EBUS-TBNA was nondiagnostic subsequently underwent surgical biopsy or a minimum of 6 months clinical and radiologic follow-up.Results EBUS-TBNA was performed on a total of 87 lymph node stations in 35 patients.Of the enlarged lymph nodes,64 (73.6％) were located in the mediastinal region and the remaining 23 ( 26.4％ ) around the hilar or interlobar area.A final diagnosis of sarcoidosis was made for 28 (80％) of the patients.In patients with a final diagnosis of sarcoidosis,EBUS-TBNA demonstrated noncaseating epithelioid cell granulomas in 25 ( 89.3％ ) of the patients.EBUS was well tolerated by all of the patients with no complications.Conclusion EBUS-TBNA is a safe procedure with a high yield for the diagnoses of thoracic sarcoidosis of stage Ⅰ or Ⅱ.

Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of thoracic diseases / 中华胸心血管外科杂志

Objective To review the experience d EBUS-TBNA for staging of lung cancer and the value in diagnosing thoracic diseases in our single center.Methods The data of 343 patients who underwent EBUS-TBNA from September 2009 to August 2011 in our institution were retrospectively reviewed.There were 219 males and 124 females with an average age of (59.4 ± 13.6 ) years.Based on their primary indication,patyients were divided into three categories:group A:with known or strongly suspected lung cancer and enlarged mediastinal lymph nodes on chest radiographic examination ( short axis ≥ 1.0cm) ; group B:with enlarged mediastinal lymph nodes or mediastinal masses of unknown origin; and group C:with pulmonary parenchymal mass located close to the central airways.Results The average short axis diameter of the thoracic lesions was ( 1.94 ± 1.01 ) cm ( range from 0.5 to 8.0cm),and 2.66 punctures were performed per lesion.In group A ( n =208 ),151 patients were confirmed to have mediestinal lymph nodes metastasis while 51 showed negative results.Four patients were diagnosed as tuberculosis and two were confirmed to be stage Ⅱ sarcoidosis.37 in the 51 patients with negative EBUS-TBNA underwent thoracoscopic or thoracotomy for pulmonary resection and mediastinal lymph node dissection.Postoperative pathology confirmed that 32 patients did not have lymph nodes metastases.The diagnostic sensitivity,specificity,accuracy,positive predictive and negative predictive of EBUS-TBNA for the mediastiral staging of lung cancer were 96.8％ (151/156),100.0％ (32/32),97.3％ ( 183/188 ),100％ ( 151/151 ) and 86.5％ (32/37),respectively.In group B ( n =94),22 patients had malignancy and 72 had benign diseases.Thirteen patients received operative validation in the 23 cases which were diagnosed as proliferative lymph nodes by EBUS-TBNA,and by further operation two and three patients were confirmed as malignancy and other benign diseases respectively.The sensitivity,negative predictive value ( NPV ) and accuracy of EBUS-TBNA in distinguishing malignant mediastinal diseases was 88.0％ (22/25)、100％ (73/73) 、95.9％ (70/73)and 97.9％ (92/94),respectively.In group C( n =41 ),malignant diagnosis was achieved in 33 patients,while 4 patients confirmed as malignancy by further operations in the other 8 negative cases.The diagnostic sensitivity and accuracy of EBUS-TBNA for the diagnosis of unknown pulmonary parenchymal mass were 89.2％ (33/37) and 90.2％ (37/41),respectively.All the procedures were uneventful and no complication occurred.Conclusion EBUS-TBNA is a highly effective and safe procedure in the diagnosis of thoracic diseases and staging.of lung cancer.

Study on solitary pulmonary nodules: correlation between diameter and clinical manifestation and pathological features / 中国肺癌杂志

<p><b>BACKGROUND AND OBJECTIVE</b>Solitary pulmonary nodules (SPN) is a knotty problem in clinical work. The clinical manifestation and pathological features of SPN in sizes may be obviously different. The aim of this study is to analyze the relationship between the diameters and clinicopathologic characteristics of SPN.</p><p><b>METHODS</b>390 patients (212 male, 178 female, ranging from 17 years to 86 years, median age 57.1 years) with SPN who were postoperatively diagnosed by pathology between Jan. 2000 and Jun. 2009 are enrolled to this study. In these cases, the number of SPN diameters which are smaller than 0.5 cm (including 0.5 cm) (group A) is 16, between 0.5 cm and 1 cm (including 1 cm, not including 0.5 cm) (group B) is 58, between 1 cm and 2 cm (group C) is 163, and between 2 cm and 3 cm (group D) is 153. The clinical manifestation, and postoperative pathological characters are analyzed in various diameter ranges.</p><p><b>RESULTS</b>All procedures were carried out securely, including tumor enucleation (n = 20), wedge resection (n = 153), lobectomy (n = 217). There are 130 benign cases (33.3%) and 260 malignant cases (66.7%). 58.5% SPN are detected incidently with no symptoms. There is an increasing incidence of clinical symptoms as the increasing diameter of SPN. All the cases are divided into 4 groups, the prevalence of malignant are separated 43.7% (group A), 50.0% (group B), 63.2% (group C), 79.1% (group D). The diameter of SPN is positively correlated with incidence of malignancy (chi2 = 22.535, P < 0.001). Single factor analysis and Logistic regression analysis show the diameter of SPN is an independent risk factor of malignant pathology (OR = 1.922, P < 0.001). Fourteen patients in all of the SPN were followed up by 2 years or more before operation, and 10 of them turn out to be malignant at last. In the 14 patients, 7 cases were found not enlarged by CT scan, and 3 of them (42.9%) were malignant.</p><p><b>CONCLUSION</b>The diameter of SPN is highly associated with clinical symptoms, and is a significant risk factor to predict pathology. Early diagnosis and treatment is so important for patients with SPN.</p>

Solitary pulmonary nodules: a risk factor analysis / 中华胸心血管外科杂志

0bjective Evaluate the clinical factors affecting the definite pathological diagnosis of solitary pulmonary odules(SPN).Methods From Jan 2000 to July 2009,390 patients(212 men,178 women,median age 57.1 years,range from 17 to 86 years)got definite pathological diagnosis of solitary pulmonary nodules in our Institute were investigated.All following clinical data were collected:age,gender,course of disease,symptoms,history and quantity of smoking,history of tumor,family history of tumor,site,diameter,calcification,spicular sign,border,lobulated,traction of pleural,vascular convergence sign,lymph nodes of mediastinum,adhesion,depression of pleural,pleural effusion.Results The surgical procedures included 20 tumor enucleation,153 wedge resection,and 217 lobectomy.There were 130 benign lesions,including hamartoma(n=33),arteriovenous istula(n=1),cyst(n=2),interstitial pneumonia(n=1),tuberculoma(n=49),lymphoproliferative(n=2),fungal ball(n=3),neurofibroma(n=1),inflammatory pseudotumor(n=27),sclerosing hemangioma(n=9),bronchiectasis(n=2).260 were malignant lesions,including Alveolar cell carcinoma(n=23),Metastatic carcinoma(n=20),Carcinoid(n=4),Squamous cell carcinoma(n=40),adenecarcinoma(n=164),Small cell carcinoma(n=9).Single factor analysis and Logistic regression analysis show that there were significant differences in age, diameter,border,calcification and depression of pleural in judgement character of SPN.In addition,there were no differences in gender,course of disease,symptoms,history and quantity of smoking,history of tumor,family history of tumor,site,spicu lar sign,lobulated,traction of pleural,vascular convergence sign,lymph nodes of mediastinum,adhesion and pleural effusion.Conclusion Age of patient,and diameter,border,calcification,pleural depression of the tumor were significant risk factors in judgment character of SPN.