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OBJECTIVESPulmonary carcinosarcoma (PCS) is a rare neoplasm. This study explored the clinicopathological characteristics and survival outcomes of PCS.METHODSThe Surveillance, Epidemiology and End Results (SEER) database (1988–2014) was queried for PCS. Overall survival (OS) was evaluated by multivariable Cox regression and nomograms were constructed to predict 3-year OS for PCS. Prognostic performance was evaluated using concordance index and area under the curve analysis. In M0 surgically treated patients, interaction assessments were performed using likelihood ratio tests. Subgroup analysis was performed according to patient age. The clinical features of PCSs were further compared to other non-small-cell lung cancers (NSCLCs).RESULTSMultivariable analysis identified age [hazard ratio (HR) 1.03, 95% confidence interval (CI) 1.01–1.04], surgery (HR 0.53, 95% CI 0.36–0.77) and chemotherapy (HR 0.51, 95% CI 0.36–0.73) as significantly associated with OS. The nomogram had a concordance index of 0.747 and an area under the curve of 0.803. The association between age and OS was stronger in those receiving pneumonectomy (P = 0.04 for interactions) compared to those that did not (HR 5.14, 95% CI 1.64–16.07), and was associated with a poorer outcome compared to lobectomy amongst the elderly (age ≥ 70 years). Patients with PCS were more likely to receive surgical treatment and had lower lymphatic metastasis compared to adenocarcinoma, squamous cell carcinoma and large cell carcinoma (all P CONCLUSIONSPCS had unique clinical features compared to common types of NSCLCs in terms of lymphatic invasion and surgical treatment. Pneumonectomy was associated with poorer survival in elderly patients.

OBJECTIVES The emergence of ultra-high-volume centres promises new opportunities for thoracic surgical training. The goal of this study was to investigate the effectiveness of a novel observership course in teaching video-assisted thoracoscopic surgery (VATS) at an ultra-high-volume centre. METHODS Two-week courses in VATS at a specialist unit now performing >10 000 major lung resections annually (>50 daily on average) were attended by 230 surgeons from around the world from 2013 to 2016. An online survey preserving responder anonymity was completed by 156 attendees (67.8%). RESULTS Attendees included 37% from Western Europe, 18% from Eastern Europe and 17% from Latin America. Experience with open thoracic surgery for more than 5 years was reported by 67%, but 79% had less than 5 years of VATS lobectomy experience. During the course, 70% observed over 30 uniportal VATS operations (including 38% observing over 50), and 69% attended an animal wet lab. Although 72% of the responders attended the course less than 12 months ago, the number of ports used (P

OBJECTIVES Although non-small-cell lung cancer (NSCLC) with malignant pleural nodules is generally contraindicated for surgery, there is no consensus concerning on-site operative decisions for unexpected, intraoperatively encountered malignant pleural disseminations. The rationale underlying the primary tumour removal and other aggressive interventions remains controversial. METHODS All surgical NSCLC cases (9576) of Shanghai Pulmonary Hospital between January 2005 and December 2013 were reviewed. Among them, 83 cases (0.9%) met the definition of 'unexpected' macroscopic malignant pleural nodules, despite routine preoperative evaluations for tumour metastasis. No pleural effusion was visualized in 52 cases during operations, and 31 had pleural effusion in minimal volume (

OBJECTIVES: Video-assisted thoracoscopic extended thymectomy (VATET) is commonly performed bilaterally to remove all the thymic tissue in the mediastinum for the surgical treatment of myasthenia gravis. We hypothesize that the therapeutic efficacy of unilateral thoracoscopic thymectomy (right-sided) is comparable to that of bilateral VATET. METHODS: We retrospectively reviewed 103 consecutive patients who received VATET for non-thymomatous myasthenia gravis (NTMG), with a minimum follow-up period of 36 months. RESULTS: Bilateral VATET was performed in the first 31 patients and right-sided VATET in the following 72. No patients died perioperatively. The operating time in the right-sided VATET group was significantly shorter than that in the bilateral VATET group (169.3 ± 19.3 vs 152.6 ± 20.7 min, P

OBJECTIVES This study was aimed to investigate potential benefits of thoracoscopic surgery for intralobar pulmonary sequestration in adult patients in terms of short-term surgical outcomes when compared with open surgery. METHODS Data of 110 consecutive adult patients undergoing thoracoscopic surgery or open surgery for intralobar sequestration from January 2000 to December 2015 at our institution were reviewed. A total of 42 video-assisted thoracic surgery cases and 68 open surgery cases were identified. Perioperative outcomes were compared between video-assisted thoracic surgery and open surgery to evaluate efficacy. RESULTS Neither group had surgical mortality. Although the overall morbidity was without statistical significance (P = 0.13), pleural effusion that required repeated thoracentesis was less frequent in thoracoscopic surgery (n = 1, 2.4% vs n = 11, 16.2%, P = 0.028). Thoracoscopic surgery was associated with less intraoperative bleeding [193 (standard deviation, SD 238) ml vs 241 (SD 221) ml, P = 0.013] and shorter postoperative stay [5.0 (SD 2.4) days vs 9.5 (SD 3.7) days, P

OBJECTIVES: The surgical outcome of neurogenic tumours arising at the thoracic apex remains largely undefined. In this retrospective study, we compared the efficacy and safety of thoracoscopic surgery and thoracotomy for neurogenic tumours at the thoracic apex in 63 patients who received surgical treatment between 1992 and 2012 at our medical centre. METHODS: Forty-four (69.8%) patients received thoracotomy (Group A) and 19 (30.2%) patients underwent video-assisted thoracoscopic surgery (Group B). Operative time, estimated blood loss (EBL), postoperative length of hospital stay and nervous system complications were recorded. RESULTS: The two groups of patients were comparable in demographic and baseline characteristics except that Group A patients had a significantly larger tumour size (mean, 4.9 ± 1.0 cm) than Group B patients (mean, 4.1 ± 1.2 cm; P = 0.01). The mean operative time was markedly greater for Group A (120.2 ± 41.2 min) than Group B (93.2 ± 34.5 min; P = 0.009). Group A had significantly greater EBL (245.23 ± 197.78 ml) than Group B (117.4 ± 138.2 ml; P < 0.001). Total tumour resection was achieved in all patients and all neurogenic tumours were benign. The mean length of postoperative hospital stay was markedly longer in Group A (7.0 ± 2.1 days) than Group B (4.8 ± 2.0; P < 0.001). Postoperatively, brachial plexus injury was found in 1 patient (2.3%) in Group A and 4 patients (21.1%) in Group B (P = 0.026). CONCLUSIONS: Though thoracoscopic surgery is associated with diminished blood loss, reduced operative time and shortened hospital stay, it has a markedly increased incidence of brachial plexus injury.

The present study attempted to evaluate the role of neoadjuvant chemotherapy combined with surgery in limited-disease small-cell lung cancer (LD-SCLC).A retrospective analysis was performed on 106 LD-SCLC patients who underwent complete resections from February 2000 to February 2012 in Shanghai Pulmonary Hospital. Among these cases, two cycles of neoadjuvant chemotherapies were administered to all pathologically confirmed patients [Group Neoadjuvant (Group N)]. For those without pathology, operations followed by adjuvant chemotherapies were performed [Group Adjuvant (Group A)]. Prognostic features and overall survival (OS) were compared using the log-rank test and calculated using the Kaplan-Meier method.Group N included 47 cases and Group A included 59 cases. A total of 57 patients were male and 49 were female, with a mean age of 56.1 ± 10.2 years. A total of 41 patients were at pathological stage (p-Stage) IIIa, and 65 patients were at I or II. The overall 5-year survival rate (5-YS) was 28%. The 5-YS for p-Stage I-II (n = 65) was significantly better than that of p-Stage III (n = 41) (35 vs 20%, P = 0.034). For p-Stage IIIa (pN2 positive), the 5-YS of Group N was significantly better than that of Group A (34 vs 12%, P = 0.020). The median overall survival for Group N and Group A in IIIa (pN2 positive) LD-SCLC patients were 46 and 15 months (P = 0.009), respectively. Multivariate analysis for survival showed mediastinal lymph node involvement; surgery and histopathology of SCLC were both significant independent predictors of long-term survival.Neoadjuvant chemotherapy combined with surgery provided reasonable options for pIIIa-N2 LD-SCLC patients, which can give them a better chance of survival.

A 47-year old woman presented with large cell carcinoma with extensive lengthwise and circumferential invasion of the lower trachea. End-to-end anastomosis by suture lines alone may be impossible and even harmful, following tumour resection with such extensive tracheal involvement. Thus, we performed a successful tracheal reconstruction with bronchoplastic closure without complications or recurrence at 12-month follow-up. This case highlights the use of this technique for the closure of massive airway defects.

OBJECTIVES Station 3A nodes have been commonly neglected in surgical practice. This retrospective study collected information on the incidence and risk factors of Station 3A node to ascertain the prognostic role of 3A nodal involvement. METHODS A total of 180 consecutive pN2 (stage IIIa) non-small-cell lung cancer (NSCLC) cases who underwent systemic lymphadenectomy and contained Station 3A nodes were enrolled. Survival rates were calculated according to the final pathology of Station 3A lymph node: Station 3A node (+) and Station 3A node (-). Statistical analysis was conducted using Kaplan-Meier and Cox regression models. RESULTS Station 3A nodal metastasis was validated in 32 cases, and the incidence of Station 3A node involvement was 17.8%. Station 3A nodes involvement was strongly associated with the metastatic status of Station 4R nodes and histological nature of pulmonary cancer. The overall 3-year survival was 53% and median survival time was 40.6 months. The 3-year survival difference was significant between Station 3A node (-) and Station 3A node (+) (63 vs 22%, χ(2) = 16.426, P < 0.001). Moreover, the overall 3-year survival was closely related with the number of involved nodal zones (χ(2) = 31.156, P < 0.001). Multivariate analysis showed two statistically significant risk factors for survival including metastasis of Station 3A node and the number of positive nodal zones (hazard ratios [HR]: 2.702; 95% confidence intervals [CI]: 1.008-7.242; P = 0.027; and HR: 7.404; 95% CI: 3.263-16.936, P < 0.001, respectively). CONCLUSIONS The involvement of Station 3A lymph nodes predicts poor prognosis of right-sided stage pIIIa-N2 NSCLC patients. Therefore, systemic lymphadenectomy for right-sided cancers should include Station 3A nodes when ascertaining a complete resection.

OBJECTIVES: Multidrug-resistant tuberculosis (MDR-TB), defined as tuberculosis resistant to at least isoniazid and rifampicin in vitro, poses a significant challenge to the control of TB worldwide. Despite global efforts to control tuberculosis, it remains the leading cause of death from an infectious agent. Although modern tuberculosis treatment relies on chemotherapy, surgery is accepted as adjuvant treatment for multidrug-resistant tuberculosis. METHODS: In a retrospective cohort study, 43 MDR-TB patients (28 males and 15 females: mean age 45.3 years) who underwent pulmonary resection between January 1993 and December 2011 were reviewed. Every patient with well-localized, cavitary lesions showed sputum-positive preoperatively. Individually tailored treatment regimens were selected at a once-weekly staff conference following review of the patient’s case history and drug susceptibility results. The variables that affected treatment outcomes were identified through multivariate regression analysis. RESULTS: There was no surgical mortality. Forty (93.0%) patients demonstrated sputum conversion and/or remained negative after surgery. Each patient had completed treatment, and during a mean of 81 follow-up months (range 18–214 months), 1 patient relapsed. This patient was cured after another course of treatment. Operative procedures included 30 (69.8%) lobectomies, 2 (4.7%) bilobectomies, 8 (18.6%) pneumonectomies and 3 (6.98%) lobectomies plus segmentectomy. There were no operation-related deaths, and there were five major postoperative complications (11.6%). Overall, 40 of 43 (93.0%) MDR-TB patients remained free of TB following surgery. The duration of chemotherapy before surgery had correlation with postoperative outcome (P= 0.001). CONCLUSIONS: The proper selection of the patients and early decision for surgical intervention can achieve a high success rate of pulmonary MDR-TB with well-localized pulmonary cavities.

The surgical treatment of pulmonary aspergilloma is challenging and controversial. This study was designed to evaluate the clinical profile, indications and surgical outcomes of pulmonary aspergilloma operated on in our institute. A total of 256 patients with pulmonary aspergilloma underwent surgical treatment from 1975 to 2010. The patients were divided into two groups: Group A (simple aspergilloma, n = 96) and Group B (complex aspergilloma, n = 160). The principal underlying lung disease was tuberculosis (71.1%). The surgical procedures consisted of 212 lobectomies in both groups; eight cavernoplasties, 10 bilobectomies, 16 pneumonectomies and six thoracoplasties in Group B; four segmentectomies and six wedge resections in Group A. Postoperative complications occurred in 40 patients (15.6%). The major complications were residual pleural space (3.9%), prolonged air leak (3.1%), bronchopleural fistula (1.6%), excessive bleeding (1.6%), respiratory insufficiency (1.9%) and empyema (1.2%). No intraoperative deaths occurred. The overall mortality within 30 days post-operation was 1.2%, occurring only in Group B. There was no statistically significant difference in the postoperative morbidity between Groups A and B (P = 0.27). With the good selection of patients, meticulous surgical techniques and good postoperative management, aggressive surgical treatment with anti-fungal therapy for pulmonary aspergilloma is safe and effective, and can achieve favourable outcomes.

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether it is valuable and safe to perform reoperation for recurrent thymoma. Altogether, more than 500 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. This paper includes 1 level 1a study and 15 level 2b studies. The operative mortality was reported in six studies, ranging from 0 to 13.3%, and the operative morbidity in five studies, ranging from 0 to 32.1%. Most patients suffering from operative mortality (5/5) and morbidity (16/19) had myasthenia gravis. One meta-analysis demonstrated improved rates of long-term overall survival in patients with recurrent thymoma who were treated surgically compared with those treated non-surgically. Ten studies showed better survival after surgical treatment than after non-surgical treatment with the difference being statistically significant in 4 of them. Two studies reported that the prognosis in patients with complete reresection was comparable with that of patients without recurrence. One study found that patients with a thymus-related syndrome improved after re-resection. Another two studies revealed that debulking surgery for recurrent thymoma was associated with poorer survival and worse outcomes than both complete resection and non-surgical therapy. From the papers identified in our search, we can conclude that reoperation can be performed with acceptable morbidity and low mortality in appropriately selected patients with locally and/or regionally recurrent thymoma. Both survival and thymus-related syndromes are improved if the recurrence is surgically resected when compared with other medical treatments. Debulking surgery should be limited to those few selected patients in whom other treatment options are not available. In addition, morbidity and mortality most commonly occur in association with myasthenia gravis, and hence medical control of this should be optimized prior to reoperation.

A 65-year old female with no history of smoking reported experiencing 6 months of tightness in the chest. Chest computed tomography showed two pulmonary nodules in the left upper lobe (one in S3 segment, the other in S4 segment), one nodule in the left lower lobe and a ground-glass opacity (GGO) in the right upper lobe. Synchronous bilateral thoracoscopic wedge resections of the lung were performed to investigate the nodules. Intraoperative frozen section pathology revealed that the two nodules in the left upper lobe were malignant, the nodule in the left lower lobe was a benign lesion and the GGO in the right upper lobe was an atypical adenomatous hyperplasia. As a result, a left upper lobectomy with lymph node dissection was performed. The final pathological diagnosis of the nodule in the left S3 segment was well differentiated adenocarcinoma (pT1bN0M0, IA), the nodule in the left S4 segment was moderately to poorly differentiated adenocarcinoma (pT1aN0M0, IA), the nodule in the left lower lobe was cryptococcal granuloma and the GGO in the right upper lobe was adenocarcinoma in situ. The patient is currently following a favourable course in her recovery. Here, we would like to share the surgical algorithm used for the treatment of heterogeneous bilateral quadruple pulmonary nodules.

We report the case of a 35-year old woman with a giant thymic carcinoid of the left hemithorax. Enhanced computed tomography showed marked vascularization of the tumour, with an enlarged drainage vein. Endovascular embolization of the major feeding arteries of the tumour was performed preoperatively with good angiographic results. A left thoracotomy was performed the following day. Minimal bleeding was observed due to prior embolization. The patient made a rapid postoperative recovery and was discharged 8 days later.

Thymic carcinoid tumour associated with pulmonary squamous cell carcinoma is very rare. We present a case of synchronous lung cancer and mediastinal tumour treated with simultaneous video-assisted thoracoscopic surgery (VATS) sleeve lobectomy and thymectomy. A 67-year old man presented with cough and bloody sputum. Chest computed tomography showed an anterior mediastinal mass with a right hilar nodule. A right upper sleeve lobectomy and a thymectomy were performed via a VATS approach. Thymic carcinoid tumour associated with pulmonary squamous cell carcinoma was diagnosed, and the patient received adjuvant radiochemotherapy.