Early Outcomes of Robotic Versus Video-Assisted Thoracoscopic Anatomical Resection for Lung Cancer.

BACKGROUND: We compared the safety and effectiveness of robotic anatomical resection and video-assisted thoracoscopic surgery (VATS). METHODS: A retrospective analysis was conducted of the records of 4,283 patients, in whom an attempt was made to perform minimally invasive anatomical resection for lung cancer at Seoul National University Hospital from January 2011 to July 2020. Of these patients, 138 underwent robotic surgery and 4,145 underwent VATS. Perioperative outcomes were compared after propensity score matching including age, sex, height, weight, pulmonary function, smoking status, performance status, comorbidities, type of resection, combined bronchoplasty/angioplasty, tumor size, clinical T/N category, histology, and neoadjuvant treatment. RESULTS: In total, 137 well-balanced pairs were obtained. There were no cases of 30-day mortality in the entire cohort. Conversion to thoracotomy was required more frequently in the VATS group (VATS 6.6% vs. robotic 0.7%, p=0.008). The complete resection rate (VATS 97.8% vs. robotic 98.5%, p=1.000) and postoperative complication rate (VATS 17.5% vs. robotic 19.0%, p=0.874) were not significantly different between the 2 groups. The robotic group showed a slightly shorter hospital stay (VATS 5.8±3.9 days vs. robotic 5.0±3.6 days, p=0.052). N2 nodal upstaging (cN0/pN2) was more common in the robotic group than the VATS group, but without statistical significance (VATS 4% vs. robotic 12%, p=0.077). CONCLUSION: Robotic anatomical resection in lung cancer showed comparable early outcomes when compared to VATS. In particular, robotic resection presented a lower conversion-to-thoracotomy rate. Furthermore, a robotic approach might improve lymph node harvesting in the N2 station.

Radiological and clinical features of screening-detected pulmonary invasive mucinous adenocarcinoma.

OBJECTIVES: The current understanding of pulmonary invasive mucinous adenocarcinoma is largely based on studies of advanced stage patients and data about early-stage invasive mucinous adenocarcinoma are sparse. We evaluated the radiological and clinical features of screening-detected early-stage invasive mucinous adenocarcinoma (SD-IMA). METHODS: Data from 91 patients who underwent surgical treatment for SD-IMA (≤3 cm) from 2013 to 2019 were reviewed retrospectively. Data on radiological characteristics, clinicopathological findings, recurrence and survival were obtained. Disease-free survival rate was analysed. RESULTS: Radiologically, SD-IMAs presented as a pure ground-glass nodule (6.6%), part-solid nodule (38.5%) or solid (54.9%). Dominant locations were both lower lobes (74.7%) and peripheral area (93.4%). The sensitivity of percutaneous needle biopsy was 78.1% (25/32). Lobectomy was performed in 70 (76.9%) patients, and sublobar resection in 21 (23.1%) patients. Seventy-three (80.2%), 15 (16.5%) and 3 (3.3%) patients had pathological stage IA, IB and IIB or above, respectively. Seven patients developed recurrence, and 3 died due to disease progression. Pleural seeding developed exclusively in 2 patients who underwent needle biopsy. The 5-year disease-free survival rate was 89.4%. The disease-free survival rates at 5 years were 86.3% in the lobectomy group and 100% in the sublobar resection group. CONCLUSIONS: SD-IMAs were mostly radiologically invasive nodules. SD-IMAs showed favourable prognosis after surgical treatment.

Electromagnetic Navigation Bronchoscopy-Guided Dye Marking for Localization of Pulmonary Nodules.

BACKGROUND: Electromagnetic navigation bronchoscopy (ENB)-guided dye marking is a useful localization method for small pulmonary nodules. This study evaluated the efficacy and safety of intraoperative full virtual ENB-guided dye marking. METHODS: Patients who underwent full virtual ENB-guided dye marking without adjunct intraoperative imaging (fluoroscopy or cone-beam computed tomography) for small pulmonary nodules were investigated retrospectively. Efficacy was evaluated on the basis of the success rates of dye marking (visible dye mark) and nodule localization, and safety was evaluated on the basis of the rate of ENB-related complications. RESULTS: ENB-guided dye marking was performed on 164 nodules in 134 patients. Twenty-seven patients (20.1%) had multiple nodules. The total number of dye marking attempts was 241, and the mean number of markings per nodule was 1.5 ± 0.7. The mean ENB procedure duration was 29.4 ± 15.7 minutes. No ENB-related complications were observed. The success rate of dye marking was 86.7% (209 of 241) and that of localization was 94.5% (155 of 164). Among 63 nodules with multiple dye marking attempts, 62 (98.4%) were successfully localized. In 101 nodules with a single dye marking attempt, 87 (86.1%) were localized with the visceral pleural dye mark. In addition, 6 nodules (5.9%) could be localized with the needle hole on the visceral pleura. The number of dye marking attempts was a significant factor in the success of localization (1.5 ± 0.7 vs 1.1 ± 0.3, P = .01). CONCLUSIONS: Full virtual ENB-guided dye marking was effective and safe for the localization of small pulmonary nodules. A multiple dye marking strategy is recommended to achieve a high success rate.

Overexpression of Populus transcription factor PtrTALE12 increases axillary shoot development by regulating WUSCHEL expression.

The TALE (Three Amino acid Loop Extension) transcription factor family has been shown to control meristem formation and organogenesis in plants. To understand the functional roles of the TALE family in woody perennials, each of the TALE members of Populus trichocarpa was overexpressed in Arabidopsis as a proxy. Among them, the overexpression of PtrTALE12 (i.e., 35S::PtrTALE12) resulted in a dramatic increase of axillary shoot development with early flowering. Interestingly, expression of WUSCHEL (WUS), a central regulator of both apical and axillary meristem formation, was significantly increased in the 35S::PtrTALE12 Arabidopsis plants. Conversely, WUS expression was downregulated in 35S::PtrTALE12-SRDX (short transcriptional repressor domain) plants. Further analysis found that PtrTALE12, expressed preferentially in meristem tissues, directly regulates WUS expression in transient activation assays using Arabidopsis leaf protoplast. Yeast two-hybrid assays showed that PtrTALE12 interacts with SHOOT MERISTEMLESS (STM); however, the interaction does not affect the WUS expression. In addition, expression of both CIRCADIAN CLOCK ASSOCIATED1 (CCA1) and LATE ELONGATED HYPOCOTYL (LHY) genes was suppressed accordingly for early flowering 35S::PtrTALE12 Arabidopsis. Indeed, transgenic poplars overexpressing PtrTALE12 as well as Arabidopsis plants overexpressing AtBLH11, a close homolog of PtrTALE12, phenocopied the 35S::PtrTALE12 Arabidopsis (i.e., increased axillary shoot development). Taken together, our results suggest that PtrTALE12 functions as a positive regulator of axillary shoot formation in both Arabidopsis and poplar.

The robotic thymectomy via the subxiphoid approach: technique and early outcomes.

OBJECTIVES: Robotic thymectomy via the subxiphoid approach (RTX) is a recently introduced surgical approach. This study aimed to report on the surgical technique and early outcomes of RTX in our institute. METHODS: RTX was performed using the 3-arm technique in the da Vinci robotic surgical system. The camera was inserted into a subxiphoid port, and 2 robotic arms were inserted in bilateral intercostal ports. A complete dissection of both cervical poles up to the thyroid gland was conducted, and bilateral phrenic nerves were identified in all cases. Radical combined resection of adjacent organs, including the lung, pericardium, phrenic nerve and the innominate vein, was performed if necessary. The resected specimen could be retrieved through the subxiphoid port site. RESULTS: A total of 110 patients underwent RTX in our institute from October 2016 to August 2019. Thymoma was the most common diagnosis (60.9%), and the mean size of the tumours was 4.9 ± 2.4 cm. Combined resection was performed in the lung (n = 9, 8.1%), pericardium (n = 6, 5.5%) and innominate vein (n = 5, 4.5%). There were 2 minor postoperative complications (1.8%), and the mean length of hospital stay was 2.2 ± 1.4 days. For the cumulative sum curve analysis of the learning curve using operative time, 50 cases were necessary to gain proficiency. CONCLUSIONS: RTX was a safe and feasible surgical approach, even in advanced thymic epithelial tumours. It should be considered one of the valuable surgical options in minimally invasive thymectomy.

Do Blebs or Bullae on High-Resolution Computed Tomography Predict Ipsilateral Recurrence in Young Patients at the First Episode of Primary Spontaneous Pneumothorax?

BACKGROUND: The relationship between the size of bullae and pneumothorax recurrence is controversial. The aim of this study was to retrospectively evaluate the role of blebs or bullae in predicting ipsilateral recurrence in young patients experiencing their first episode of primary spontaneous pneumothorax (PSP) who underwent conservative treatment. METHODS: A total of 299 cases of first-episode PSP were analyzed. The status of blebs or bullae was reviewed on high-resolution computed tomography (HRCT). The dystrophic severity score (DSS; range, 0 to 6 points) was calculated based on HRCT. RESULTS: The 5-year recurrence rate was 38.2%. In univariate analysis, age (<20 years), body mass index (<20 kg/m2), a unilateral lesion, and intermediate risk (DSS 4 and 5) were associated with recurrence. Sex; smoking history; and the presence, number, and maximal size of blebs or bullae were not related to recurrence. In Cox regression, age and intermediate risk were independent risk factors for recurrence. High risk (DDS 6) was not an independent risk factor. CONCLUSION: The presence, number, and size of blebs or bullae did not affect ipsilateral recurrence. DSS failed to show a positive correlation between severity and recurrence. The decision to perform surgery in patients experiencing their first episode of PSP should not be determined by the severity of blebs and bullae.

Primary Pulmonary Chordoid Meningioma.

Primary pulmonary meningioma is a rare disease, and chordoid meningioma is an uncommon variant of meningioma in the central nervous system (CNS) with a high recurrence rate. We report a case of primary pulmonary chordoid meningioma that presented as a solitary pulmonary nodule (SPN). The SPN was resected by thoracoscopic wedge resection and was revealed to have characteristics of chordoid meningioma. After confirming the absence of a meningioma in the CNS by brain imaging, the nodule was diagnosed as a primary pulmonary chordoid meningioma. The patient remained disease-free after 26 months postoperatively. To our knowledge, this is the third case of primary pulmonary chordoid meningioma to be reported.

Efficacy of EUS-guided and ERCP-guided biliary drainage for malignant biliary obstruction: prospective randomized controlled study.

BACKGROUND AND AIMS: ERCP-guided biliary drainage (ERCP-BD) is a criterion standard treatment for malignant biliary obstruction when curative surgery is not an option. Alternative methods such as percutaneous transhepatic biliary drainage would significantly lower the quality of life. EUS-guided biliary drainage (EUS-BD) has been developed and performed by experienced endoscopists. Therefore, the aims of this study were to evaluate the efficacy and safety of EUS-BD compared with ERCP in malignant biliary obstruction. METHODS: The prospective randomized controlled study was conducted, and 30 patients were enrolled: 15 for each EUS-BD and ERCP-BD arms. The technical success, procedural time, clinical success, and adverse events were evaluated. RESULTS: Thirty patients had extrahepatic malignant biliary tract obstruction (19 men, 11 women). Twenty-seven patients had unresectable pancreatic ductal adenocarcinomas, 1 patient had distal common bile duct cancer, and 2 patients had metastatic malignant lymphadenopathy. There were no significant differences both in terms of technical success rate and clinical success rate (100% vs 93% and 93% vs 100% in ERCP-BD vs EUS-BD, respectively; P = 1.00, P = 1.00). Four patients (31%) had tumor ingrowth-caused stent dysfunction in the ERCP-BD group, whereas 2 patients had food impaction and 2 patients had stent migration in the EUS-BD group. No significant procedure-related adverse events occurred in either group. CONCLUSIONS: This prospective randomized controlled study suggests that EUS-BD has similar safety to ERCP-BD. EUS-BD was not superior to ERCP-BD in terms of relief of malignant biliary obstruction. EUS-BD may have fewer cases of tumor ingrowth but may also have more cases of food impaction or stent migration. (Clinical trial registration number: NCT01421836.).

Poplar MYB transcription factor PtrMYB012 and its Arabidopsis AtGAMYB orthologs are differentially repressed by the Arabidopsis miR159 family.

A phenotype-based screening of the T1 transgenic Arabidopsis population transformed by overexpression constructs of the entire poplar MYB transcription factor family found that overexpression of a poplar MYB transcription factor, PtrMYB012, in Arabidopsis resulted in upwardly curled rosette leaves, dwarfism and male sterility. Sequence analysis identified that PtrMYB012 is homologous to the Arabidopsis GAMYB genes (e.g., AtMYB65 and AtMYB33). Gene expression analysis revealed that PtrMYB012 is specifically expressed in floral tissues, especially in male catkins, similar to AtMYB65. It was well known that Arabidopsis GAMYBs are negatively regulated by microRNA159 (miR159) during vegetative growth; thus, the typical phenotypes of upwardly curled leaves, dwarfism and male sterility were only shown in overexpression of GAMYBs with mutations in the miR159 target sequence. To confirm our phenotypic consequences, we independently re-produced transgenic Arabidopsis plants overexpressing PtrMYB012 without mutations in the miR159 target sequence. The resulting 35 S::PtrMYB012 Arabidopsis plants phenocopied the previous transgenic Arabidopsis plants, suggesting that PtrMYB012 is probably not a target of Arabidopsis miR159 despite containing the conserved miR159 target sequence. To gain further insight, we produced transgenic poplars overexpressing the intact PtrMYB012. As a result, no conspicuous phenotype was found in 35 S::PtrMYB012 poplar plants. These results suggest that PtrMYB012 transcripts are down-regulated by miR159 in poplar but not in Arabidopsis. Indeed, subsequent 5'-RACE analysis confirmed that PtrMYB012 transcripts are completely degraded in poplar, probably by miR159, but not in Arabidopsis. These results suggest that species-specific family members of miR159 are important for the regulation of normal growth and development in plants.

Positive Emotional Effects of Leisure in Green Spaces in Alleviating Work-Family Spillover in Working Mothers.

Studies have shown that family and work spillover affects well-being and that leisure activities can alleviate the negative effects of work-related stress on health. However, few studies have focused on investigating the effects of specific leisure activities among specific populations. To examine whether leisure activities in green spaces can promote individual recovery processes and alleviate the effects of work and family spillover on positive emotions, this study applied the effort-recovery model to a population of working mothers. Through online and paper questionnaires, sample data were collected from 221 working mothers in Taiwan. Structural equation modeling was used to test the experimental hypothesis, and mediation analysis was used to determine whether leisure in green spaces is a mediating factor. The results indicated that leisure in green spaces is a mediator of the relationship of negative work and family spillover with positive emotions. In addition, strolls and park visits were found to provide greater psychological benefits to working mothers, compared with picnics.

Bone Tunnel Diameter Measured with CT after Anterior Cruciate Ligament Reconstruction Using Double-Bundle Auto-Hamstring Tendons: Clinical Implications.

OBJECTIVE: To evaluate the correlation between bone tunnel diameter after anterior cruciate ligament (ACL) reconstruction measured by computed tomography (CT) using multiplanar reconstruction (MPR) and stability or clinical scores. MATERIALS AND METHODS: Forty-seven patients (41 men and 6 women, mean age: 34 years) who had undergone ACL reconstruction with the double bundle technique using auto-hamstring graft and had subsequently received CT scans immediately after the surgery (T1: range, 1-4 days, mean, 2.5 days) and at a later time (T2: range, 297-644 days, mean, 410.4 days) were enrolled in this study. The diameter of each tunnel (two femoral and two tibial) at both T1 and T2 were independently measured using MPR technique by two radiologists. Stability and clinical scores were evaluated with a KT-2000 arthrometer, International Knee Documentation Committee objective scores, and the Lysholm score. Statistical analysis of the correlation between the diameter at T2 or the interval diameter change ratio ([T2 - T1] / T1) and clinical scores or stability was investigated. RESULTS: The tibial bone tunnels for the anteromedial bundles were significantly widened at T2 compared with T1 (observer 1, 0.578 mm to 0.698 mm, p value of < 0.001; observer 2, 0.581 mm to 0.707 mm, p value of < 0.001). There was no significant correlation between the diameter at T2 and stability or clinical scores and between the interval change ratio ([T2 - T1] / T1) and stability or clinical scores (corrected p values for all were 1.0). Intraobserver agreement for measurements was excellent (> 0.8) for both observers. Interobserver agreement for measurement was excellent (> 0.8) except for the most distal portion of the femoral bone tunnel for anterior medial bundle in immediate postoperative CT, which showed moderate agreement (concordance correlation coefficient = 0.6311). CONCLUSION: Neither the diameter nor its change ratio during interval follow-up is correlated with stability or clinical scores.

Clinical significance of serum CA-125 in Korean females with ascites.

PURPOSE: Mycobacterium tuberculosis is endemic in Korea. Because tuberculous peritonitis is characterized by ascites, abdominal pain, abdominal mass and elevation of serum CA-125, it can be confused with ovarian malignancies. The aim of this study was to evaluate the significance of serum CA-125 level in the differential diagnosis of tuberculous peritonitis and ovarian malignancy in a Mycobacterium tuberculosis-endemic area. MATERIALS AND METHODS: The medical records of patients diagnosed with tuberculous peritonitis (n=48) or epithelial ovarian malignancy (n=370) at Samsung Medical Center from January 2000 to October 2009 were retrospectively reviewed. RESULTS: Median serum CA-125 level in the epithelial ovarian cancer group was significantly higher than that in the tuberculous peritonitis group (p ≤ 0.01). Only one patient (2.1%) in the tuberculous peritonitis group had a serum CA-125 level over 2000 U/mL. However, 109 patients (29.5%) in the epithelial ovarian cancer group had a serum CA-125 level over 2000 U/mL. At the CA-125 ranges of 400 to 599 and 600 to 799, the proportions of those with tuberculous peritonitis were 24% and 21.9%, respectively. At a serum CA-125 level over 1000 U/mL, however, the proportion of tuberculous peritonitis was much lower (2.1%). CONCLUSION: Tuberculous peritonitis should be considered in the evaluation of female patients with ascites and high serum CA-125.

A clinical predictor of varices and portal hypertensive gastropathy in patients with chronic liver disease.

BACKGROUND/AIMS: The aim of this study was to identify the parameters that could noninvasively predict the presence of esophageal/gastric varices and portal hypertensive gastropathy (PHG) in patients with chronic liver disease (CLD), and to determine the accuracy of those parameters. METHODS: We retrospectively analyzed 232 patients with CLD who underwent both upper endoscopy and liver CT within an interval of 3 months. The multidimensional index (M-Index) for spleen volume was obtained from the multiplication of splenic length, width, and thickness, as measured by computer tomography. RESULTS: The multivariate analysis revealed that platelet, albumin, and M-Index were independently associated with the presence of varices and PHG. We combined three independent parameters, and developed a varices and portal hypertensive gastropathy (VAP) scoring system (=[platelet count (/mm(3))×albumin (g/dL)]/[M-Index (cm(3))]). The area under the receiver operating characteristic curve of the VAP score was 0.850 (95% confidence interval, 0.801-0.899). The VAP cut-off value of 861 had a sensitivity of 85.3%, a positive likelihood ratio of 3.17, and a negative predictive value of 86.4%. For predicting high-risk lesions for bleeding, with a cut-off value of 861 the sensitivity was 92.0%, the positive likelihood ratio was 2.20, and the negative predictive value was 96.4%. CONCLUSIONS: The VAP score can predict the presence of varices and PHG in patients with CLD and may increase the cost-benefit of screening endoscopy in the clinical practice setting. A prospective validation study is necessary in the future.

Comparison of usefulness of clinical diagnostic criteria for hepatocellular carcinoma in a hepatitis B endemic area.

BACKGROUND/AIMS: We compared the accuracy and usefulness of clinical diagnostic criteria for hepatocellular carcinoma in a hepatitis B virus (HBV)-endemic area. METHODS: We reviewed the medical records of 355 patients who had undergone liver resection or biopsy at our institution between January 2008 and December 2009. These patients were reevaluated using four noninvasive diagnostic criteria for hepatocellular carcinoma proposed by the European Association for the Study of the Liver (EASL), the American Association for the Study of Liver Diseases (AASLD), the Korean Liver Cancer Study Group and the National Cancer Center (KLCSG/NCC), and National Comprehensive Cancer Network (NCCN) guidelines. RESULTS: The overall sensitivity was highest using the KLCSG/NCC criteria (79.8%), followed by the AASLD (51.5%), EASL (38.4%), and NCCN (10.1%; P<0.001) criteria, whereas the specificity (84.5-98.3%) and positive predictive value (96.2-98.3%) were similar for all of the criteria. The KLCSG/NCC criteria had an acceptable false-positive rate and the highest sensitivity among all of the patients, including those positive for HBsAg, those without liver cancer, and those with a tumor of at least 2 cm. CONCLUSIONS: The KLCSG/NCC and AASLD criteria exhibited the highest sensitivity, and all four guidelines had a high specificity among all of the patients. Based on the sensitivity and false-positive rate, the KLCSG/NCC criteria was the most useful in the majority of patients. Inclusion of HBV infection in the clinical diagnostic criteria for hepatocellular carcinoma would be reasonable and may lead to an improvement in the sensitivity, with acceptable false-positive rates, in HBV-endemic areas.

Characteristics of Killian-Jamieson diverticula mimicking a thyroid nodule.

BACKGROUND: Killian-Jamieson (K-J) diverticula have been incidentally detected on neck ultrasonography and could be misdiagnosed as thyroid nodules. The purpose of this study was to define the clinical and ultrasonographic characteristics of K-J diverticula. METHODS: We analyzed 13 patients with K-J diverticula mimicking thyroid nodules including 4 of our patients and 11 previously reported cases between 1984 and August 2009. RESULTS: Seven patients (54%) were women, and all patients were asymptomatic. The average lesion's diameter was 1.5 cm (range, 0.5-4.0). Most of the lesions (92%) were located in the left thyroid lobe. Ultrasonography showed heterogeneous echogenic masses with echogenic foci and hypoechoic rims. A connection with the adjacent esophageal wall was found in 7 diverticula (54%) at the time of initial diagnosis. CONCLUSION: The K-J diverticula had unique ultrasonographic findings. Awareness of the fact that K-J diverticula can be misdiagnosed as thyroid nodules is important to avoid unnecessary interventions.

Frontal sinus lymphoma presenting as progressive multiple cranial nerve palsy.

Primary frontal sinus lymphoma is a very uncommon disease. In all the previously reported cases, the presenting symptoms have been due to the tumor mass effect. We present an unusual case report of an immunocompetent patient who presented with facial palsy, and then progressively developed other cranial nerve palsies over several months. He was later diagnosed with diffuse large B cell lymphoma originating from the frontal sinus. The patient underwent chemotherapy, but eventually had to receive autologous peripheral blood stem cell transplantation. He is currently disease-free. The clinical course, diagnostic workup, and therapeutic outcome are described.

Concurrent endobronchial carcinoid tumor and sarcoidosis.

Sarcoidosis is an inflammatory disease of unknown cause which is characterized by the presence of noncaseating granulomas. The association of sarcoidosis with malignancy has been an issue and remains controversial. We herein report endobronchial carcinoid tumor in a patient with sarcoidosis diagnosed by nasal mucosal biopsy, excisional biopsy of cervical lymph nodes and mediastinal lymph node dissection.