Thoracic skeletal muscle mass predicts mortality in patients with surgery for pleural empyema: A case control study.

BACKGROUND: This study investigated the role of the thoracic skeletal muscle mass as a marker of sarcopenia on postoperative mortality in pleural empyema. METHODS: All consecutive patients (n = 103) undergoing surgery for pleural empyema in a single tertiary referral center between January 2020 and December 2022 were eligible for this study. Thoracic skeletal muscle mass index (TSMI) was determined from preoperative computed tomography scans. The impact of TSMI and other potential risk factors on postoperative in-hospital mortality was retrospectively analyzed. RESULTS: A total of 97 patients were included in this study. The in-hospital mortality rate was 13.4%. In univariable analysis, low values for preoperative TSMI (p = 0.020), low preoperative levels of thrombocytes (p = 0.027) and total serum protein (p = 0.046) and higher preoperative American Society of Anesthesiologists (ASA) category (p = 0.007) were statistically significant risk factors for mortality. In multivariable analysis, only TSMI (p = 0.038, OR 0.933, 95% CI: 0.875-0.996) and low thrombocytes (p = 0.031, OR 0.944, 95% CI: 0.988-0.999) remained independent prognostic factors for mortality. CONCLUSIONS: TSMI was a significant prognostic risk factor for postoperative mortality in patients with pleural empyema. TSMI may be suitable for risk stratification in this disease with high morbidity and mortality, which may have further implications for the selection of the best treatment strategy.

ERASURE: early autologous blood pleurodesis for postoperative air leaks-a randomized, controlled trial comparing prophylactic autologous blood pleurodesis versus standard watch and wait treatment for postoperative air leaks following thoracoscopic anatomic lung resections.

BACKGROUND: The prolonged air leak is probably the most common complication following lung resections. Around 10-20% of the patients who undergo a lung resection will eventually develop a prolonged air leak. The definition of a prolonged air leak varies between an air leak, which is evident after the fifth, seventh or even tenth postoperative day to every air leak that prolongs the hospital stay. However, the postoperative hospital stay following a thoracoscopic lobectomy can be as short as 2 days, making the above definitions sound outdated. The treatment of these air leaks is also very versatile. One of the broadly accepted treatment options is the autologous blood pleurodesis or "blood patch". The purpose of this trial is to investigate the impact of a prophylactic autologous blood pleurodesis on reducing the duration of the postoperative air leak and therefore prevent the air leak from becoming prolonged. METHODS: Patients undergoing an elective thoracoscopic anatomic lung resection for primary lung cancer or metastatic disease will be eligible for recruitment. Patients with an air leak of > 100 ml/min within 6 h prior to the morning round on the second postoperative day will be eligible for inclusion in the study and randomization. Patients will be randomized to either blood pleurodesis or watchful waiting. The primary endpoint is the time to drain removal measured in full days. The trial ends on the seventh postoperative day. DISCUSSION: The early autologous blood pleurodesis could lead to a faster cessation of the air leak and therefore to a faster removal of the drain. A faster removal of the drain would relieve the patient from all the well-known drain-associated complications (longer hospital stay, stronger postoperative pain, risk of drain-associated infection, etc.). From the economical point of view, faster drain removal would reduce the hospital costs as well as the costs associated with the care of a patient with a chest drain in an outpatient setting. TRIAL REGISTRATION: German Clinical Trials Register (DRKS) DRKS00030810. 27 December 2022.

An update on red blood cell transfusion in non-cardiac thoracic surgery.

Background: The aim of this study was to evaluate risk factors for red blood cell (RBC) transfusion in non-cardiac thoracic surgery. Methods: All patients undergoing non-cardiac thoracic surgery in a single tertiary referral center between January and December 2021 were eligible for this study. Data on blood requests and perioperative RBC transfusion were retrospectively analyzed. Results: A total of 379 patients were included, of whom 275 (72.6%) underwent elective surgery. The overall RBC transfusion rate was 7.4% (elective cases: 2.5%, non-elective cases: 20.2%). Patients with lung resections required transfusion in 2.4% of the cases versus 44.7% in patients undergoing surgery for empyema. In multivariable analysis, empyema (P=0.001), open surgery (P<0.001), low preoperative hemoglobin (P=0.001), and old age (P=0.013) were independent risk factors for RBC transfusion. The best predictor of blood transfusion was preoperative hemoglobin with a cut-off value <10.4 g/dL (sensitivity 82.1%, specificity 86.3%, area under the curve 0.882). Conclusions: The rate of RBC transfusion in current non-cardiac thoracic surgery is low, especially in elective lung resections. In urgent cases and open surgery, transfusion rates remain high, particularly in empyema cases. Preoperative requesting of RBC units should be tailored to patient-specific risk factors.

Successful resolution of ectopic Cushing syndrome by minimally invasive thoracoscopic resection of the neuroendocrine tumor of the thymus: a rare case report.

BACKGROUND: Ectopic Cushing syndrome (ECS) is a sporadic condition. Even uncommon is an ECS that derives from a carcinoid tumor of the thymus. These tumors may pose several diagnostic and therapeutic conundrums. This report discusses the differential diagnosis, clinicopathological findings, and effective treatment of a rare case of ECS using a minimally invasive approach. CASE PRESENTATION: A 29-year-old woman with Cushing syndrome presented with facial flushing. Physical examination revealed hypertension (blood pressure: 141/100 mmHg). A mediastinal tumor was discovered to be the cause of the patient's chronic hypokalemia and hypercortisolemia. Cortisol levels increased in the morning, reaching 47.7 ug/dL. The levels of the hormones ACTH, aldosterone, and renin were determined to be 281 pg/mL, 3.0 ng/dL, and 2.1 pg/mL, respectively. The presence of hypertension, hypokalemia, and alkalinity suggested Cushing's syndrome, which was proven to be ACTH-dependent ECS by a dexamethasone suppression test. A chest CT scan revealed inflammation in the posterior basal region of the right lower lobe. The superior anterior mediastinum was characterized by round-shaped isodensity lesions with distinct borders. She underwent thoracoscopic anterior mediastinal tumor excision via the subxiphoid technique (R0 resection); following surgery, her blood pressure returned to normal, and the hypernatremia/hypopotassemia resolved. The tumor was determined to be a thymic carcinoid. Most notably, cortisol levels fell to half of their presurgical levels after one hour of surgery, and other abnormalities corrected substantially postoperatively. CONCLUSION: Thoracoscopic excision of thymic tumors by subxiphoid incision may be a useful treatment option for ECS caused by neuroendocrine tumors of the thymus.

Open redo thymectomy for a large recurrent thymoma in a patient with myasthenia gravis: a case report.

Thoracoscopic and robotic approaches are becoming increasingly popular for thymoma surgery. Yet open thymectomy must still be mastered today, as it may be the only viable option in challenging cases. In this study, we report a case of an extended local recurrence of myasthenia gravis associated thymoma and a history of previous sternotomy. The mediastinal mass infiltrated the left upper lobe of the lung, the pericardium, and presumably the aortic arch. Although the standard for thymoma resection at our institution is the robotic approach, we performed primary open redo thymectomy in standby of cardiopulmonary bypass in this case. Intraoperatively, bleeding from the aortic arch occurred, which was promptly controlled due to the open approach and due to immediate availability of cardiopulmonary bypass. The patient was transferred to the normal ward on the first postoperative day, was treated according to fast-track principles and recovered well. The pathology revealed a WHO B2:B1 thymoma with negative resection margins. Thymectomy is recommended as the principal treatment for thymoma and is also advised in the case of recurrence. However, there is no evidence regarding the optimal surgical approach. Our case indicates that in the era of minimally invasive thymectomy, the decision to conduct open surgery is wise when the risk of serious bleeding is anticipated or adherence to oncologic principles is challenged by tumor size or growth pattern.

[Management of Chest Drains after Elective, Thoracoscopic, Anatomical Lung Resections. A Survey in Thoracic Surgical Departments in Germany]. / Management von Thoraxdrainagen nach elektiven, thorakoskopischen, anatomischen Lungenresektionen an thoraxchirurgischen Zentren in Deutschland . Eine Umfrage über die Deutsche Gesellschaft für Thoraxchirurgie (DGT).

INTRODUCTION: The increasing use of minimally invasive techniques along with the introduction of the "Enhanced Recovery After Surgery" (ERAS) guidelines have reduced the perioperative risk of anatomic lung resections. However, the prolonged postoperative air leak still remains one of the major postoperative issues. The purpose of this survey was to evaluate the perioperative management of chest drains and the current clinical practice in treating prolonged air leaks after elective, thoracoscopic, anatomic lung resections in Germany. METHODS: We performed a survey among the thoracic surgical units, which are listed in the Database of the German Thoracic Society (n = 160). Based on the number of resections annually, the centres were divided into high- and low-volume and the results were presented accordingly. RESULTS: The response rate was 35.6%. Most of the units routinely place a single, 24 Ch. chest drain, which they connect to a digital system on suction. 42.1% of the thoracic units treat a postoperative air leak after the 7th postoperative day. The majority of the surgeons either reduce the suction or use other conservative measures to deal with the air leak. There is no significant difference in the drain management between high- and low-volume centres. CONCLUSION: The postoperative hospital stay after an uncomplicated lobectomy has come down to a few days whereas the lower limit of the length of stay has been reduced to 2 days. Nevertheless, 80% of the German thoracic surgeons define a postoperative air leak as prolonged, when it lasts beyond the 5th postoperative day and 65% deal with it only after the 5th postoperative day. The available evidence on this field is limited. New prospective clinical studies are required in order to improve the management of this common complication.

A Tuft Cell-Like Signature Is Highly Prevalent in Thymic Squamous Cell Carcinoma and Delineates New Molecular Subsets Among the Major Lung Cancer Histotypes.

INTRODUCTION: In-depth genomic characterization of thymic epithelial tumors (TETs), comprising thymomas and thymic carcinomas (TCs), failed to identify targetable mutations and suggested unique biology of TETs, including KIT expression in most TCs. Recently, tuft cell-like medullary thymic epithelial cells were identified in the murine thymus, and our reanalysis of the published gene expression data revealed that these cells express KIT. In addition, recently, a minor subset of SCLCs with tuft cell-like features was described. METHODS: We interrogated mRNA expression data from our tumor cohorts (N = 60) and publicly available, independent data sets from TETs and NSCLC (N = 1199) for expression of tuft cell genes and KIT. Expression of KIT and of POU2F3 protein, the master regulator of tuft cells, was analyzed in cancer tissue (N = 344) by immunohistochemistry. RESULTS: Normal human thymic tuft cells and most TCs coexpressed KIT and known tuft cell genes, particularly POU2F3 and GFI1B. Unexpectedly, small subsets of tuft cell-like tumors coexpressing POU2F3, GFI1B, and KIT were also identified among pulmonary squamous cell carcinomas, adenocarcinomas, and large cell neuroendocrine carcinoma and clustered together in each histologic cohort. In addition to the tuft cell-like signature, both thymic and lung tuft cell-like carcinomas had distinct genetic, pathologic, and clinical features in each cohort. CONCLUSIONS: We suggest that the tuft cell-like phenotype defines novel subsets of thymic and pulmonary carcinoma. Its high prevalence in thymic squamous cell carcinomas that have no known toxic or viral etiologies suggests a new mechanism of carcinogenesis that may lead to specific drug susceptibilities.

Management of Progressive Pulmonary Nodules Found during and outside of CT Lung Cancer Screening Studies.

Although the effectiveness of screening for lung cancer remains controversial, it is a fact that most lung cancers are diagnosed at an advanced stage outside of lung cancer screening programs. In 2013, the U.S. Preventive Services Task Force revised its lung cancer screening recommendation, now supporting lung cancer screening by low-dose computed tomography in patients at high risk. This is also endorsed by many major medical societies and advocacy group stakeholders, albeit with different eligibility criteria. In Europe, population-based lung cancer screening has so far not been recommended or implemented, as some important issues remain unresolved. Among them is the open question of how enlarging pulmonary nodules detected in lung cancer screening should be managed. This article comprises two parts: a review of the current lung cancer screening approaches and the potential therapeutic options for enlarging pulmonary nodules, followed by a meeting report including consensus statements of an interdisciplinary expert panel that discussed the potential of the different therapeutic options.

From diagnosis to therapy in lung cancer: management of CT detected pulmonary nodules, a summary of the 2015 Chinese-German Lung Cancer Expert Panel.

The first Chinese-German Lung Cancer Expert Panel was held in November 2015 one day after the 7th Chinese-German Lung Cancer Forum, Shanghai. The intention of the meeting was to discuss strategies for the diagnosis and treatment of lung cancer within the context of lung cancer screening. Improved risk classification criteria and novel imaging approaches for screening populations are highly required as more than half of lung cancer cases are false positive during the initial screening round if the National Lung Screening Trial (NLST) demographic criteria [≥30 pack years (PY) of cigarettes, age ≥55 years] are applied. Moreover, if the NLST criteria are applied to the Chinese population a high number of lung cancer patients are not diagnosed due to non-smoking related risk factors in China. The primary goal in the evaluation of pulmonary nodules (PN) is to determine whether they are malignant or benign. Volumetric based screening concepts such as investigated in the Dutch-Belgian randomized lung cancer screening trial (NELSON) seem to achieve higher specificity. Chest CT is the best imaging technique to identify the origin and location of the nodule since 20% of suspected PN found on chest X-ray turn out to be non-pulmonary lesions. Moreover, novel state-of-the-art CT systems can reduce the radiation dose for lung cancer screening acquisitions down to a level of 0.1 mSv with improved image quality to novel reconstruction techniques and thus reduce concerns related to chest CT as the primary screening technology. The aim of the first part of this manuscript was to summarize the current status of novel diagnostic techniques used for lung cancer screening and minimally invasive treatment techniques for progressive PNs that were discussed during the first Chinese-German Lung Cancer. This part should serve as an educational part for the readership of the techniques that were discussed during the Expert Panel. The second part summarizes the consensus recommendations that were interdisciplinary discussed by the Expert Panel.

In vivo Quantification of the Effects of Radiation and Presence of Hair Follicle Pores on the Proliferation of Fibroblasts in an Acellular Human Dermis in a Dorsal Skinfold Chamber: Relevance for Tissue Reconstruction following Neoadjuvant Therapy.

INTRODUCTION: In neoadjuvant therapy, irradiation has a deleterious effect on neoangiogenesis. The aim of this study was to examine the post-implantation effects of neoadjuvant irradiation on the survival and proliferation of autologous cells seeded onto an acellular human dermis (hAD; Epiflex). Additionally, we examined the influence of dermal hair follicle pores on viability and proliferation. We used dorsal skinfold chambers implanted in rats and in-situ microscopy to quantify cell numbers over 9 days. METHODS: 24 rats received a skinfold chamber and were divided into 2 main groups; irradiated and unirradiated. In the irradiated groups 20Gy were applied epicutaneously at the dorsum. Epiflex pieces were cut to size 5x5mm such that each piece had either one or more visible hair follicle pores, or no such visible pores. Fibroblasts were transduced lentiviral with a fluorescent protein for cell tracking. Matrices were seeded statically with 2.5x104 fluorescent fibroblasts and implanted into the chambers. In each of the two main groups, half of the rats received Epiflex with hair follicle pores and half received Epiflex without pores. Scaffolds were examined in-situ at 0, 3, 6 and 9 days after transplantation. Visible cells on the surface were quantified using ImageJ. RESULTS: In all groups cell numbers were decreased on day 3. A treatment-dependent increase in cell numbers was observed at subsequent time points. Irradiation had an adverse effect on cell survival and proliferation. The number of cells detected in both irradiated and non-irradiated subjects was increased in those subjects that received transplants with hair follicle pores. DISCUSSION: This in-vivo study confirms that radiation negatively affects the survival and proliferation of fibroblasts seeded onto a human dermis transplant. The presence of hair follicle pores in the dermis transplants is shown to have a positive effect on cell survival and proliferation even in irradiated subjects.

Confocal laser scanning microscopy evaluation of an acellular dermis tissue transplant (Epiflex®).

The structure of a biological scaffold is a major determinant of its biological characteristics and its interaction with cells. An acellular dermis tissue transplant must undergo a series of processing steps, to remove cells and genetic material and provide the sterility required for surgical use. During manufacturing and sterilization the structure and composition of tissue transplants may change. The composition of the human cell-free dermis transplant Epiflex® was investigated with specific attention paid to its structure, matrix composition, cellular content and biomechanics. We demonstrated that after processing, the structure of Epiflex remains almost unchanged with an intact collagen network and extracellular matrix (ECM) protein composition providing natural cell interactions. Although the ready to use transplant does contain some cellular and DNA debris, the processing procedure results in a total destruction of cells and active DNA which is a requirement for an immunologically inert and biologically safe substrate. Its biomechanical parameters do not change significantly during the processing.

Acellular dermal matrix seeded with autologous fibroblasts improves wound breaking strength in a rodent soft tissue damage model in neoadjuvant settings.

Soft tissue defects following resectional surgery or trauma often result in deadspaces and require free or pedicled flaps. A programmed formation of filling tissue with enhanced biomechanical properties could be helpful. This study examined the effects on wound healing of acellular dermal matrix (ADM) seeded with autologous fibroblasts in a standardized rodent model. As pre- or postoperative radiotherapy is standard in many treatments of malignancies, we also investigated the effects of additional radiotherapy. Fischer rats were randomised and received a standardized unilateral soft tissue defect at the buttock. The defect was filled with ADM+fibroblasts or ADM alone. Controls received no filling. Either no radiation, adjuvant (postoperative) or neoadjuvant (preoperative) radiation was applied to the defect site. Six weeks later the defect volume was measured by MR-tomography. Wound breaking strength was examined by tensiometry according to German Industrial Standards. Filling of the defect side was significantly larger in ADM and ADM+fibroblast treated groups compared to the control group in all settings. Wound breaking strength in the unimodal setting was significantly improved in the ADM+fibroblasts group compared to the ADM group. In the neoadjuvant setting there was no significant difference between control and ADM group. However, the ADM+fibroblasts groups showed a significantly increased wound breaking strength compared to the control and the ADM-alone group. Seeded or unseeded ADM is able to fill deadspace in this rodent model in all settings. Implanting non-irradiated, vital, proliferating autologous fibroblasts on ADM results in significantly increased wound breaking strength.