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Interdisciplinary Cardiovascular and... Feb 2024Salvage surgery following immunotherapy is a promising treatment option for advanced malignant tumour. However, only a few cases of salvage surgery for malignant pleural...
Salvage surgery following immunotherapy is a promising treatment option for advanced malignant tumour. However, only a few cases of salvage surgery for malignant pleural mesothelioma (MPM) have been reported. This retrospective study was conducted to assess the feasibility of salvage surgery following immunotherapy for initially unresectabele MPM. Among 61 patients who received pleurectomy/decortication (P/D) for MPM, 7 patients received salvage P/D after immunotherapy. Surgical indication of salvage P/D was conversion to resectability in 5 patients and local relapse in 2 patients, and macroscopic complete resection was achieved in all patients. Although salvage P/D was associated with longer operation time (median, 507 min), higher intraoperative blood loss (median, 2573 mL) and higher morbidity (≥ grade 3, 29%), no patient died after surgery. Radiographic response to immunotherapy was well correlated with pathologic response, as all 4 patients with partial response showed significant pathologic response (viable cells, ≤50%). With the median postoperative follow-up duration of 9.0 months, all patients were alive mostly without tumour recurrence as local recurrence developed in 1 patient. To conclude, salvage P/D after immunotherapy may be a feasible treatment option for selected patients with advanced MPM, which should be validated in future multi-institutional studies. In addition, a long-term follow-up is essential to reveal the clinical benefit achieved with salvage P/D following immunotherapy.
PubMed: 37966912
DOI: 10.1093/icvts/ivad173 -
Journal of Pediatric Surgery Feb 2024Recent advances in lymphatic imaging allow understanding the pathophysiology of lymphatic central conduction disorders with great accuracy. This new imaging data is... (Review)
Review
AIM
Recent advances in lymphatic imaging allow understanding the pathophysiology of lymphatic central conduction disorders with great accuracy. This new imaging data is leading to a wide range of novel surgical interventions. We present here the state-of-the-art imaging technology and current spectrum of surgical procedures available for patients with these conditions.
METHOD
Descriptive report of the newest lymphatic imaging technology and surgical procedures and retrospective review of outcome data.
RESULTS
There are currently two high-resolution imaging modalities for the central lymphatic system: multi-access dynamic contrast-enhanced MR lymphangiogram (DCMRL) and central lymphangiography (CL). DCMRL is done by accessing percutaneously inguinal and mesenteric lymph nodes and periportal lymphatics vessels. DCMRL provides accurate anatomical and dynamic data on the progression, or lack thereof, of the lymphatic fluid throughout the central lymphatic system. CL is done by placing a catheter percutaneously in the thoracic duct (TD). Pleural effusions are managed by pleurectomy and intraoperative lymphatic glue embolization guided by CL. Anomalies of the TD are managed by TD-to-vein anastomosis and/or ligation of aberrant TD branches. Chylous ascites and organ-specific chylous leaks are managed by intraoperative glue embolization, surgical lymphocutaneous fistulas, and ligation of aberrant peripheral lymphatic channels, among several other procedures.
CONCLUSION
The surgical management of lymphatic conduction disorders is a new growing field within pediatric general surgery. Pediatric surgeons should be familiar with the newest imaging modalities of the lymphatic system and with the surgical options available for patients with these complex surgical conditions to provide prompt treatment or referral.
LEVEL OF EVIDENCE
V.
Topics: Child; Humans; Magnetic Resonance Imaging; Lymphatic Vessels; Lymphatic Diseases; Lymphatic System; Thoracic Duct
PubMed: 37953163
DOI: 10.1016/j.jpedsurg.2023.10.039 -
Interdisciplinary Cardiovascular and... Nov 2023The goal was to evaluate the accuracy of preoperative histological assessment and the factors affecting the accuracy and the subsequent effect on postoperative survival...
Perioperative discordance in mesothelioma cell type after pleurectomy/decortication-a possible detrimental effect of neoadjuvant chemotherapy due to epithelial to mesenchymal transition?
OBJECTIVES
The goal was to evaluate the accuracy of preoperative histological assessment and the factors affecting the accuracy and the subsequent effect on postoperative survival after surgical treatment for malignant pleural mesothelioma (MPM).
METHODS
We analysed the perioperative course of patients who underwent surgery for MPM in a single institution over a 5-year period. The primary end point was to evaluate the proportion of histological discordance between preoperative assessment and postoperative histological diagnosis. The secondary end point was to evaluate its prognostic effect on postoperative survival after surgical treatment.
RESULTS
One-hundred and twenty-nine patients were included in this study. Histological discordance between preoperative assessment and postoperative histological diagnosis was found in 27 of 129 patients (20.9%): epithelial to biphasic/sarcomatoid (negative discordance) in 24 and biphasic to epithelial (positive discordance) in 3 (P-value < 0.001). All 24 patients who exhibited epithelial-to-mesenchymal transition (EMT) had received neoadjuvant chemotherapy (P-value: 0.006). In the 34 patients who underwent upfront surgery, only 1 case (2.9%) of EMT was identified (P-value: 0.127). EMT was not associated with a less invasive method of biopsy (P-value: 0.058) or with the volume or maximum diameter of the biopsy (P-value: 0.358 and 0.518, respectively), but it was significantly associated with the receipt of neoadjuvant chemotherapy (P-value: 0.006). At a median follow-up of 17 months (IQR: 11.0-28.0), 50 (39%) patients are still alive. Overall survival was significantly reduced in those patients who received neoadjuvant chemotherapy and who exhibited discordance (EMT) compared to those who did not: 11 (95% CI: 6.2-15.8) months versus 19 (95% CI: 14.2-23.8) months (P-value < 0.001). In addition, there was no difference in overall survival between those who received neoadjuvant chemotherapy and those who had upfront surgery: 16 (95% CI: 2.5-19.5) months versus 30 (95% CI: 11.6-48.4) months (P-value: 0.203).
CONCLUSIONS
The association of neoadjuvant chemotherapy with perioperative histological discordance can be explained by EMT, which leads to worse survival. Therefore, there is an argument for the preferential use of upfront surgery in the treatment of otherwise resectable MPM.
PubMed: 37851340
DOI: 10.1093/icvts/ivad145 -
Turk Gogus Kalp Damar Cerrahisi Dergisi Jul 2023This study aims to evaluate overall survival, diseasefree survival, and prognostic factors in patients undergoing pleurectomy-decortication and hyperthermic...
BACKGROUND
This study aims to evaluate overall survival, diseasefree survival, and prognostic factors in patients undergoing pleurectomy-decortication and hyperthermic intrathoracic chemotherapy with the diagnosis of malignant pleural mesothelioma.
METHODS
Between January 2020 and November 2021, a total of 53 patients (27 males, 26 females; mean age: 58.1±1.3 years; range, 39 to 81 years) who underwent pleurectomy-decortication and hyperthermic intrathoracic chemotherapy with the diagnosis of malignant pleural mesothelioma were retrospectively analyzed. Data including characteristics, comorbidities, postoperative complications, recurrence and mortality status of the patients were recorded. Overall survival and disease-free survival and prognostic factors were evaluated.
RESULTS
The median disease-free survival was 11.67 months and the median overall survival was 24.60 months. The median disease-free survival was 8.80 months in men and 13.17 months in women, indicating a statistically significant difference as it showed that recurrence was detected earlier in male patients (p=0.037). The median disease-free survival and overall survival was 6.13 months and 11.70 in cases diagnosed with biphasic mesothelioma, respectively, while it was 11.67 months and 25.46 months in cases with epithelial mesothelioma, respectively. Pathological subtype was found to be an effective prognostic factor for both survival (p=0.049 and p<0.001, respectively).
CONCLUSION
Hyperthermic intrathoracic chemotherapy following cytoreductive surgery is a preferable and tolerable method in the treatment of malignant pleural mesothelioma. While evaluating surgical indications, it should be kept in mind that cases with epithelial mesothelioma may benefit more from surgical treatment.
PubMed: 37664769
DOI: 10.5606/tgkdc.dergisi.2023.24329 -
Medicine Sep 2023A recent study showed that thoracic epidural block (TEB) suppressed the occurrence of major complications after pleurectomy/decortication (P/D) for malignant pleural... (Observational Study)
Observational Study
Intraoperative nociception and postoperative inflammation associated with the suppression of major complications due to thoracic epidural block after pleurectomy/decortication for malignant pleural mesothelioma under general anesthesia: A retrospective observational study.
A recent study showed that thoracic epidural block (TEB) suppressed the occurrence of major complications after pleurectomy/decortication (P/D) for malignant pleural mesothelioma (MPM) under general anesthesia. To investigate the mechanisms underlying the correlation, both acute inflammatory status and intraoperative nociception were evaluated in the present study. In a single-institutional observational study, consecutive adult patients undergoing P/D were enrolled from March 2019 to April 2022. Perioperative acute inflammatory status was evaluated using differential White blood cell (WBC) counts and serum concentration of C-reactive protein (CRP) both before and after the surgery on postoperative day (POD) 1. The averaged value of nociceptive response index during surgery (mean NR) was obtained to evaluate the level of intraoperative nociception. Multivariable logistic regression analysis was performed to determine the association between perioperative variables and major complications Postoperative major postoperative complication was defined as Clavien-Dindo grades ≥ III. We conducted this study with 97 patients. After logistic regression analysis showed that general anesthesia without TEB was a sole risk factor for major complications, patients were divided into 2 groups: general anesthesia with and without TEB. The incidence of major complications was significantly lower in patients with TEB (33.3%, n = 33) than in those without TEB (64.1%, n = 64, P < .01). Although there was no significant difference in the CRP level between 2 groups, the lymphocyte-to-monocyte ratio (LMR) on POD 1 in patients with TEB was significantly higher than that in patients without TEB (P = .04). The mean NR was significantly lower in patients with TEB than that in those without TEB (P = .02). Both lower mean NR during surgery and higher LMR on POD 1 are likely associated the suppression of major complications due to TEB after P/D under general anesthesia. Decreases in the postoperative acute inflammatory response, caused by the reduction of intraoperative nociception due to TEB, may help suppress major complications after P/D.
Topics: Adult; Humans; Anesthesia, General; Inflammation; Mesothelioma, Malignant; Nociception; Postoperative Complications; Retrospective Studies; Anesthesia, Epidural; Male; Female; Middle Aged; Aged; Monitoring, Intraoperative
PubMed: 37657017
DOI: 10.1097/MD.0000000000034832 -
Translational Lung Cancer Research Jul 2023Malignant pleural mesothelioma (MPM) is an incurable, late presenting primary cancer, conferring a survival of 8-14 months. Different intrapleural treatments have been...
BACKGROUND
Malignant pleural mesothelioma (MPM) is an incurable, late presenting primary cancer, conferring a survival of 8-14 months. Different intrapleural treatments have been tested as part of a multimodality approach to treat a select group of patients with limited disease, increasing survival. Recently, povidone-iodine has been shown to induce apoptosis in microscopic tumour cells , with no reported complications. This is the first study assessing the apoptotic rate caused by intraoperative hyperthermic betadine lavage using routine immunohistochemistry combined with transmission electron microscopy (TEM).
METHODS
We included surgically fit patients aged >18, undergoing minimally invasive video-assisted thoracoscopic surgery (VATS) pleural biopsy between December 2016 and February 2018, for confirmed or presumed pleural malignancy. Parietal pleural biopsies were obtained at 7.5, 15 and 30 minutes after hyperthermic betadine lavage, and compared to pre-lavage biopsy samples, for apoptotic changes. Viable tumour samples underwent histological, immunohistochemical and ultrastructural analysis as well as TEM for features of apoptosis.
RESULTS
N=6. Median age was 76 years. Median overall survival was 26.7 months. There was no statistical impact on survival of side of disease (left right). There was no significant difference in expressions of markers of apoptotic index pre and post betadine treatment upon immunohistochemical analysis. There was no discernible effect on morphological features of apoptosis seen with betadine treatment, on TEM analysis. No side effects were identified post betadine lavage.
CONCLUSIONS
Although hyperthermic betadine lavage is a safe antiseptic solution with no toxicity when performed intraoperatively, it confers no effect on apoptotic rate or necrosis. It is therefore unlikely that hyperthermic betadine lavage will have an impact on reducing the microscopic residual disease after pleurectomy decortication and enhancing survival.
PubMed: 37577311
DOI: 10.21037/tlcr-22-282 -
Thoracic Cancer Sep 2023Pleurectomy and decortication (PD) in malignant pleural mesothelioma has a high morbidity mostly associated with aspiration pneumonia (PNA), deep vein thrombosis (DVT),...
BACKGROUND
Pleurectomy and decortication (PD) in malignant pleural mesothelioma has a high morbidity mostly associated with aspiration pneumonia (PNA), deep vein thrombosis (DVT), and foreign catheter sepsis. We instituted four strategies to reduce these complications and report our experience.
METHODS
This was a retrospective review of patients who underwent PD at the University of Pennsylvania between 2015 and 2022. Our patients underwent standard of care PD in addition to tracheostomy and gastrostomy/jejunostomy tube with therapeutic anticoagulation (AC) leading up to surgery. Measured outcomes were postoperative PNA, DVT, and sepsis. The predicted risk of those same outcomes had patients not undergone the interventions was calculated based on the American College of Surgeons (ACS) surgical risk calculator (SRC). A McNemar's test was used to determine whether the risk of having PNA, DVT and sepsis differed between the two subgroups.
RESULTS
Fifty-five patients were included in the study. The mean age was 70 years (SD 6.2) with a mean of 21 (SD 19) pack-years of smoking. PNA, DVT, and catheter-related sepsis occurred in 12, four, and seven patients, respectively. Upon using the ACS SRC prediction model of the nonintervention group, PNA, DVT and catheter related sepsis was predicted to occur in 24 (paired data OR 5, 95% CI: 1.4-17.2; McNemar's test p = 0.008), 14 (paired data OR 3.5, 95% CI: 1.15-10.6; McNemar's test p = 0.03), and 17 (paired OR 3, 95% CI: 1.09-8.3; McNemar's test p = 0.04) patients, respectively.
DISCUSSION
Patients undergoing tracheostomy creation, therapeutic AC at the time of diagnosis, and gastrostomy tube placement had a reduced risk of aspiration PNA, DVT, and catheter sepsis.
Topics: Humans; Aged; Mesothelioma, Malignant; Mesothelioma; Pleural Neoplasms; Lung Neoplasms; Treatment Outcome; Morbidity; Sepsis
PubMed: 37574596
DOI: 10.1111/1759-7714.15067 -
Journal of Thoracic Oncology : Official... Dec 2023The International Association for the Study of Lung Cancer developed an international pleural mesothelioma database to improve staging. Data entered from 1995 to 2009...
INTRODUCTION
The International Association for the Study of Lung Cancer developed an international pleural mesothelioma database to improve staging. Data entered from 1995 to 2009 (training data set) were analyzed previously to evaluate supplemental prognostic factors. We evaluated these factors with new clinical data to determine whether the previous models could be improved.
METHODS
Patients entered into the database from 2009 to 2019 (validation cohort) were assessed for the association between previous prognosticators and overall survival using Cox proportional hazards regression with bidirectional stepwise selection. Additional variables were analyzed and models were compared using Harrell's C-index.
RESULTS
The training data set included 3101 patients and the validation cohort, 1733 patients. For the multivariable pathologic staging model applied to the training cohort, C-index was 0.68 (95% confidence interval [CI]: 0.656-0.705). For the validation data set (n = 497), C-index was 0.650 (95% CI: 0.614-0.685), and pathologic stage, histologic diagnosis, sex, adjuvant therapy, and platelet count were independently associated with survival. Adding anemia to the model increased the C-index to 0.652 (95% CI: 0.618-0.686). A basic presentation model including all parameters before staging yielded a C-index of 0.668 (95% CI: 0.641-0.695). In comparison, the European Organization for Research and Treatment of Cancer model yielded C-indices of 0.550 (95% CI: 0.511-0.589) and 0.577 (95% CI: 0.550-0.604) for pathologic staging and presentation models, respectively.
CONCLUSIONS
Although significant predictors differed slightly, the International Association for the Study of Lung Cancer training model performed well in the validation set and better than the model of the European Organization for Research and Treatment of Cancer. International collaboration is critical to improve outcomes in this rare disease.
Topics: Humans; Lung Neoplasms; Prognosis; Mesothelioma, Malignant; Mesothelioma; Pleural Neoplasms; Neoplasm Staging; Pneumonectomy; Treatment Outcome; Retrospective Studies
PubMed: 37567386
DOI: 10.1016/j.jtho.2023.08.005 -
Ulusal Travma Ve Acil Cerrahi Dergisi =... Aug 2023Pneumothorax in patients with underlying lung pathology is called secondary spontaneous pneumothorax (SSP). It is an important health problem worldwide, with significant...
BACKGROUND
Pneumothorax in patients with underlying lung pathology is called secondary spontaneous pneumothorax (SSP). It is an important health problem worldwide, with significant morbidity, high health-care expenses, and possibility of mortality. This study aimed to evaluate the epidemiological characteristics, risk factors for mortality and morbidity, and treatment options of SSP.
METHODS
Outcomes of 133 patients with SSP were evaluated retrospectively. Patients with SP with evidence of underlying lung disease or a smoking history over 50 years of age were considered SSP. The patients were analyzed in terms of epidemiological fea-tures, underlying diseases, treatment methods, complications, and mortality. The treatment options included thoracotomy (T), video-assisted thoracoscopic surgery (VATS), tube thoracostomy, and conservative treatment.
RESULTS
The mean age was 50.50±20.374 years, and the age range was 16-95. Ninety-three (69.9%) of the patients were smokers. The most common clinical finding was dyspnea in 77 (57.9%) patients. The most common underlying disease was chronic obstructive pulmonary disease in 62 patients (46.6%). Six (4.5%) patients received conservative treatment, a chest tube was placed in 89 (66.9%) patients, and 38 (28.6%) patients were treated with surgery. As an operative procedure, lung wedge resection was performed in 24 (18.0%) patients and bulla resection was performed in 6 (4.5%) patients. Parietal pleurectomy was performed in 27 (20.3%) patients. Axillary mini-T or T was performed more frequently in large pneumothorax, smokers, and in obstructive pulmonary disease. Tube thoracostomy was used more frequently in poor physical performance, comorbidities, and infectious diseases. Complications were ob-served in 55 patients (41.4%). The most common complication was persistent air leakage in 18 (13.5%) patients. Complications were associated with large pneumothorax (P=0.003), poor physical performance (P=0.009), infectious diseases (P= 0.030), and occupational risk factors (P=0.032). Recurrence was developed in 12 (9.0%) patients. Postoperative recurrence was observed in 1 patient. Four (3%) patients died. Mortality was higher in patients with poor physical performance (P=0.027), comorbidities (P=0.008), and patients with complications (P=0.027). The length of stay in the hospital was high in mini-axillary T (AT)/T (P<0.001) and VATS (P<0.001). There was no significant relationship between the mini-AT/T and VATS in terms of length of hospital stay.
CONCLUSION
Large pneumothorax, poor physical performance, and comorbidity are associated with morbidity and mortality. Conservative treatment for small pneumothorax and chest tube for large pneumothorax is the most appropriate initial treatment. Resection of the bullous region through VATS or mini-AT/T is the most appropriate surgical technique.
Topics: Humans; Middle Aged; Adult; Aged; Pneumothorax; Retrospective Studies; Thoracic Surgery, Video-Assisted; Thoracotomy; Morbidity; Recurrence; Treatment Outcome
PubMed: 37563896
DOI: 10.14744/tjtes.2023.20566 -
Journal of Thoracic Disease Jul 2023The aim of this study is to evaluate feasibility of monitoring the process of pleurodesis after surgical pleurectomy with thoracic ultrasound. Repetitive measurements...
The aim of this study is to evaluate feasibility of monitoring the process of pleurodesis after surgical pleurectomy with thoracic ultrasound. Repetitive measurements with thoracic ultrasound after surgical pleurectomy could provide information on the extent and development speed of pleurodesis. We conducted a prospective single-center cohort study. Adult patients who required surgical pleurectomy after pneumothorax were eligible. Participants had daily thoracic ultrasound examination until discharge to determine lung sliding [present (0 point), questionable (1 point), or absent (2 points)], and pleural thickening [normal (0 point), questionable (1 point), or present (2 points)]. Thoracic ultrasound was performed in six regions, the sum of all scores was divided by the number of regions. Fourteen patients were enrolled. Thoracic ultrasound on day 1-4 was 0.25±0.26, 0.39±0.48, 0.84±0.49, 1.12±0.56 for mean lung sliding, and 1.0±0.56, 1.17±0.48, 1.44±0.44, 1.54±0.34 for mean pleural thickening. Lung sliding and pleural thickening increased significantly between day 1 and day 4 (P=0.002 and P=0.023, respectively). One (7%) and 3 (21%) patients reached the maximum achievable grade for lung sliding and pleural thickening, respectively. Thoracic ultrasound grades tended to be lower in three patients with recurrent pneumothorax, although this was not statistically significant. This study shows a significant increase in thoracic ultrasound grading for pleurodesis lung sliding and pleural thickening during the first postoperative days after surgical pleurectomy, probably attributable to progressing pleurodesis. Only a minority of patients reached complete pleurodesis before discharge despite complete surgical pleurodesis (SP). The results of this study may guide future research regarding optimal timing of chest tube removal.
PubMed: 37559644
DOI: 10.21037/jtd-23-116