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Esophageal leiomyoma is the most common benign tumor of the esophagus, which usually arises from the muscularis propria or muscularis mucosae. Incidence of benign esophageal neoplasms was reported to be in the range of 0.005% to 7.9% in autopsy cases, while leiomyomas account for 70–80% of them (1). Options for management include surveillance for small-sized tumors and surgical or endoscopic resection for large or symptomatic ones. Leiomyoma is commonly located in the lower two-thirds of the esophagus. In open surgery, right-sided surgical approach is preferred for lesions in the middle and upper esophagus, and left-sided approach for those in the distal lower esophagus. Video-assisted thoracoscopic surgery (VATS) for esophageal leiomyoma was first described by Everitt in 1992 (2,3). As scattered researches reported, enucleation of benign esophageal tumors can be performed effectively and safely with low morbidity (4-6), mostly through right-sided approach. The major complication after the enucleation of esophageal leiomyomas is mucosal injury, which may lead to esophageal leakage or perforation. We hereby report a novel approach using combined thoracoscopy and endoscopy to facilitate tumor removal and prevent mucosal injury.

Background: The purpose of this study is to develop a predictive model to accurately predict the malignancy of solid solitary pulmonary nodule (SPN) by data mining methods. Methods: A training cohort of 388 consecutive patients with solid SPNs was used to develop a predictive model to evaluate the malignancy of solid SPNs. By using SPSS Modeler, we utilized logistic regression (LR), artificial neural network (ANN), k-nearest neighbor (KNN), random forest (RF), and support vector machines (SVM) classifiers to build predictive models. Another cohort of 200 consecutive patients with solid SPNs was used to verify the accuracy of the predictive model. Predictive performance was evaluated using the area under the receiver operating characteristic curve (AUC). Results: There was no significant difference in patients’ characteristics between the training cohort and the validation cohort. The AUCs of LR, ANN, KNN, RF, and SVM models for the validation cohort were 0.874±0.0280 (P=0.605), 0.833±0.0351 (P=0.104), 0.792±0.0418 (P=0.014), 0.775±0.0400 (P=0.013), and 0.890±0.0323 (reference), respectively. The SVM algorithm had the highest AUC, and the best sensitivity (90.3%), specificity (80.4%), positive predictive value (93.9%), negative predictive value (71.2%) and accuracy (88.0%) for the validation cohort among the five models. Conclusions: Data mining by SVM might be a useful auxiliary algorithm in predicting malignancy of solid SPNs.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has been increasingly used in the treatment of lung cancers. But it is still unclear whether mediastinal lymph node dissection (LND) under VATS is safe and feasible. The aim of this study is to figure out whether LND by VATS is safe and feasible. METHODS: Consecutive patients with primary resectable lung cancers referred for lobectomy and LND or sampling by VATS between January 2012 and December 2016 were retrospectively reviewed. Clinicopathological characteristics and perioperative results were collected for statistical analysis. RESULTS: Seven-hundred and seventy-three VATS lobectomy patients were included in this study, 494 received LND and 279 received lymph node sampling (LNS). There were more male patients, higher pathological T and N stage in the LND group than in the LNS group. Multivariate analysis suggested that clinical N stage higher than cN0 category and LND were independent risk factors for finding pN2 diseases in all lung cancers, while higher than cN0 category, solid or micropapillary component, and LND were independently related to finding pN2 stage in adenocarcinomas. Propensity-score matching rendered 279 pairs of patients with no significant difference in age, gender, co-morbidity, tumor location, or T stage. Although the LND group had longer operation time (128 vs. 114 minutes, P

Esophageal cancer (EC) is a highly prevalent malignancy in China. According to the data released by National Cancer Registry Center of China in 2015, the prevalence of EC was 21.17/100,000 in China in 2012, ranking fifth among all malignancies; the mortality rate was 15.58/100,000, ranking fourth. It is expected that there will be 477,900 new EC cases nationwide in 2015, whereas 375,000 people will die from EC (1,2). Worldwide, EC is the 8 th most common malignancy, with 416,000 new cases in 2012 (3). At present, EC treatment is based on multidisciplinary treatment, but surgery remains the most effective therapy in optimizing long-term prognosis in patients without metastatic disease. The ideal surgical approach is a matter of debate.

In 1883, Leyden successfully performed percutaneous transthoracic needle biopsy (PTNB) of the lung in three patients with pneumonia according the records (1); three years later, Menetrier was the first recorded to employ this technique for the diagnosis of lung cancer (2).

Surgery is the most important therapy for thymic malignancies. The last decade has seen increasing adoption of minimally invasive thymectomy (MIT) for thymic tumors. MIT for early stage diseases has been shown to yield similar oncological results while being helpful in minimizing surgical trauma, improving postoperative recovery, and reducing incisional pain. Similar surgical and oncological principles should be observed in both minimally invasive and open procedures so as to ensure radical resection and accurate staging of the tumor.

Cancer is an independent major risk factor for venous thromboembolism (VTE), which is the second leading cause of death in medically and surgically treated patients with cancer (1-5). The association between VTE and lung cancer has been reported more than 20 years ago (6,7).

Limited resections for early stage lung cancer have been of increasing interests recently. However, it is still unclear to what extent a limited resection could preserve pulmonary function comparing to standard lobectomy, especially in the context of minimally invasive surgery. The purpose of this study was to evaluate postoperative changes of spirometry in patients undergoing video-assisted thoracic surgery (VATS) lobectomy or limited resections.Spirometry tests were obtained prospectively before and 6 months after 75 VATS lobectomy, 34 VATS segmentectomy, 15 VATS wedge resection. Eleven VATS mediastinal procedures without lung resection were taken as a control group. Results were compared between groups of different resection extent.Demographic characteristics and preoperative pulmonary function showed no differences among the four groups. Forced vital capacity (FVC) loss after lobectomy was significantly greater than after segmentectomy (P=0.048), and much significantly greater than after wedge resection (P0.001). Forced expiratory volume in 1 second (FEV1) loss after lobectomy was similar to segmentectomy (P=0.273), both significantly greater than after wedge resection (P0.01). Diffusing capacity of the lungs for carbon monoxide (DLCO) loss was similar among these three groups (P=0.293). There was no significant difference in any spirometry index between wedge resection and mediastinal procedures (FVC: P=0.856; FEV1: P=0.671; DLCO: P=0.057). When compared by average value per segment resected, pulmonary function loss was significantly less after lobectomy than after segmentectomy in all spirometry indexes (P0.001). On average, pulmonary function loss was around 5% per segment for VATS lobectomy and 10% per segment for VATS segmentectomy.In minimal invasive surgery, wedge resection best preserves pulmonary function with similar spirometry change with VATS mediastinal procedures without lung resection. Compared with VATS lobectomy, VATS segmentectomy may help minimize loss of FVC but not FEV1 or DLCO. Pulmonary function loss per segment resected is doubled after VATS segmentectomy than after lobectomy. These results should be taken into account when deciding the extent of resection for patients with early stage lung cancer.

Background: Segmentectomy for small-sized stage Ia non-small cell lung cancer (NSCLC) may be comparable to lobectomy regarding prognosis and local recurrence. However, the clinical results of wedge resection for such patients are still under debate. In this international multicenter study, we retrospectively studied surgical outcomes of sublobar resections for patients with small-sized stage Ia adenocarcinoma to elucidate whether wedge resection is inferior to segmentectomy for such patients. Methods: Between March 2000 and August 2011, 173 patients underwent segmentectomy (group I), and 181 patients underwent wedge resection (group II) at three institutions in Japan and China. The tumor was defined as Ground glass opacity (GGO) type when the proportion of GGO was equal or more than 50% in HRCT, while solid type was defined as the proportion of GGO less than 50%. Clinicopathologic factors, local recurrence rate, and survival were compared. Results: The two groups were similar in sex, comorbidity rate, and composition of Noguchi type. There was no in-hospital death. Postoperative morbidity rate of group I was significantly higher than that of group II (11.0% vs . 2.2%, P=0.016). Local recurrence rates were similar between group I (4.0%) and group II (4.4%), while no patient with GGO type tumors had local recurrence. Overall and lung cancer-specific survivals were of no significant difference between the two groups. Lung cancer-specific survival rates at 10 years were significantly better in patients with GGO type tumors than in those with solid type tumors (100% vs . 76.9%, P Conclusions: Our data suggests that sublobar resection is an acceptable procedure for small lung adenocarcinomas without nodal involvement, and wedge resection may not be inferior to segmentectomy for small GGO type tumors. Our study also demonstrates that GGO type is an independent prognostic factor of disease-free survival for small-sized (diameter ≤2.0 cm) stage Ia lung adenocarcinomas.

Background: Discuss an appropriate strategy for treatment of invasive thymoma invading adjacent great vessels. Methods: A retrospective study on 25 patients with invasive thymoma invading neighboring great vessels was performed. The corresponding data including clinical presentation, operation procedure, adjuvant radio-chemotherapy and follow-up were reviewed. Results: Twenty of 25 (80%) patients with invasive thymoma underwent complete resection of the tumor along with vessel reconstruction. Intraoperatively, different types of operation were conducted, namely, brachiocephalic vein (BCV)-right atrial appendage (RAA) reconstruction in 11 cases, complex vessel reconstruction (more than one graft) in 1 case and superior vena cava (SVC)-SVC reconstruction in the remaining cases. Ringed polytetrafluoroethylene (PTFE) grafts were used for vessel reconstruction. Postoperatively, three cases suffered from pulmonary infection, and three cases had haemothorax, chylothorax and atelectasis, respectively. Two patients died due to acute respiratory distress syndrome within 90 days after the surgery. Within the remaining patients, 11 cases (44%) experienced a relapse and finally 8 (32%) patients died. Compared to R1 resection group, R0 resection group had a better prognosis (Log-rank P=0.0196). The 3- and 5-year survival rates were 79.6% and 59.1%, with median survival time of 84 months. Conclusions: Reconstruction of mediastinal vessels for invasive thymoma is a feasible technology method. Radical resection of the tumor with involved neighboring structures is the key to prolong overall survival for patients suffered from invasive thymoma.

Background: Video-assisted thoracoscopic surgery (VATS) is now increasingly used for the treatment of early stage thymic malignancies. However, VATS has not been advocated for patients with locally advanced diseases. We reviewed our initial experience in VATS thymectomy with partial superior vena cava (SVC) resection for IASLC/ITMIG stage III thymic tumors. Methods: From August 2017 to October 2018, patients who underwent VATS thymectomy with partial SVC resection were retrospectively reviewed, and peri-operative outcomes and short-term follow-up results were analyzing. Results: Four patients with partial SVC resection via VATS were identified. All of them had pathologically confirmed IASLC/ITMIG stage III thymic tumors invading the SVC. The average of operative time was 228 minutes and mean blood loss was 88 mL. The mean duration of chest tube drainage and post-operative hospital stay were 4.5 and 7.3 days respectively. No major complication was encountered after surgery. No mortality was observed. And no recurrence was detected with the longest follow-up time of 14 months. Conclusions: With careful patient selection and plenty surgical expertise, VATS thymectomy for locally invasive thymic tumors with limited the SVC invasion is challenging yet technically feasible.

Thymoma is an epithelial neoplasm of the thymus. It commonly lies in the anterior mediastinum and represents 20–30% of mediastinal tumours in adults. In this report we present a case of giant thymoma locating in the anterior-inferior mediastinum. A 46-year-old male came to our institute with slight pectoralgia and dyspnea. Chest CT shows a giant tumor measuring 19 cm × 16 cm × 15 cm in the left thoracic cavity. After careful examination, we performed surgery. At surgery, we found the tumor was adherent to left upper lobe of the lung, mediastinal pleura, and parietal pleural. The tumor was completely resected with combined resection of part left upper lobe of lung. The weight of the tumor was 2,135 g. Pathological diagnosis indicated a type AB thymoma according to the World Health Organization classification and a diagnosis of Masaoka stage IIB was made.

The World Health Organization (WHO) histological classification of the thymoma and thymic carcinoma (TC) has been criticized for poor interobserver reproducibility or inconsistencies in the routine pathological diagnosis. The International Thymic Malignancy Interest Group (ITMIG) panel achieved an agreement to maintain the widely accepted WHO framework but to refine historic definitions and histological criteria, and further introduce some new terms with the aim to improve interobserver reproducibility. This review addresses the enlightenments we can get from the ITMIG consensus on the WHO histological classification of the thymoma and TC, which may be helpful for most pathologists.

To compare the predictive effect of the Masaoka-Koga staging system and the International Association for the Study of Lung Cancer (IASLC)/the International Thymic Malignancies Interest Group (ITMIG) proposal for the new TNM staging on prognosis of thymic malignancies using the Chinese Alliance for Research in Thymomas (ChART) retrospective database.From 1992 to 2012, 2,370 patients in ChART database were retrospectively reviewed. Of these, 1,198 patients with complete information on TNM stage, Masaoka-Koga stage, and survival were used for analysis. Cumulative incidence of recurrence (CIR) was assessed in R0 patients. Overall survival (OS) was evaluated both in an R0 resected cohort, as well as in all patients (any R status). CIR and OS were first analyzed according to the Masaoka-Koga staging system. Then, they were compared using the new TNM staging proposal.Based on Masaoka-Koga staging system, significant difference was detected in CIR among all stages. However, no survival difference was revealed between stage I and II, or between stage II and III. Stage IV carried the highest risk of recurrence and worst survival. According to the new TNM staging proposal, CIR in T1a was significantly lower comparing to all other T categories (P0.05) and there is a significant difference in OS between T1a and T1b (P=0.004). T4 had the worst OS comparing to all other T categories. CIR and OS were significantly worse in N (+) than in N0 patients. Significant difference in CIR and OS was detected between M0 and M1b, but not between M0 and M1a. OS was almost always statistically different when comparison was made between stages I-IIIa and stages IIIb-IVb. However, no statistical difference could be detected among stages IIIb to IVb.Compared with Masaoka-Koga staging, the IASLC/ITMIG TNM staging proposal not only describes the extent of tumor invasion but also provides information on lymphatic involvement and tumor dissemination. Further study using prospectively recorded information on the proposed TNM categories would be helpful to better grouping thymic tumors for predicting prognosis and guiding clinical management.

Thymic tumors are relatively rare malignancies comparing to other solid tumors in the chest (1). Its incidence is estimated to be at 3.93 per 1,000,000, which is about 1/00 of lung cancer and 1/25 of esophageal cancer in China. And it appears to be higher than that reported from North America, which is only 2.14 per 1,000,000 according to the SEER database. However, in the SEER database, the incidence rate was much higher in Asians (3.74 per 1,000,000) than in Caucasians (1.89 per 1,000,000) and close to the data from China. This implicates that there might be some ethnical and generic difference in thymic tumors. In the meantime, both these two registrations record only ‘malignant tumors’ that are clinically advanced diseases. A large part of early stage, low grade lesions are considered ‘benign tumors’ and thus, not registered. Therefore, the actual incidence of thymic tumors is much under-estimated. With the increasing use of screening for other malignancies such as lung cancer, it can be expected that more early stage thymic tumors would be discovered.

Esophageal cancer is an aggressive malignancy and a major cause of cancer-related deaths globally. In 2012, about 460,000 new cases of esophageal cancer were diagnosed worldwide, with 400,000 deaths attributed to the disease (1).

Esophageal cancer is ranked as the malignant tumor with the 6th highest morbidity and mortality rate worldwide. Chinese people are prone to develop esophageal cancer, and the number of new cases that occur every year account for more than half of the esophageal cancer patients worldwide (1,2). Although reports have confirmed the effectiveness of chemoradiotherapy for esophageal cancer, esophageal resection remains the primary means of treatment. Anastomotic leaks and pulmonary complications are the most common postoperative complications of esophageal cancer and carcinoma of the gastric cardia. Pulmonary complications have become more noticeable (3) as the incidence of postoperative anastomotic fistula (8–15%) has decreased due to the improvement of surgical techniques, the use of disposable staplers, and the continuous improvement of postoperative nutritional support Cervical and upper thoracic esophageal cancer are associated with a higher risk for postoperative pulmonary infection.

Background: The purpose of this study was to develop a predictive model that could accurately predict the malignancy of the pulmonary ground-glass nodules (GGNs) and the invasiveness of the malignant GGNs. Methods: The authors built two binary classification models that could predict the malignancy of the pulmonary GGNs and the invasiveness of the malignant GGNs Results: Results of our developed model showed random forest could achieve 95.1% accuracy to predict the malignancy of GGNs and 83.0% accuracy to predict the invasiveness of the malignant GGNs. Conclusions: The malignancy and invasiveness of pulmonary GGNs could be predicted by random forest.

Background To assess the feasibility and perioperative outcomes of single-port (SP) and multi-port (MP) approaches for video-assisted thoracoscopic surgery (VATS) lobectomy and anatomical segmentectomy. Methods Retrospective data from 458 patients who received VATS lobectomy or anatomical segmentectomy at Shanghai Chest Hospital, Korea University Guro Hospital, Affiliated Hospital of National Taiwan University, University of Hong Kong Queen Mary Hospital and Shenzhen Hospital were collected. Patients were divided into SP group and MP group according to the surgical approach. Perioperative factors such as operation time, blood loss during surgery, conversion rate, the number and stations of lymph nodes harvested, postoperative chest tube drainage time, postoperative hospitalization time, perioperative morbidity and mortality, and pain scores during the first 3 days after surgery were compared between the two groups. Results There were no differences in the number (P=0.278) and stations (P=0.564) of lymph nodes harvested, postoperative morbidity (P=0.414) or mortality(P=0.246), and pain score on the third day (P=0.630) after surgery between the two groups. The SP group had a longer operation time (P=0.042) and greater intraoperative blood loss (P

Patients undergoing lobectomy are at significantly increased risk of lung injury. One-lung ventilation is the most commonly used technique to maintain ventilation and oxygenation during the operation. It is a challenge to choose an appropriate mechanical ventilation strategy to minimize the lung injury and other adverse clinical outcomes. In order to understand the available evidence, a systematic review was conducted including the following topics: (I) protective ventilation (PV); (II) mode of mechanical ventilation [e.g., volume controlled (VCV) versus pressure controlled (PCV)]; (III) use of therapeutic hypercapnia; (IV) use of alveolar recruitment (open-lung) strategy; (V) pre-and post-operative application of positive end expiratory pressure (PEEP); (VI) Inspired Oxygen concentration; (VII) Non-intubated thoracoscopic lobectomy; and (VIII) adjuvant pharmacologic options. The recommendations of class II are non-intubated thoracoscopic lobectomy may be an alternative to conventional one-lung ventilation in selected patients. The recommendations of class IIa are: (I) Therapeutic hypercapnia to maintain a partial pressure of carbon dioxide at 50–70 mmHg is reasonable for patients undergoing pulmonary lobectomy with one-lung ventilation; (II) PV with a tidal volume of 6 mL/kg and PEEP of 5 cmH 2 O are reasonable methods, based on current evidence; (III) alveolar recruitment [open lung ventilation (OLV)] may be beneficial in patients undergoing lobectomy with one-lung ventilation; (IV) PCV is recommended over VCV for patients undergoing lung resection; (V) pre- and post-operative CPAP can improve short-term oxygenation in patients undergoing lobectomy with one-lung ventilation; (VI) controlled mechanical ventilation with I:E ratio of 1:1 is reasonable in patients undergoing one-lung ventilation; (VII) use of lowest inspired oxygen concentration to maintain satisfactory arterial oxygen saturation is reasonable based on physiologic principles; (VIII) Adjuvant drugs such as nebulized budesonide, intravenous sivelestat and ulinastatin are reasonable and can be used to attenuate inflammatory response.

To study the role of postoperative chemotherapy and its prognostic effect in Masaoka-Koga stage III and IV thymic tumors.Between 1994 and 2012, 1,700 patients with thymic tumors who underwent surgery without neoadjuvant therapy were enrolled for the study. Among them, 665 patients in Masaoka-Koga stage III and IV were further analyzed to evaluate the clinical value of postoperative chemotherapy. The Kaplan-Meier method was used to obtain the survival curve of the patients divided into different subgroups, and the Cox regression analysis was used to make multivariate analysis on the factors affecting prognosis. A Propensity-Matched Study was used to evaluate the clinical value of chemotherapy.Two-hundred and twenty-one patients were treated with postoperative chemotherapy, while the rest 444 cases were not. The two groups showed significant differences (P0.05) regarding the incidence of myasthenia gravis, World Health Organization (WHO) histological subtypes, pathological staging, resection status and the use of postoperative radiotherapy. WHO type C tumors, incomplete resection, and postoperative radiotherapy were significantly related to increased recurrence and worse survival (P0.05). Five-year and 10-year disease free survivals (DFS) and recurrence rates in patients who underwent surgery followed by postoperative chemotherapy were 51% and 30%, 46% and 68%, comparing with 73% and 58%, 26% and 40% in patients who had no adjuvant chemotherapy after surgery (P=0.001, P=0.001, respectively). In propensity-matched study, 158 pairs of patients with or without postoperative chemotherapy (316 patients in total) were selected and compared accordingly. Similar 5-year survival rates were detected between the two groups (P=0.332).Pathologically higher grade histology, incomplete resection, and postoperative radiotherapy were found to be associated with worse outcomes in advanced stage thymic tumors. At present, there is no evidence to show that postoperative chemotherapy may help improve prognosis in patients with Masaoka-Koga stage III and IV thymic tumors.

Adenocarcinoma has become the most common histologic type of lung cancers. Ground glass nodules (GGN), most of them early stage noninvasive or minimally invasive adenocarcinomas (MIA), have been encountered more frequently with the application of computed tomography (CT) screening. The International Association for the Study of Lung Cancer (IASLC)/American Thoracic Society (ATS)/European Respiratory Society (ERS) histologic lung adenocarcinoma classification combines radiologic, histologic, clinic, and molecular features to form a diagnostic approach for different subgroups of diseases. One of the major focuses of this new classification is the introduction of adenocarcinoma in situ (AIS) and MIA, to replace the old term of bronchioloalveolar carcinoma (BAC). Not all GGNs are malignant lesions that should be surgically resected upon first presentation. A management approach different to solid nodules has been suggested based on the understanding that these lesions tend to have a more indolent nature. Hasty intervention should be avoided and potential surgical risks, radiation exposure, patient psychology, and socio-economical burden must be balanced comprehensively before surgery is decided upon. In the mean time, surgical issues concerning extent of resection and lymphadenectomy should also be carefully contemplated once intervention is deemed necessary. Extremely good prognosis with a near 100% disease-free survival could be expected when a pure GGN is completely resected. This has led to re-evaluation of sublobar resections, including both segmentectomy and big wedge resection, for small (≤2 cm) less invasive histology (AIS or MIA) appearing as GGN on CT scan. Evidences are accumulating that these limited resections are oncologically equivalent to standard lobectomy. And extensive lymph node dissection may not have additional staging or prognostic benefit. These would add new meaning to the contemporary definition of minimally invasive surgery for lung cancers. Overall, joint effort from a multiple disciplinary team is imperative, and decision making should be based on both anatomical and biological nature of the disease.

Acute lung injury (ALI) is a major cause of morbidity and mortality after open thoracotomy. The purpose of the study was to identify the incidence and risk factors for ALI so as to prevent its occurrence and improve surgical results.A prospective controlled study was carried out in 364 patients undergone open thoracotomy. Fifty-eight high risk elderly patients and 56 young patients as matched controls were prospectively entered into the study. The two groups were compared to identify the possible risk factors for ALI.ALI occurred exclusively in elderly patients, accounted for 2.7% of the whole series (10/364) and 7.9% of elderly patients (10/127). The mortality for patients with ALI was 30%, significantly higher than those without (1.0%, P=0.001). Upon univariate analysis, increased age, obesity, chronic obstructive pulmonary disease (COPD), poor spirometry, and positive fluid balance on postoperative day 1 were associated with increased risk of developing ALI. Upon multivariate analysis, only poor spirometry and excessive positive fluid balance on postoperative day 1 were revealed as independent risk factors for ALI.ALI after open thoracotomy has a high mortality. COPD and excessive positive fluid balance on the first postoperative day are significant predictors, suggesting stringent patient selection and timely conservative fluid management may be helpful in reducing this extremely devastating complication.