Bronchoscopic management of bronchopleural fistula using free fat pad transplant with platelet-rich plasma: a case study.

BACKGROUND: A bronchopleural fistula (BPF) occurs when an abnormal connection forms between the bronchial tubes and pleural cavity, often due to surgery, infection, trauma, radiation, or chemotherapy. The outcomes of both surgical and bronchoscopic treatments frequently prove to be unsatisfactory. CASE PRESENTATION: Here, we report a case of successful bronchoscopic free fat pad transplantation combined with platelet-rich plasma, effectively addressing a post-lobectomy BPF. Contrast-enhanced chest tomography revealed pleural thickening with heterogeneous consolidations over the right upper and middle lobes, indicative of destructive lung damage and bronchiectasis. The patient underwent thoracoscopic bilobectomy of the lungs. During surgery, severe adhesions and calcification of the chest wall and lung parenchyma were observed. The entire hilar structure was calcified, presenting challenges for dissection, despite the assistance of energy devices. Bronchoscopic intervention was required, during which two abdominal subcutaneous fat pads were retrieved. CONCLUSION: This innovative approach offers promise in the management of BPF and signals potential advancements in enhancing treatment efficacy and patient recovery.

Exposure to nickel chloride induces epigenetic modification on detoxification enzyme glutathione S-transferase M2.

Nickel (Ni) is a human carcinogen with genotoxic and epigenotoxic effects. Environmental and occupational exposure to Ni increases the risk of cancer and chronic inflammatory diseases. Our previous findings indicate that Ni alters gene expression through epigenetic regulation, specifically impacting E-cadherin and angiopoietin-like 4 (ANGPTL4), involved in epithelial-mesenchymal transition and migration. GST-M2, a member of the glutathione S-transferase (GST) enzyme family, plays a crucial role in cellular defense against oxidative damage and has been increasingly associated with cancer. GST-M2 overexpression inhibits lung cancer invasion and metastasis in vitro and in vivo. Hypermethylation of its promoter in cancer cells reduces gene expression, correlating with poor prognosis in non-small-cell lung cancer patients. The impact of Ni on GST-M2 remains unclear. We will investigate whether nickel exerts regulatory effects on GST-M2 through epigenetic modifications. Additionally, metformin, an antidiabetic drug, is being studied as a chemopreventive agent against nickel-induced damage. Our findings indicate that nickel chloride (NiCl2 ) exposure, both short-term and long-term, represses GST-M2 expression. However, the expression can be restored by demethylation agent 5-aza-2'-deoxycytidine and metformin. NiCl2 promotes hypermethylation of the GST-M2 promoter, as confirmed by methylation-specific PCR and bisulfite sequencing. Additionally, NiCl2 also influences histone acetylation, and metformin counteracts the suppressive effect of NiCl2 on histone H3 expression. Metformin reestablishes the binding of specificity protein 1 to the GST-M2 promoter, which is otherwise disrupted by NiCl2 . These findings elucidate the mechanism by which Ni reduces GST-M2 expression and transcriptional activity, potentially contributing to Ni-induced lung carcinogenesis.

Pulmonary Recruitment Prior to Intraoperative Multiple Pulmonary Ground-Glass Nodule Localization Increases the Localization Accuracy-A Retrospective Study.

The standard treatment for early-stage lung cancer is complete tumor excision by limited resection of the lung. Preoperative localization is used before video-assisted thoracoscopic surgery (VATS) to improve the accuracy of pulmonary nodule excision. However, lung atelectasis and hypoxia resulting from controlling apnea during the localization procedure may affect the localization accuracy. Pre-procedural pulmonary recruitment may improve the respiratory mechanics and oxygenation during localization. In this study, we investigated the potential benefits of pre-localization pulmonary recruitment prior to pulmonary ground-glass nodule localization in a hybrid operating room. We hypothesized that pre-localization pulmonary recruitment would increase the localization accuracy, improve oxygenation, and prevent the need for re-inflation during the localization procedure. We retrospectively enrolled patients with multiple pulmonary nodule localizations before surgical intervention in our hybrid operating room. We compared the localization accuracy between patients who had undergone pre-procedure pulmonary recruitment and patients who had not. Saturation, re-inflation rate, apnea time, procedure-related pneumothorax, and procedure time were also recorded as secondary outcomes. The patients who had undergone pre-procedure recruitment had better saturation, shorter procedure time, and higher localization accuracy. The pre-procedure pulmonary recruitment maneuver was effective in increasing regional lung ventilation, leading to improved oxygenation and localization accuracy.

Artificial Intelligence Assisted Computational Tomographic Detection of Lung Nodules for Prognostic Cancer Examination: A Large-Scale Clinical Trial.

Low-dose computed tomography (LDCT) has emerged as a standard method for detecting early-stage lung cancer. However, the tedious computer tomography (CT) slide reading, patient-by-patient check, and lack of standard criteria to determine the vague but possible nodule leads to variable outcomes of CT slide interpretation. To determine the artificial intelligence (AI)-assisted CT examination, AI algorithm-assisted CT screening was embedded in the hospital picture archiving and communication system, and a 200 person-scaled clinical trial was conducted at two medical centers. With AI algorithm-assisted CT screening, the sensitivity of detecting nodules sized 4−5 mm, 6~10 mm, 11~20 mm, and >20 mm increased by 41%, 11.2%, 10.3%, and 18.7%, respectively. Remarkably, the overall sensitivity of detecting varied nodules increased by 20.7% from 67.7% to 88.4%. Furthermore, the sensitivity increased by 18.5% from 72.5% to 91% for detecting ground glass nodules (GGN), which is challenging for radiologists and physicians. The free-response operating characteristic (FROC) AI score was ≥0.4, and the AI algorithm standalone CT screening sensitivity reached >95% with an area under the localization receiver operating characteristic curve (LROC-AUC) of >0.88. Our study demonstrates that AI algorithm-embedded CT screening significantly ameliorates tedious LDCT practices for doctors.

Spontaneous pneumothorax with pulmonary Langerhans cell histiocytosis (PLCH) in an adult heavy cigarette smoker-A case report.

Pulmonary Langerhans cell histiocytosis is a rare disease caused by the proliferation of CD1a-positive histiocyte-like cells infiltrating the lung's interstitial layer. Most cases affect young to middle-aged persons, especially adult heavy cigarette smokers. A 49-year-old male heavy smoker (40 pack-year), with non-productive cough, dyspnoea and desaturation, presented with a right-sided pneumothorax on chest x-ray with total atelectasis. Chest computed tomography (CT) revealed bilateral multiple thick-walled infiltrated cysts and multiple ground-glass nodules throughout the entire lung. Surgery with minimal invasive thoracoscopic lung biopsy and pleurodesis was performed. Pathology showed histiocyte-like cells aggregates in the pulmonary parenchyma. Immunohistochemical stain demonstrated CD1a(+), S100(+) and CD68(+). After 3 months of smoking cessation, clear improvement was evidenced with a chest CT showing bilateral multiple thin-walled rounded cysts and multiple ground-glass nodules that are smaller in size and decreased in numbers. Early minimal invasive thoracoscopic lung biopsy and pleurodesis can also be a choice if the development of secondary spontaneous pneumothorax occurs.

Association between coarse particulate matter (PM10-2.5) and nasopharyngeal carcinoma among Taiwanese men.

The nasopharyngeal tract traps mainly coarse particles in inhaled air. Soluble carcinogenic compounds, endotoxins, and trace metals contained in these particles are potential causes of inflammation and oxidative stress which could enhance carcinogenesis. The aim of this study was to determine the association between coarse particulate matter (PM10-2.5) and nasopharyngeal cancer (NPC). A total of 521,098 men (355 cases and 520,743 non-cases), aged ≥40 years were included in this study. Data were retrieved from the Taiwan Cancer Registry, the Adult Preventive Medical Services Database, and the Air Quality Monitoring Database. PM10-2.5 was significantly associated with a higher risk of NPC after adjusting for SO2, NOx, O3, age, body mass index, smoking, alcohol drinking, betel nut chewing, exercise, hypertension, diabetes, and hyperlipidemia. With PM10-2.5<20.44 µg/m3 as the reference, the ORs and 95% CIs were 1.47; 1.03-2.11, 1.34; 0.94-1.91, and 1.68; 1.16-2.44 for 20.44≤PM10-2.5<24.08, 24.08≤PM10-2.5<29.27, and PM10-2.5≥29.27 µg/m3, respectively. PM10-2.5 remained significantly associated with a higher risk of NPC after further adjustments were made for the aforementioned covariates and PM2.5 The ORs; 95% CIs were 1.42; 0.96 to 2.12, 1.41; 0.94 to 2.10, and 1.71; 1.10 to 2.66 for 20.44≤PM10-2.5<24.08, 24.08≤PM10-2.5<29.27, and PM10-2.5≥29.27 µg/m3, respectively. In conclusion, PM10-2.5 was significantly associated with a higher risk of NPC in Taiwanese men.

Association between chronic obstructive pulmonary disease and PM2.5 in Taiwanese nonsmokers.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death in the world. Not much is known regarding the influence of non-smoking-related risk factors on COPD in Taiwan. We examined the relationship between exposure to particulate matter <2.5 µm (PM2.5) and COPD among nonsmokers in Taiwan. METHODS: This population-based study involved 3941 nonsmoking Taiwanese adults who were recruited in the Taiwan Biobank project between 2008 and 2015. Air pollution data between 2006 and 2011 were obtained from the air quality monitoring database (AQMD). COPD was the outcome of interest and was identified using the National health insurance Research Database (NHIRD). The data were analyzed using multiple logistic regression models. RESULTS: Compared with the lowest quartile (PM2.5 = 29.38), exposure to PM2.5 in the highest quartile (>38.98 µg/m3) was significantly associated with COPD (OR, 1.29; CI 1.01-1.65) after multivariate adjustments. However, exposures to concentrations of 32.07-38.98 µg/m3 (OR, 1.12 CI 0.88-1.44) and 29.38-32.07 µg/m3 (OR, 1.09 CI 0.84-1.41) showed positive but non-significant associations. However, the test for trend was significant (Ptrend = 0.043). The ORs for exposure to sulfur dioxide (SO2), ozone (O3), carbon monoxide (CO) and NOx (nitrogen monoxide (NO were not significant. CONCLUSIONS: Based on our data, exposure to PM2.5 at concentrations greater than 38.98 µg/m3 increased susceptibility to COPD among Taiwanese nonsmokers. Combatting COPD would involve integrating tobacco control and pollution management strategies.

Overexpression of matrix metalloproteinases in lung tissue of patients with primary spontaneous pneumothorax.

BACKGROUND: Although blebs and bullae are frequently found in the apexes of lungs of patients with primary spontaneous pneumothorax (PSP), its pathogens remain unclear. OBJECTIVES: To examine the role of proteases [matrix metalloproteinase (MMP)-2, MMP-7 and MMP-9] and antiproteases [tissue inhibitors of metalloproteinase (TIMP)-1, TIMP-2, TIMP-3 and TIMP-4] in the pathogenesis of PSP. METHOD: Fifty consecutive PSP patients who received standard surgical care were enrolled in the study. Lung tissues from 20 patients with stage I non-small cell lung cancer were used as a control. Immunohistochemistry (IHC), reverse transcription-polymerase chain reaction (RT-PCR) and gelatin zymography were used to evaluate the expression of MMP and TIMP in the lung tissue of patients with PSP. RESULTS: Overexpression of MMP-2, MMP-7 and MMP-9 was found in the afflicted lung by IHC, zymography and RT-PCR. By IHC, higher expression of MMP-2 and MMP-9 in PSP patients was identified in alveolar macrophages and type II pneumocytes (88 and 92% of patients in macrophages, and 72 and 70% of patients in type II pneumocytes, respectively). MMP-2, MMP-7 and MMP-9 expression in patients was higher in mesothelial cells (66, 76 and 76%). Overexpression of TIMP-2 was detected in the extracellular matrix around bullae and blebs. Expression levels of TIMP-1, TIMP-3 and TIMP-4 were negligible (<10% of cells) in both PSP patients and controls. CONCLUSIONS: MMP-2, MMP-9, MMP-7 and TIMP-2 were upregulated in PSP lesions. These results suggest that an imbalance between the expression of proteases and antiproteases may be involved in the pathogeneses of PSP.

Cost and effectiveness of video-assisted thoracoscopic surgery for clinical stage I non-small cell lung cancer: a population-based analysis.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is a minimally invasive alternative to conventional surgery (CS). We aimed to estimate the short-term cost-effectiveness of VATS vs. CS for clinical stage I non-small cell lung cancer (NSCLC-c-stage-I) patients from the payer's perspective (National Health Insurance). METHODS: We identified NSCLC-c-stage-I patients diagnosed and received surgery within 2007-2009 through a comprehensive population-based database containing cancer and death registries, and reimbursement data. The duration of interest was 1 year. We included potential confounding covariables through literature searching and our own experience, and used a propensity score to construct a 1:1 population for adjustment. RESULTS: Our study population constituted 966 patients. The mean hospital stay [days, standard deviation (SD)] were 14.4 [7] and 16.1 (7.7) for VATS and CS respectively (P=0.002). The mean cost (2013 USD) and survival (year) was $22,316 vs. $21,976 and 0.98 vs. 0.974 for VATS vs. CS. The probability for VATS to be cost-effective (i.e., positive net benefit) was 0.49 & 0.56 at willingness-to-pay (WTP) 50,000 & 100,000 USD/life-year, respectively. CONCLUSIONS: We provide the first empirical evidence that when compared to CS, VATS was potentially cost-effective in the short term (1 year) within the common WTP levels in Taiwan.

Single-incision thoracoscopic surgery for primary spontaneous pneumothorax.

OBJECTIVE: Single-incision laparoscopic surgery had been proven effective for appendectomy, cholecystectomy, and inguinal hernia repair. However, single-incision thoracoscopic surgery (SITS) in primary spontaneous pneumothorax (PSP) has not been reported. METHODS: We prospectively enrolled 30 PSP patients who received thoracoscopic surgery in the division of Thoracic Surgery of China Medical University Hospital. Ten patients received SITS and 20 patients received traditional three-port thoracoscopic surgery. The operative time, blood loss, wound size, visual analog scale (VAS) pain score, and patient satisfaction score were compared. RESULTS: There was no significant difference in the operative time and blood loss between the two groups. However, the VAS pain scores were significantly better in the SITS group in first 24 hours after surgery. Patient satisfaction scores in the SITS group were also significantly better in the first 24 and 48 hours after operation. CONCLUSION: Although three-port thoracoscopic surgery for PSP is well established, SITS results in better patient satisfaction and decreased postoperative pain in the treatment of PSP.

Inflammatory myofibroblastic tumor of the lung--a case report.

A 45-year-old man presented with a six-month history of progressive dyspnea with productive cough and wheezing. The patient was a heavy smoker and had a history of tongue cancer, hypertension, and asthma. Chest X-ray and computed tomography showed a mass lesion in the left hilar region and total collapse of the upper left lobe of the lung. Bronchoscopy revealed a whitish solid tumor obstructing the left upper lobe bronchus. Positron emission tomography showed increased tracer uptake in the lesion. A thoracoscopic lobectomy of the left upper lobe of the lung was performed. The final pathologic diagnosis was inflammatory myofibroblastic tumor.

Effect of formalin fixation on tumor size determination in stage I non-small cell lung cancer.

BACKGROUND: Tumor size is an important prognostic factor in non-small cell lung cancer (NSCLC), but the American Joint Committee on Cancer staging system does not mandate a specific measurement method. Moreover, measuring fresh specimens and formalin-fixed specimens may yield disparate results. Our goal was to evaluate this disparity for stage I NSCLC. METHODS: We enrolled 401 patients with stage I NSCLC who underwent surgical interventions and follow-up in our hospital between 1993 and 2002. Tumors invading visceral pleura, involving the main bronchus, or associated with atelectasis or obstructive pneumonitis were excluded. Tumor size was measured immediately after resection by surgeons and after formalin fixation by pathologists. Patients were assigned to one of three groups. Group 1 included 201 patients with tumors of 3 cm or less as indicated by both operation notes and pathology reports. Group 2 included 160 patients with tumors larger than 3 cm by both records. Group 3 included 40 patients with tumors larger than 3 cm according to operation notes but 3 cm or less according to pathology reports. Survival rates were compared. RESULTS: Mean follow-up was 58 months. Five-year survival was 70.1% in group 1, 49.1% in group 2, and 51.1% in group 3. As expected, there was a significant survival difference between groups 1 and 2 (p < 0.001); however, there was also a difference between groups 1 and 3 (p = 0.006). CONCLUSIONS: Formalin fixation may cause tumor shrinkage and migration from T2 to T1. For accurate tumor staging, size measurements should be performed immediately after resection instead of after formalin fixation. TNM staging should specify how to measure tumor size and the specimen status to be measured.