Importance of tumor size in resectable stage III-N2 non-small cell lung cancer.

OBJECTIVE: The 8th TNM edition classifies stage III-N2 disease as IIIA and IIIB based on a tumor size cutoff of 5 cm. However, the importance of tumor size on survival in patients with resectable stage III-N2 disease has not been analyzed systematically. METHODS: Survival analysis based on tumor size (>5 cm vs ≤ 5 cm) for 255 consecutive patients with nonbulky (maximal lymph node diameter of 1.5 cm) stage III-N2 non-small cell lung cancer treated with surgery in our institution. RESULTS: Ninety patients (35.3%) underwent induction chemoradiation therapy (n = 72, 28%) or induction chemotherapy (n = 18, 7%), and 165 patients underwent primary surgery followed by adjuvant chemotherapy (n = 52, 32%), adjuvant chemoradiation therapy (n = 47, 29%), or adjuvant radiation therapy (n = 14, 13.2%). After a median follow-up of 6.5 years, the overall survival was 46.5% at 5 years and 28.9% at 10 years. In tumors 5 cm or less, there was no difference in survival between patients treated with induction or adjuvant therapy. However, in tumors greater than 5 cm, the survival was significantly better after induction therapy compared with adjuvant therapy or surgery alone. Pathologic multi-station N2 disease was more frequently detected in tumors greater than 5 cm (31% vs 18% in tumors ≤5 cm, P = .042), and the rate of R1 resection was lower after induction therapy (2.2% vs 8.5% in primary surgery, P = .048). CONCLUSIONS: These results support the redefinition of tumors greater than 5 cm with resectable N2 disease to stage IIIB. This change should help to refine the multimodality approach for stage III-N2 lung cancer.

The painless combination of anatomically contoured titanium plates and porcine dermal collagen patch for chest wall reconstruction.

BACKGROUND: A plethora of new biomaterials and dedicated rib fixator implant systems have been introduced into the field of chest wall reconstruction. The aim of our study is to evaluate the surgical outcomes of a novel combination of the anatomically contoured titanium rib implant and porcine dermal collagen patch for chest wall reconstruction. METHODS: We performed a retrospective review of eight consecutive patients who underwent chest wall resection and reconstruction between January 2014 to August 2015 in a single institution. MatrixRib Fixation System and Permacol Surgical Implant were utilized to achieve chest wall reconstruction. RESULTS: The indication for reconstruction was malignant infiltration in 50% of patients. Three other subjects (37.5%) had chest wall resections to achieve adequate and safe surgical exposure. One patient had a right lung apical mycetoma with chest wall invasion. All patients underwent lung resections with the removal of 2 to 6 (median 3) ribs. Reconstruction was performed using the MatrixRib system, with a median of 2.5 (range, 2-4) ribs fixed in each patient. There was no post-operative mortality. One patient had a superficial wound infection which resolved with one week of oral antibiotics. Upon discharge, the pain scores were near zero with minimal analgesic requirements. None of the patients required repeat surgery or removal of their implants. CONCLUSIONS: Our early experience indicates that the combination of the MatrixRib system and Permacol patch for chest wall reconstruction is safe and feasible with promising results in terms of anatomical restoration of the chest wall mechanics, infection and pain.

Primary pulmonary lymphoepithelioma-like carcinoma in Singapore.

BACKGROUND: Primary pulmonary lymphoepithelioma-like carcinoma (PPLELC) is a rare subtype of nonsmall cell lung cancer (NSCLC) predominantly reported in East Asia. We aimed to evaluate clinical characteristics, diagnosis, treatment, and prognosis of PPLELC in Singapore. METHODS: Retrospective review of all patients diagnosed with PPLELC at our center between 2000 and 2014. RESULTS: All 28 patients were Chinese, 67.9% were female, and the median age was 58 years (range37-76 years). Majority (89.3%) were never smokers and 53.6% asymptomatic at diagnosis. About 28.6% presented with Stage I/II disease, 25% had Stage III disease, and 46.4% had Stage IV disease. All patients with Stage I/II disease underwent lobectomy without adjuvant treatment. Four out of 7 patients with Stage III disease underwent surgery with or without adjuvant therapy while the rest received chemoradiation. Twelve out of 13 patients with Stage IV disease received chemotherapy with or without radiotherapy. At the end of 2016, survival data were available for all 28 patients. Two-year survival rates for Stage I/II, Stage III, and Stage IV disease were 100%, 85.7%, and 61.5%, respectively, while survival was 100%, 85.7%, and 9.6%, respectively, at five years. CONCLUSION: The majority (46.4%) of patients presented with metastatic disease. For those with Stage I-III disease, 5-year survival for PPLELC was better than other NSCLC subtypes. Multimodality treatment including surgery could be considered in locally advanced disease. In Stage IV disease, it tended to approximate that of NSCLC.

Feasibility of transapical cardioscopic surgery in a pig model.

BACKGROUND AND AIM: We introduced a cardioscopic surgical platform for a wide range of cardiac procedures, to address various intracardiac pathologies, through the left ventricular (LV) apex on the arrested heart. The method involves endoscopic access into the LV cavity; hence the term "transapical cardioscopic surgery (TACS)." METHODS: For this proof-of-concept study, we obtained transapical access to the left ventricle in five pigs. A right minithoracotomy was used for cannulation and cardiopulmonary bypass A purse string-secured incision at the apex allows for introduction of a self-made intracavitary expander, 5 mm steerable-tip endoscopic camera as well as 5 and 3 mm endoscopic instruments. RESULTS: The trans-apical approach provided a good exposure and an adequate surgical field, which allowed us to perform mitral valve repair, mitral valve replacement, and aortic valve replacement. This approach also enabled excellent access and visualization for atrial ablation and intra-aortic procedures. All animals were rewarmed and weaned off bypass. CONCLUSIONS: The proposed transapical cardioscopic platform is feasible for major intra-cardiac procedures.

Chest wall secondary chondrosarcoma arising from enchondroma in a young Asian female.

INTRODUCTION: Enchondromas are benign tumours derived from cartilaginous tissue and they rarely undergo malignant transformation unless they occur in multiple sites such as in the case of Ollier disease. PRESENTATION OF CASE: We report a rare case of a 36-year-old Chinese female, without any past medical history, who had a right chest wall tumour which was initially diagnosed to be benign, for which she was loss to follow up. The mass had been stable in size for the past 7 years until recently, when it gradually grew bigger. computed tomography (CT) scan of the thorax revealed that the mass had invaded the right chest wall suggestive of malignant change. She subsequently underwent an elective open right chest wall resection of the mass and chest wall reconstruction with mesh. A 3cm by 3cm tumour arising from the anterior aspect of the 4th rib was found intra-operatively. Post-operative course was uneventful. Histologically, the mass was confirmed to be chrondrosarcoma and resection margins were negative. The patient was discharged on 4th post-operative day and her latest CT thorax during follow up 2 years after operation did not show any tumour recurrence. DISCUSSION: The aim of chest wall reconstruction is to avoid instability and prevent thoracic organs from being exposed if the defect size is ≥10cm or at least three ribs are resected. Polypropylene mesh may be relatively weak in terms of mechanical support for the chest wall, however, in this case, the defect is not too large and the laterally reflected pectoral muscle can provide enough support together with the mesh. CONCLUSION: Secondary chondrosarcoma in a young Asian female arising from a benign solitary enchondroma in the absence of multiple enchondromatosis, such as Ollier disease or Maffucci syndrome, is extremely rare. Regular follow up including physical assessment and radiological imaging can result in earlier detection of malignant transformation obviating the need for aggressive surgical treatment involving multiple rib resections.