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Over 2.5% of deaths in Canada occur as a result from medical assisting in dying (MAID), and a subset of these deaths result in organ donation. However, detailed outcomes of lung transplant recipients using these donors is lacking. This is a retrospective single center cohort study comparing lung transplantation outcomes after donation using MAID donors compared to neurologically determined death and controlled donation after circulatory death (NDD/cDCD) donors from February 2018 to July 2021. Thirty-three patients received lungs from MAID donors, and 560 patients received lungs from NDD/cDCD donors. The donor diagnoses leading to MAID provision were degenerative neurological diseases (n = 33) and end stage organ failure (n = 5). MAID donors were significantly older than NDD/cDCD donors (56 [IQR 49-64] years vs. 48 [32-59]; p = .0009). Median ventilation period and 30 day mortality were not significantly different between MAID and NDD/cDCD lungs recipients (ventilation: 1 day [1-3] vs 2 days [1-3]; p = .37, deaths 0% [0/33] vs. 2% [11/560], p = .99 respectively). Intermediate-term outcomes were also similar. In summary, for lung transplantation using donors after MAID, recipient outcomes were excellent. Therefore, where this practice is permitted, donation after MAID should be strongly considered for lung transplantation as a way to respect donor wishes while substantially improving outcomes for recipients with end-stage lung disease.

BACKGROUND Donor-recipient size-matching has been repeatedly reported to improve outcomes following lung transplantation (LTx). However, there is significant variability in practice and the optimal strategy for size-matching is yet to be defined. For recipients with ILD, size-matching decisions are complicated by concerns regarding the potential impact of pre-LTx pulmonary restriction. We evaluate whether a specific donor-to-recipient size-matching strategy, based on predicted total lung capacity, benefits this patient group. METHODS This retrospective, single-centre, cohort study describes the post-LTx outcomes of adults who underwent LTx for ILD between 1983 and 2020. Only patients with restrictive physiology, based on pre-LTx pulmonary function testing were included. Post-LTx outcomes were compared based on donor-recipient predicted TLC (D-R pTLC) ratio. A D-R pTLC ratio of ≥0.8 or

BACKGROUND The contribution of lung transplantation to the treatment of patients with end-stage cystic fibrosis (CF) has been debated. We aimed to describe achievable outcomes from high-volume CF and lung transplant programs. This study reports on the largest single-center experience of lung transplantation for adult and pediatric patients with CF. It also highlights the evolution of practice and outcomes over time. METHODS A retrospective analysis of the prospectively collected Toronto Lung Transplant database was carried out. Post-transplant survival in CF was calculated using the Kaplan–Meier method and analyzed with log-rank tests. RESULTS From 1983 to 2016, a total of 1,885 transplants were performed at our institution, where 364 (19.3%) were CF recipients and another 39 (2.1%) were CF retransplants. The mean age at first transplant was 29.5 ± 9.7 years where 56.6% were males and 91.5% were adults. Pre-transplantation, 88 patients (24.2%) were Burkholderia cepacia complex (BCC)-positive, 143 (39.3%) had diabetes mellitus, and the mean forced expiratory volume in one second was 26.0 ± 7.2%, as predicted at listing. The 1-, 5-, and 10-year probabilities of survival in adults who were BCC-negative were 94%, 70%, and 53%, respectively. Pediatric, BCC-positive, and retransplant recipients had worse survival than adult patients who were BCC-negative. Strategies to improve the donor pool did not affect survival but possibly reduced waitlist mortality. For the entire cohort, the most common causes of death after lung transplant were infection and chronic lung allograft dysfunction. CONCLUSIONS Lung transplantation for CF provides excellent short- and long-term outcomes. These results strongly support lung transplantation as the standard of care for patients with CF having advanced lung disease.

Uncontrolled donation after cardiac death (uDCD) has the potential to ameliorate the shortage of suitable lungs for transplant. To date, no lung transplant data from these donors are available from North America. We describe the successful use of these donors using a simple method of in situ lung inflation so that the organ can be protected from warm ischemic injury. Forty-four potential donors were approached, and family consent was obtained in 30 cases (68%). Of these, the lung transplant team evaluated 16 uDCDs on site, and 14 were considered for transplant pending ex vivo lung perfusion assessment. Five lungs were ultimately used for transplant (16.7% use rate from consented donors). The mean warm ischemic time was 2.8 hours. No primary graft dysfunction grade 3 was observed at 24, 48, or 72 hours after transplant. Median intensive care unit stay was 5 days (range: 2-78 days), and median hospital stay was 17 days (range: 8-100 days). The 30-day mortality was 0%. Four of 5 patients are alive at a median of 651 days (range: 121-1254 days) with preserved lung function. This study demonstrates the proof of concept and the potential for uDCD lung donation using a simple donor intervention.

Background The use of a novel extracellular oxygen carrier (EOC) preservation additive known as HEMO2Life has recently been shown to lead to a superior preservation of different types of solid organs. Our study aimed to investigate the effect of this EOC on extending lung preservation time and its mechanism of action. Methods Donor pigs were randomly allocated to either of the following 2 groups (n = 6 per group): (1) 36 hours cold preservation or (2) 36 hours cold preservation with 1 g/liter of EOC. The lungs were evaluated through 12 hours of normothermic ex vivo lung perfusion (EVLP) followed by a left-single lung transplant into a recipient pig. Grafts were reperfused for 4 hours, followed by right pulmonary artery clamping to assess graft oxygenation function. Results During EVLP assessment, EOC-treated lungs showed improvements in physiologic parameters, whereas the control lungs deteriorated. After a total of 48 hours of preservation (36 hours cold + 12 hours normothermic EVLP), transplanted grafts in the treatment group displayed significantly better oxygenation than in the controls (PaO2/FiO2: 437 ± 36 mm Hg vs 343 ± 27 mm Hg, p = 0.041). In addition, the use of EOC led to significantly less edema formation (wet-to-dry ratio: 4.95 ± 0.29 vs 6.05 ± 0.33, p = 0.026), less apoptotic cell death (p = 0.041), improved tight junction preservation (p = 0.002), and lower levels of circulating IL-6 within recipient plasma (p = 0.004) compared with non-use of EOC in the control group after transplantation. Conclusion The use of an EOC during an extended pulmonary preservation period led to significantly superior early post-transplant lung function.

Background There is still controversy whether full lung palpation is required for patients undergoing pulmonary metastasectomy. We aimed to compare pulmonary ipsilateral recurrence (IR) after video-assisted thoracic surgery (VATS) or open surgery. Methods A retrospective study of all patients who underwent surgery for colorectal cancer lung metastases between 2003 and 2012 was performed. IR rate was compared between the 2 groups after adjusting for a propensity score matching based on age, sex, disease-free interval, number of metastases, type of resection, presence of a cardiovascular risk factor, presence of a respiratory risk factor, as well as the interaction between the number of metastases and the disease-free interval. The propensity score was used for matched and weighted comparisons of VATS and open patients. Results A total of 211 patients underwent surgery for colorectal cancer lung metastases. Of these, 75 (35.5%) were performed via VATS and 136 (64.5%) via open surgery. Before matching, 118 (55.9%) were male and the median age at the time of metastases diagnosis was 61 (range, 49.8-72.2) years. Median disease free-interval was 20 (19.7 ± 28.3) months; 22 (21.6 ± 28.5) months in VATS and 19 (19.0 ± 28.3) months in open surgery. In total, 19 (25.3%) developed IR in VATS, and 39 (28.7%) in open surgery. Five-year overall survival was 53.1% (61.9% VATS; 49.2% open). In the matched sample, IR was 23.6% in VATS vs 26.2% in open surgery (95% confidence interval for risk reduction with VATS: –22.6% to 17.5%; P = .80). Conclusions No significant difference was observed in IR rates between VATS and open surgery in the treatment of colorectal cancer lung metastases.

Summary Background A substantial proportion of organ donors test positive for hepatitis C virus (HCV) infection. To date, only a few studies have evaluated the safety of using lungs from these donors for transplantation, and no direct interventions to donor organs have been done with the aim of preventing HCV transmission via organ transplantation. We aimed to assess the safety and efficacy of lung transplantation in humans from HCV-positive donors to HCV-negative recipients after application of ex-vivo lung perfusion (EVLP) plus ultraviolet C (UVC) perfusate irradiation. Methods We did a single centre, prospective, open-label, non-randomised trial in which donor lungs from HCV-viraemic donors (HCV-positive) were transplanted into HCV-negative recipients at Toronto General Hospital, University Health Network (Toronto, ON, Canada). Donors were younger than 65 years old and tested positive for HCV by nucleic acid testing. Donors who tested positive for hepatitis B virus, HIV, human T-lymphotropic virus 1 or 2 were excluded. Recipients were on the lung transplant waiting list without significant liver disease (stage 2 fibrosis or higher were excluded) or active HCV infection. Before implantation, all HCV-positive donor lungs were treated with EVLP with or without UVC perfusate irradiation to reduce the concentration of HCV RNA and infectivity. For the first week after transplantation, patients' HCV RNA blood concentrations were measured once daily, then once per week for 12 weeks. All patients received 12 weeks of oral sofosbuvir 400 mg plus velpatasvir 100 mg, starting at least 2 weeks after transplantation. The primary endpoint was a composite of survival and HCV-free status at 6 months after transplantation in all patients who received HCV-positive lungs. Patient outcomes such as survival, time in hospital, and incidence of acute rejection were compared between those receiving HCV-positive lungs and all patients who received HCV-negative lung transplants during the study period. The study is registered with ClinicalTrials.gov, NCT03112044. Findings From Oct 1, 2017, to Nov 1, 2018, 209 patients had a transplantation; of 27 donors who were HCV-positive and initially considered, 22 were suitable for transplantation. The remaining 187 donors were HCV-negative. Before implantation, 11 of the HCV-positive donor lungs were treated with EVLP alone and the other 11 were treated with EVLP plus UVC. Lung disease, urgency status, and positive donor-recipient HLA crossmatch were similar between the patients who received HCV-positive and HCV-negative lungs. 20 (91%) patients in the HCV-positive group developed HCV viraemia within the first week after transplantation and had sofosbuvir plus velpatasvir treatment, starting at a median of 21 days after transplantation (IQR 16·76–24·75). Donor organ treatment with EVLP plus UVC was associated with significantly lower recipient viral loads in blood within the first week after transplantation than with EVLP alone (median of 167 IU/mL [IQR 20–12 000] vs 4390 IU/mL [1170–112 000] at day 7; p=0·048) and prevented transmission in two (18%) of 11 patients. All 20 infected patients achieved negative HCV PCR within 6 weeks of treatment initiation. The primary endpoint of survival and HCV-free status at 6 months after transplantation was achieved in 19 (86%) of 22 patients in the HCV-positive group. 6-month survival was 95% in recipients receiving lungs from HCV-viraemic donors versus 94% in recipients receiving lungs from HCV-negative donors. The most common grade 3–4 adverse events in the HCV-positive group were respiratory complications (five [23%]) and infections (four [18%]). Serious adverse events requiring admission to hospital occurred in ten (45%) patients. One (5%) patient who did not develop HCV infection died at day 31 from multiorgan failure related to pseudomonas sepsis. Two patients presented with HCV relapse within 3 months after sofosbuvir plus velpatasvir completion and required retreatment. Interpretation Early and intermediate clinical outcomes were not significantly different between patients receiving viraemic HCV donor lungs and HCV-negative donor lungs. Donor organ treatment with UVC perfusate irradiation during EVLP significantly decreased HCV viral loads within the first 7 days after transplantation and shows the proof-of-concept for a novel approach of minimising viral load ex vivo before transplantation, with intent of preventing donor–recipient transmission. Funding Canadian Institutes of Health Research.

Chronic lung diseases remain major healthcare burdens, for which the only curative treatment is lung transplantation. In vitro human models are promising platforms for identifying and testing novel compounds to potentially decrease this burden. Directed differentiation of pluripotent stem cells is an important strategy to generate lung cells to create such models. Current lung directed differentiation protocols are limited as they do not 1) recapitulate the diversity of respiratory epithelium, 2) generate consistent or sufficient cell numbers for drug discovery platforms, and 3) establish the histologic tissue-level organization critical for modeling lung function. In this review, we describe how lung development has formed the basis for directed differentiation protocols, and discuss the utility of available protocols for lung epithelial cell generation and drug development. We further highlight tissue engineering strategies for manipulating biophysical signals during directed differentiation such that future protocols can recapitulate both chemical and physical cues present during lung development., Graphical abstractUnlabelled Image, Highlights • Detailed review of existing directed differentiation protocols in the lung. • Utility and limitations of differentiation products in drug screening platforms. • Relevance and limited application of biophysical cues in lung differentiation. • Tissue engineering strategies for manipulating biophysical signals in protocols.

The study objective was to determine whether donor substance abuse (opioid overdose death, opioid use, cigarette or marijuana smoking) impacts lung acceptance and recipient outcomes.Donor offers to a single center from 2013 to 2019 were reviewed to determine if lung acceptance rates and recipient outcomes were affected by donor substance abuse.There were 3515 donor offers over the study period. A total of 154 offers (4.4%) were opioid use and 117 (3.3%) were opioid overdose deaths. A total of 1744 donors (65.0%) smoked cigarettes and 69 donors (2.6%) smoked marijuana. Of smokers, 601 (35.0%) had less than 20 pack-year history and 1117 (65.0%) had more than 20 pack-year history. Substance abuse donors were younger (51.5 vs 55.2 P .001), more often male (65.6 vs 54.8%, P .001), more often White (86.2 vs 68.7%, P .001), and had hepatitis C (8.3 vs 0.8%, P .001). Donor acceptance was significantly associated with brain dead donors (odds ratio, 1.56, P .001), donor smoking history (odds ratio, 0.56, P .001), hepatitis C (odds ratio, 0.35, P .001), younger age (odds ratio, 0.98, P .001), male gender (odds ratio, 0.74, P = .004), and any substance abuse history (odds ratio, 0.50, P .001), but not opioid use, opioid overdose death, or marijuana use. Recipient survival was equivalent when using lungs from donors who had opioid overdose death, who smoked marijuana, or who smoked cigarettes for less than 20 patient-years or more than 20 patient-years, and significantly longer in recipients of opioid use lungs. There was no significant difference in time to chronic lung allograft dysfunction for recipients who received lungs from opioid overdose death or with a history of opioid use, marijuana smoking, or cigarette smoking.Donor acceptance was impacted by cigarette smoking but not opioid use, opioid overdose death, or marijuana use. Graft outcomes and recipient survival were similar for recipients of lungs from donors who abused substances.

A large proportion of controlled donation after circulatory death (cDCD) donor lungs are declined because cardiac arrest does not occur within a suitable time after the withdrawal of life-sustaining therapy. Improved strategies to preserve lungs after asystole may allow the recovery team to arrive after death actually occurs and enable the recovery of lungs from more cDCD donors. The aim of this study was to determine the effect of donor positioning on the quality of lung preservation after cardiac arrest in a cDCD model. Cardiac arrest was induced by withdrawal of ventilation under anesthesia in pigs. After asystole, animals were divided into 2 groups based on body positioning (supine or prone). All animals were subjected to 3 hours of warm ischemia. After the observation period, donor lungs were explanted and preserved at 4°C for 6 hours, followed by 6 hours of physiologic and biological lung assessment under normothermic ex vivo lung perfusion. Donor lungs from the prone group displayed significantly greater quality as reflected by better function during ex vivo lung perfusion, less edema formation, less cell death, and decreased inflammation compared with the supine group. A simple maneuver of donor prone positioning after cardiac arrest significantly improves lung graft preservation and function.

Purpose Preoperative assessment of benign subglottic stenosis is usually performed by endoscopy and a computed tomography scan. Both diagnostic modalities have relevant limitations and sometimes an accurate assessment of the extent of disease is challenging. Description Based on computed tomography scans of benign glotto-subglottic stenosis and a control airway, color-coded three-dimensional (3D) models were produced using a commercially available 3D printer. The diagnostic relevance of 3D models was tested by means of a quiz. Evaluation 52 thoracic surgeons from 4 North American and 1 European institution with different levels of experience in airway surgery were invited to test the diagnostic accuracy of 3D models against endoscopy films and computed tomography scans. 3D models were found to be superior to the other two diagnostic tools in terms of grading the extent of the stenosis and selecting the correct surgical strategy. The group of residents benefited the most from the 3D models. Conclusions 3D models of complex glotto-subglottic airway stenosis are a useful supplement of the preoperative assessment. In addition, they can serve as a teaching tool for residents and fellows.

Near-infrared fluorescence mapping with indocyanine green dye is a recent advancement in minimally invasive segmental resection. This technique has not yet been reproduced, validated, or objectively evaluated in a large prospective case series. We hypothesized that near-infrared fluorescence mapping is associated with an increased oncological margin distance from the tumor, over and above the best judgment of the surgeon.This was a phase 2 prospective cohort trial in patients who are undergoing robotic segmentectomy for lung tumors3 cm. The predicted intersegmental plane was first identified by consensus between 2 thoracic surgeons. The true plane was then mapped by indocyanine green injection. A 7-item binary rating scale was used for the evaluation of feasibility, reproducibility, and added oncological margin distance from the tumor. The margin distance between the tumor and the true plane was compared with the margin distance between the tumor and the predicted plane.Fifty-three patients were enrolled between September 2016 and May 2018 and 31 patients (58.4%) received the planned operation with indocyanine green mapping. In 74.2% of cases (23 out of 31), a score of 7 out of 7 was achieved, indicating the true intersegmental plane identified by indocyanine green mapping was different than the predicted plane identified by the surgeon. In 61.2% (19 out of 31) of those cases, the mean additional margin distance from the tumor to the staple line attributable to the indocyanine green mapping was 2.41 ± 1.6 cm. The overall complication rate was 18.5% (10 out of 53) and there were no deaths.Near-infrared fluorescence mapping in robotic segmentectomy is associated with increased oncological margin length, over and above the best judgment of the surgeon, in the majority cases where it is used.

We have developed ultrasmall porphyrin-high-density lipoprotein (HDL) nanoparticles (20 nm), called "porphyrinHDL," that have a high density of porphyrin molecules and dissociate rapidly upon tumor cell accumulation to become fluorescent and photoactive. This is introduced as a novel activatable photosensitizer for image-guided photodynamic therapy (PDT). Here, we report the studies of these nanoparticles targeted to scavenger receptor class B type I (SR-BI) expressed on lung cancer cells as a first step toward development of a minimally invasive treatment for peripheral lung cancer and metastatic lymph nodes of advanced lung cancer.The in vitro uptake of porphyrinHDL and the corresponding PDT efficacy were evaluated in both SR-BI-positive and SR-BI-negative lung cancer cell lines. A clinically relevant orthotopic lung cancer model in mice was used to examine fluorescence activation and quantification of uptake in tumor. In addition, we investigated the effect of porphyrinHDL-mediated PDT.PorphyrinHDL promoted proper intracellular uptake in the H460 human lung cancer cell line. When irradiated with a 671-nm PDT laser, porphyrinHDL produced significant therapeutic effectiveness in vitro. After systemic administration in mice with orthotopic lung cancer xenografts, porphyrinHDL demonstrated selective accumulation and photoactivation in tumor with significantly enhanced disease-to-normal tissue contrast. Moreover, porphyrinHDL-PDT significantly induced cell apoptosis in lung tumors (73.2%) without toxicity in normal tissues or damage to adjacent critical structures.SR-BI-targeted porphyrinHDL-mediated PDT of lung cancer is selective and effective in vitro and in vivo. These initial proof-of-principle studies suggest the potential of a "smart" PDT approach for highly selective tumor ablation.

Esophagectomy is a complex operation with potential for prolonged recovery. We aimed to identify the incidence of and risk factors for any and frequent emergency department visits within 1 year of esophagectomy.A retrospective cohort study was performed looking at consecutive esophagectomies at a tertiary Canadian center (1999-2014). Multivariable analyses identified factors associated with any emergency department visits and frequent emergency department use (≥3 visits) within 1 year postesophagectomy.There were 520 esophagectomies with in-hospital mortality of 6% (n = 31). Of those discharged, 29.7% (n = 145) had ≥ 1 emergency department visit. Most common causes were feeding tube problems (39.3%; n = 57) and dysphagia/stricture (13.1%; n = 19). Higher income (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.04-1.42 per $10,000) and use of hybrid/minimally invasive esophagectomy (aOR, 3.24; 95% CI, 1.71-6.11) were independently associated with having emergency department visits. Patients with hybrid/minimally invasive esophagectomy were discharged earlier than others (P .0001). Living outside of our metropolitan area (aOR, 0.36; 95% CI, 0.27-0.49) and having surgery in the later years of the study period (aOR, 0.91; 95% CI, 0.86-0.97; P = .006) were both independently associated with lower odds of emergency department visits. Forty-three patients (8.8%) were frequent emergency department users, with the most common causes of repeat emergency visits being feeding tube problems. Living outside of our metropolitan area was associated with lower odds of frequent emergency visits (aOR, 0.25; 95% CI, 0.14-0.45).There is high emergency department use within 1 year postesophagectomy. Patients living farther away from our hospital had a lower rate of emergency department use. It is possible that they are utilizing emergency departments nearer to home; this needs further study. Feeding tube problems are the biggest culprits and are potentially modifiable.

BACKGROUND Venovenous (VV) extracorporeal membrane oxygenation (ECMO) is the preferred configuration for bridging respiratory failure patients while awaiting lung transplantation. However, there is no consensus on intraoperative extracorporeal cardiopulmonary support during lung transplantation in these patients. METHODS The configuration of the intraoperative extracorporeal circuit after VV ECMO bridge was reviewed and correlated with clinical outcomes. This retrospective cohort study performed at our university hospital included 34 patients who were successfully bridged solely with VV ECMO to lung transplantation during the period 2007 to 2016. Indications to switch to intraoperative venoarterial (VA) ECMO were hemodynamic compromise (systemic hypotension or mean pulmonary artery pressure >40 mm Hg) or when this scenario was thought to be highly likely. RESULTS The median duration of bridging was 12 (IQR 7 to 19) days. Intraoperatively, 3 patients (8.8%) required cardiopulmonary bypass. Twenty patients (58.8%) stayed on VV ECMO and 11 (32.3%) were switched to central VA ECMO. Between the 2 types of intraoperative ECMO (VV vs VA), there were no significant differences in post-operative ECMO duration, chest reopening for bleeding, or renal replacement therapy. There was no significant difference in 90-day mortality (0% and 9.0%, p = 0.35) or in long-term survival (p = 0.59). The intraoperative transfusion of red blood cells tended to be higher in the VA group (5 [4 to 9] vs 8 [6 to 13] units, p = 0.06). Use of intraoperative VA ECMO was associated with the use of low-flow VV device bridging and lobar transplantation. CONCLUSIONS Using the existing VV ECMO bridge intraoperatively during lung transplantation is feasible and provides comparable outcomes to patients converted to central VA ECMO for compromised hemodynamics.

Tracheal injury, stenosis, and malignancy demand tracheal reconstruction, which often fails due to the lack of a functioning epithelium. We performed an extensive comparative analysis to determine optimal biomaterials for developing tracheal epithelial grafts with mucociliary function. We screened Hyaluronan-Poly(Ethylene Glycol), Chitosan-Collagen, Collagen Vitrigel Membrane, Fibrin Glue, Silk Fibroin, and Gelatin based on various parameters including mechanical strength, bulk degradation, cell attachment, spreading, metabolic activity, focal adhesion formation, and differentiation into ciliated and goblet cells. Silk Fibroin had significantly higher tensile strength (21.23 ± 4.42 MPa), retained 50% of its mass across 5 weeks, allowed 80–100% cell spreading and increasing metabolic activity across 10 days, focal adhesion formation within 2 h, and differentiation into 5.9 ± 2.6% goblet cells. Silk Fibroin, however, led to poor ciliation, producing 5.5 ± 3.9% ciliated cells, whereas Collagen Vitrigel Membrane promoted excellent ciliation. To capitalize on the mechanical and differentiation benefits of its respective components, we developed a composite biomaterial of Silk Fibroin and Collagen Vitrigel Membrane (SF-CVM), which demonstrated enhanced maturation into 20.6 ± 1.7% ciliated and 5.6 ± 1.0% goblet cells. Development of biomaterials-based airway epithelial grafts that provide desirable mechanics and differentiation is a major step towards treatment of airway disease. Statement of Significance Tracheal blockage, injury, and malignancy greater than 50% of the adult tracheal length cannot be safely resected. Tracheal replacement is one approach, but a major cause of transplant failure is the lack of a functioning epithelium. While tissue engineering for tracheal regeneration using biomaterials is promising, there is currently no gold standard. Therefore, we performed a systematic comparative study to characterize relevant materials for generating a biomaterials-based airway epithelial graft. We developed a composite biomaterial intended for surgical implantation providing tensile strength, slow biodegradation, and optimal support for differentiation of mature epithelia. This is a significant step augmenting current state-of-the-art methods for airway surgeries, laryngeal reconstruction, and tracheal tissue engineering.

Background: GO2 sought to optimise chemotherapy dosing in older/frail patients with advanced gastroesophageal cancer, and explored baseline geriatric assessment (GA) as a tool for treatment decision-making. Methods: Patients were recruited for whom full-dose combination chemotherapy was considered unsuitable. Two randomisation options were available: CHEMO-INTENSITY compared oxaliplatin/capecitabine at Level A (doses as used in the standard epirubicin/oxaliplatin/capecitabine regimen), B (0·8x A) or C (0·6x A). Non-inferiority of PFS was assessed using boundary HR=1·34, selected by a forum of patients and clinicians. Overall Treatment Utility (OTU), which combines efficacy, toxicity, QL and patient value/acceptability, was scored at nine weeks. Alternatively, if the patient and clinician agreed the indication for chemotherapy was uncertain, they could enter the CHEMO-BSC randomisation, comparing Level C versus best supportive care. Findings: 514 patients entered the CHEMO-INTENSITY randomisation: non-inferior PFS was confirmed for B vs A (HR=1·09 [CI=0·89-1·32]) and C vs A (HR=1·10 [0·90-1·33]). Level C produced less toxicity and better OTU than A or B. No subgroup benefited from higher doses: Level C produced better OTU even in the younger, fitter patients. 45 patients entered the CHEMO-BSC randomisation: overall survival was non-significantly longer with chemotherapy: median 6·1 vs 3·0 months, HR=0·69 [0·32-1·48], p=0·34. In multivariate analysis, baseline frailty, QL and neutrophil:lymphocyte ratio were independently associated with OTU, so can be combined in a model to estimate the probability of better or worse outcome. Interpretation: Reduced-intensity chemotherapy provided non-inferior efficacy with an improved patient experience. Baseline geriatric assessment can help predict the utility of chemotherapy. Trial Registration: [Trial registration: ISRCTN44687907] Funding Statement: Cancer Research UK [CRUK/12/022] Declaration of Interests: Dr. Grabsch reports personal fees from Merck Sharpe Dome, outside the submitted work; all other authors have nothing to declare. Ethics Approval Statement: This study was approved by the UK National Research Ethics Service and overseen by independent Trial Steering and Data Monitoring & Ethics Committees (TSC; IDMC).

The study aim is to compare the diagnostic yield, safety, and cost of outpatient awake thoracoscopy (AT) with video-assisted thoracoscopic surgery (VATS) pleural biopsy in undiagnosed pleural effusions.The diagnostic yield of pleural biopsy performed by AT or VATS in patients with undiagnosed exudative pleural effusions at a tertiary thoracic surgery center in Canada between 2011 and 2015 was retrospectively evaluated. Test sensitivity, specificity, positive predictive value, and negative predictive value were compared. Procedure safety, hospital length of stay, additional pleural-based interventions, and procedure-related costs were compared.Patients underwent either AT (n = 78) or VATS (n = 99) during the study period. Sensitivity, specificity, positive predictive value, and negative predictive value were 85%, 100%, 100%, and 79% for AT and 93%, 94%, 99%, and 76% for VATS, with no significant difference in diagnostic test performance. There was no difference in the rate of major complications (2 AT [2.6%] versus 4 VATS [4.0%], p = 0.696), minor complications (14 AT [17.9%] versus 16 VATS [16.2%], p = 0.841) or need for additional pleural-based procedures (20 AT [25.6%] versus 18 VATS [18.2%], p = 0.270). The VATS was associated with longer median hospital stay (VATS 3 days [interquartile range: 1 to 4] versus AT 0 days [interquartile range: 0 to 1], z = 6.98, p0.001) and a higher procedure-related average cost (VATS Canadian dollars $7,962 [95% confidence interval: $7,134 to $8,790] versus AT Canadian dollars $2,815 [95% confidence interval: $2,010 to $3,620], p0.001).Awake thoracoscopy and VATS have similar diagnostic yield and safety profiles in the assessment of undiagnosed pleural effusions; however, AT is associated with shorter length of stay and lower average per-procedure cost. In the appropriate clinical setting, AT may be the diagnostic test of choice.

Background Molecular testing in advanced lung cancer is standard in guiding treatment selection. However, population-wide implementation of testing remains a challenge. We developed a knowledge translation intervention to improve understanding among diagnostic specialists about molecular testing and appropriate diagnostic sampling in lung cancer. Methods Specialty-specific education programs were developed from existing literature and input from Canadian leaders in lung pathology, respirology, interventional radiology, thoracic surgery, radiation oncology, and medical oncology. The programs, including key messages, review of current data, existing guidelines, group discussion, and participant feedback, were administered at provincial and national specialty meetings. Participant knowledge was assessed before and after the intervention by using anonymous questionnaires. Molecular ( EGFR ) testing rates in Ontario were also evaluated before and after the intervention period. Results Ten programs were administered to diagnostic specialists, including respirologists, pathologists, thoracic surgeons, radiologists, radiation oncologists, and medical oncologists, with completion of 255 preintervention and 219 postintervention surveys. At baseline, 30% were unsure of tissue handling methods for molecular testing, 20% chose an incorrect technique, and half were unfamiliar with how to initiate testing. After intervention, specialist knowledge improved regarding tissue handling and appropriate fixation techniques and uncertainty decreased from 30% to 2% ( p EGFR ) testing requests in Ontario was observed over the intervention period ( p = 0.0032). Conclusions Significant knowledge gaps exist among diagnostic specialists regarding molecular testing and targeted therapy in lung cancer. This initiative significantly improved understanding of the importance and methods of successful molecular testing and correlated with increased testing rates.

Ex vivo lung perfusion (EVLP) enables assessment of marginal donor lungs for transplantation, with similar clinical outcomes to conventional lung transplantation. We investigated whether cell death-related proteins in the EVLP perfusate could predict primary graft dysfunction (PGD) after transplantation.M30 (indicating epithelial apoptosis), M65 (indicating total epithelial cell death), and high mobility group box 1 (HMGB-1, related to cell death and inflammation) protein levels in EVLP perfusate were measured by enzyme-linked immunosorbent assay and correlated with clinical outcomes.From 100 sequential EVLP patients, 79 lungs were transplanted. Patients who were bridged with extracorporeal life support (ECLS, n = 6) or who received lobar/single lung (n = 25) were excluded. PGD grade 3 (partial pressure of arterial oxygen/fraction of inspired oxygen200 or need for ECLS) developed in 11 at any time within 72 hours after transplantation (PGD Group). PGD grade 3 did not develop in 34 patients (Control Group). M30 was significantly higher in the PGD Group than in the Control Group at 1 hour (PGD: 73.3 ± 24.9, control: 53.9 ± 15.9 U/liter; p0.01) and at 4 hours (PGD: 137.0 ± 146.6, Control: 72.4 ± 40.0 U/liter; p = 0.046) of EVLP. The increase of HMGB-1 from 1 to 4 hours of EVLP was significantly greater in the PGD Group (PGD: 37.0 ± 25.4, Control: 7.2 ± 16.8 ng/ml; p0.001). Higher levels of or a greater increase in M30 and a greater increase in HMGB-1 were associated with higher mortality in Cox regression.Levels of M30 and HMGB-1 in the EVLP perfusate correlate with PGD after lung transplantation and might therefore be useful biomarkers to improve donor lung assessment during EVLP.

Purpose This study explores feasibility and safety of using enzymes (FpGalNAc deacetylase & FpGalNase) to remove ABO-A antigens from donor lungs during ex vivo lung perfusion (EVLP). The enzymes have been reported to efficiently convert ABO-A blood to O (Withers, Nat Microbiol, 2019). Methods Human lungs (ABO-A1, n=5), declined for transplant, were treated with the enzymes during EVLP. Tissues were sampled before and after. The distribution and expression level of ABO antigens were analyzed by immunohistochemistry and flow cytometry. Lung function was monitored for side-effects. Immediate post-transplant immune response was simulated in an ex vivo model of hyperacute lung rejection, with introduction of ABO-O plasma (carrying ABO antibodies) as the surrogate for the recipient circulation (Fig.1H, n=1). The physiology and histology of lungs were analyzed for anti-A-induced immune responses. Results The histo-blood type A (BTA) antigens in the A1 lungs are observed primarily on endothelial and epithelial cells. BTA were cleared remarkably well from treated lungs (Fig.1A). The enzymes convert vascular BTA to the blood group H (BTH) antigens found in ABO-O tissue (Fig.1B). Over 97% of endothelial BTA antigens were removed within the typical 4h clinical EVLP timeframe using very low dose (1 µg/mL) enzymes (Fig.1C). No acute side-effects were seen (Fig.1D-G). The rejection model showed that the 3-hour treatment of human lung with low dose enzymes prevented the damage triggered by type O plasma (presumably due to anti-A antibodies) as observed in the physiology and histology of the control lung (Fig.1I-J). Conclusion Ex vivo enzymatic treatment can efficiently remove ABO-A antigen in donor lungs without acute side-effects. Preliminary results show that the treatment can prevent ABO mismatch-induced early damages. The treatment can potentially allow expansion of ABO-incompatible lung transplantation, leading to significant improvements in logistics and fairness of organ allocation.

Background Despite guidelines for preoperative invasive mediastinal staging (IMS) for non-small cell lung cancer (NSCLC), concordance with guidelines and whether the use of these guidelines results in expected frequency of lymph node metastases has not been evaluated. Our objectives were to determine guideline concordance, reasons for nonconcordance, and, in patients who did not receive IMS, to determine the use of operative nodal sampling and final pathologic staging. Methods Patients who had a resection for NSCLC between 2010 and 2012 were identified from the Institutional Cancer Registry. A chart audit was performed to determine adherence to Cancer Care Ontario (CCO) IMS guideline criteria, and pathologic reports were reviewed to determine postresection staging. Results Of 242 resections performed in the study period 102 (42%) did not receive IMS. 66 patients (65%) did not require IMS based on CCO guidelines and thus were concordant with guidelines, whereas 36 (36%) were guideline nonconcordant. Of 102 patients who did not have preoperative IMS, only 72 had intraoperative lymph node assessment and only 35 (34%) had sampling of three or more ipsilateral (N2) nodal stations. In the guideline concordant group, 2 of 66 patients (5%) had positive N2 nodes, whereas in the nonconcordant group 3 of 36 patients (11%) were N2 positive. Conclusions Although overall IMS was used in only 140 patients (58%), concordance with guidelines was high at 85% (206 of 242 patients). However, rates of intraoperative nodal sampling for non-IMS cases (both concordant and nonconcordant) was lower than expected, resulting in potentially understaged patients.

Pulmonary lobectomy is the standard of care for resection of non-small cell lung cancer (NSCLC). Patients with compromised lung function who are considered high risk may be denied surgical treatment; thus, proper identification of those truly at high risk is critical. Video-assisted thoracic surgery (VATS) may reduce the operative risk. This study reviews our institutional experience of pulmonary lobectomy by open thoracotomy or VATS techniques in patients deemed to be high risk.A retrospective review of an institutional database was performed for all patients undergoing lobectomy from 2002 to 2010. Patients were grouped into high-risk (HR) and standard-risk (SR) cohorts according to the American College of Surgeons Oncology Group Z4099/Radiation Therapy Oncology Group 1021 criteria.From 2002 to 2010, 72 HR and 536 SR patients underwent lobectomy. Mean age was 73 years for HR and 66 years for SR (p0.0001). Rates of overall (p 0.0001) and pulmonary complications (p0.0001) were significantly higher in the HR group. However, when HR patients were resected by VATS, there was no significant difference in overall (p = 0.1299) or pulmonary complications (p = 0.2292) compared with the SR VATS group. Moreover, overall survival was significantly lower for HR patients who had an open operation compared with VATS lobectomy or SR open (p = 0.0028).VATS lobectomy offers patients who are considered to be at increased risk for open lobectomy a feasible procedure, with no difference in overall survival compared with SR patients, and decreased morbidity compared with open lobectomy. VATS lobectomy should be considered for patients who historically may not have been considered for surgical resection.

To assess the cost-effectiveness of various modes of mediastinal staging in non-small cell lung cancer (NSCLC) in a single-payer health care system.We performed a decision analysis to compare the health outcomes and costs of 4 mediastinal staging strategies: no invasive staging, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), mediastinoscopy, and EBUS-TBNA followed by mediastinoscopy if EBUS-TBNA is negative. We determined incremental cost effectiveness ratios (ICER) for all strategies and performed comprehensive deterministic sensitivity analyses using a willingness to pay threshold of $80,000/quality adjusted life year (QALY).Under the base-case scenario, the no invasive mediastinal staging strategy was least effective (QALY, 5.80) and least expensive ($11,863), followed by mediastinoscopy, EBUS-TBNA, and EBUS-TBNA followed by mediastinoscopy with 5.86, 5.87, and 5.88 QALYs, respectively. The ICER was ∼$26,000/QALY for EBUS-TBNA staging and ∼$1,400,000/QALY for EBUS-TBNA followed by mediastinoscopy. The mediastinoscopy strategy was dominated. Once pN2 exceeds 2.5%, EBUS-TBNA staging is cost-effective (∼$80,000/QALY). Once the pN2 reaches 57%, EBUS-TBNA followed by mediastinoscopy is cost-effective (ICER ∼$79,000/QALY). Once EBUS-TBNA sensitivity exceeds 25%, EBUS-TBNA staging is cost-effective (ICER ∼$79,000/QALY). Once pN2 exceeds 25%, confirmatory mediastinoscopy should be added, in cases of EBUS-TBNA sensitivity ≤ 60%.Invasive mediastinal staging in NSCLC is unlikely to be cost-effective in clinical N0 patients if pN22.5%. In patients with probability of mediastinal metastasis between 2.5% and 57% EBUS-TBNA is cost-effective as the only staging modality. Confirmatory mediastinoscopy should be considered in high-risk patients (pN2 57%) in case of negative EBUS-TBNA.

Background Surgery offers the best chance for survival for early (stage I and II) non-small cell lung cancer (NSCLC), but worldwide resection rates range from 49% to 77%. We investigated factors that may play a role in resection rates. Methods Using administrative data, new diagnoses of NSCLC from 2010 through 2012 were captured. The rate of surgical consultation and resection overall and by age group were determined, as well as rates of pulmonary function testing and radiation therapy. Results Of 4,309 persons diagnosed with stage I or II NSCLC between 2010 and 2012, 3,487 (80.9%) received surgical consultations, but only 58.9% (2,539) received surgery. Rates of consultation and surgery decreased with increasing patient age: only 60.3% of patients older than 80 received consultations and 29.9% had resections. Of the 1,770 patients who did not receive surgery, 948 (53.6%) received a surgical consultation, and in this group, 688 (72.5%) were treated with radiation. Of the 822 patients who did not see a surgeon, only 476 (57.9%) were treated with radiation. Pulmonary function testing was performed in 799 (84.3%) of patients who had surgical consults but in only 569 (69.2%) of those who did not see a surgeon. Conclusions Resection rates for early lung cancer appear low, which may be partly due to low rates of surgical consultation. Interestingly, patients who are seen by surgeons but who do not receive surgery are more likely to receive radiation than patients who are not referred for surgery. Further research is required to identify factors influencing resection rates.

Summary Background Ex-vivo lung perfusion (EVLP) can be used to extend overall lung preservation time by splitting one long cold ischaemic time into two shorter ones and interposing an additional EVLP time. We assessed the outcomes after clinical transplantation of lungs with more than 12 h of preservation time. Methods For this retrospective study, we searched the Toronto Lung Transplant Program database for patients who had received at least one lung transplant between Jan 1, 2006, and April 30, 2015, at a single hospital in Toronto, Canada. We split the identified patients into those with a total preservation time of more than 12 h and those with a total preservation time of less than 12 h to act as the control group. Total preservation time was defined as the sum of first cold ischaemic time, EVLP time, and second cold ischaemic time. We excluded patients if they had received a heart–lung transplant or were younger than 18 years. In bilateral lung transplantations, we used the longer preservation time of the two lungs for analysis. Lung preservation was done according to present standards of care and EVLP was done according to the Toronto EVLP technique. The primary outcomes were survival and International Society for Heart and Lung Transplantation Primary Graft Dysfunction (PGD) grade at 72 h post-transplantation. We compared outcomes with our control group using univariable and multivariable models. Findings We identified 906 patients who met eligibility criteria and had sufficient data for analysis ( vs >12 h group [n=97]; 875·7 min [109·0]). Median hospital and intensive-care unit length of stay were similar between the less than 12 h group and the more than 12 h group (hospital stay: 23 days [16–42] vs 25·5 days [17–50·25], p=0·60; intensive-care unit stay: 4 days [2–14] vs 4 days [2–16], p=0·53). PGD grade was also not different between the two groups at 72 h post-transplantation (p=0·85). There was also no difference in survival between the two groups as shown on Kaplan-Meier survival curves (p=0·61). Multivariable survival analysis using Cox's model showed increasing recipient age to be a significant variable affecting survival. Interpretation Extension of graft preservation time beyond 12 h with EVLP does not negatively affect early lung transplantation outcomes. Extension of clinical lung preservation times might allow for more transplantations to be done as a result of improved facilitation and increased flexibility around timing of lung transplantation operations. Funding None.

Purpose We explored the feasibility and safety of using recently developed enzymes (FpGalNAc deacetylase and FpGalNase) to remove histo-blood type antigens from donor lungs during ex vivo lung perfusion (EVLP). The enzymes have been reported to efficiently convert Type A whole blood to O (Withers, Nature Microbiology, 2019). Methods Human type A red blood cells (RBCs, n=5/group) and arteries (aorta and pulmonary arteries, n=3/group) were treated with enzyme-containing EVLP solution and lung preservation solution. Human donor lungs (type A) declined for transplantation were treated with the enzymes (1µg/mL) during normothermic EVLP for 1 and 3 h. Lung physiological parameters were monitored throughout treatment. Cell and tissue samples were taken before and after treatment. The distribution and expression levels of blood type antigens were analyzed by flow cytometry and immunohistochemistry. Results The enzymes achieved over 99% antigen removal from RBC within 1h at a dose of 4 µg/mL (Fig1A) in EVLP solution and lung preservation solution. The histo-blood type antigens in human arteries were observed primarily on endothelial cells - blood type A (BTA) antigens co-localized with endothelial marker CD31 (Fig1B, Pre-treatment). In vitro static treatment of arteries demonstrated 92±1% of BTA antigen removal with 1 µg/mL enzyme (Fig1B). Blood type antigen in human lungs were observed on both endothelial and epithelial cells. Within 1h of perfusion, human lungs treated with enzyme had remarkable clearance of intravascular BTA antigens (Fig1C). Similar results were observed after 3h treatment. No acute physiological side effects were observed from the enzymatic treatment. Conclusion Ex vivo enzymatic treatment can efficiently remove blood type antigen in donor lungs without acute side effects. This treatment has potential to be developed as an adjuvant therapy in ABO-incompatible organ transplantation, minimizing the need for recipient antibody removal procedures or augmented immunosuppression.

Background: A significant proportion of organ donors currently test positive for hepatitis C virus (HCV) infection. To date, only a few studies have evaluated the safety of using lungs from these donors for transplantation, and no direct interventions to donor organs have been performed with the aim of preventing HCV transmission via organ transplantation. Methods: We performed a single center prospective non-randomized trial where donor lungs from HCV viremic donors were transplanted into HCV negative (HCV-ve) recipients. Outcomes of study recipients were compared to patients receiving HCV-ve donors. Primary endpoints were survival and HCV status at 6 months after transplantation. Prior to implantation, all donor lungs were treated with ex vivo lung perfusion (EVLP) with (n=11) or without (n=11) ultraviolet C (UVC) perfusate irradiation to reduce HCV RNA levels and infectivity. All patients becoming viremic received 12 weeks of sofosbuvir/velpatasvir (S/V) starting at least 2 weeks after transplantation. Findings: During the 13-month study period, 22 patients were transplanted using viremic HCV donors and 187 with HCV-ve donors. Recipient age, lung disease, urgency status and positive donor-recipient HLA crossmatch were similar between the 2 groups. Post-transplant outcomes such as primary graft dysfunction grades, ICU and hospital length of stay, and survival were similar between the 2 groups. Twenty patients (91%) developed HCV viremia within the first week after transplantation and underwent S/V treatment starting at a median of 21 days after transplantation (range 14-71 days). Donor organ treatment with EVLP+UVC was associated with significantly lower recipient viral loads in blood within the first week after transplantation, and prevention of transmission in 2/11 patients. All infected patients achieved negative HCV PCR within 6 weeks of treatment initiation. Two patients presented with HCV relapse within 3 months after S/V completion requiring retreatment. Interpretation: Early and intermediate-term clinical outcomes using viremic HCV donors were similar to patients receiving HCV-ve donor lungs. Donor organ treatment using UVC perfusate irradiation during EVLP showed a significant impact in decreasing HCV viral loads within the first 7 days after transplantation. Trial Registration Number: The trial was registered at clinicaltrials.gov (NCT03112044). Funding Statement: This study was an investigator-initiated study funded by an operating grant from the Canadian Institutes of Health Research (CIHR). Gilead Sciences provided S/V (Epclusa) for all patients in the study. XVIVO perfusion (Gothenburg, Sweden) provided Steen solution for EVLP Declaration of Interests: Dr. Cypel, Waddell and Keshavjee are co-founders of Perfusix Canada, XOR Labs Toronto, and consultants for Lung Bioengineering (United Therapeutics). Ethics Approval Statement: This study was approved by the Research Ethics Board of University Health Network and subjects provided written informed consent while on the transplant waiting list prior to the offer of HCV+ve donor lungs.

Purpose Single lung transplantation (SLT) is an option for certain lung transplant recipients and allows for maximal utility of a limited donor pool. However, whether a single lung should be transplanted when the contralateral donor lung is too injured for transplant is a challenging clinical scenario. The introduction of ex vivo lung perfusion (EVLP) has improved donor lung assessment and we hypothesize that it has improved SLT outcomes in this setting. We examined outcomes in SLT recipients with and without the use of EVLP. Methods A retrospective single-centre review of all SLT performed between 2000 and 2017 was performed. To account for the introduction of EVLP in our program in 2008, we considered the years 2000-2008 the “pre-EVLP era” and 2009-2017 the “EVLP era”. SLT recipients were classified as Group 1 (Control) when both donor lungs were transplanted, Group 2 (Pre-EVLP era) when one lung was declined at the donor site and the other transplanted directly, Group 3a (EVLP era; non-EVLP) when one lung was declined at the donor site and the other transplanted directly, and Group 3b (EVLP era; EVLP utilized) when one lung was declined but the transplanted lung deemed acceptable using EVLP. The outcomes of interest were survival, time-to-extubation, and ICU and hospital stay. Results A total of 244 SLT were performed between 2000 and 2017. There were 143 SLT in Group 1, 21 in Group 2, 33 in Group 3a, and 47 in Group 3b. There was a significantly better 30-day mortality in the EVLP era (Table 1). Use of SLT increased from 12.7% of lung transplants pre-EVLP era to 16.8% in the EVLP era. Conclusion Though not every SLT with rejected contralateral lung necessitated evaluation by EVLP, the availability of EVLP allowed for additional evaluation of questionable single lungs. This has led to increased utilization rates and improved outcomes of SLT with a rejected contralateral lung in the EVLP era.

Background Despite curative intent resection in patients with non-small cell lung cancer (NSCLC), recurrence leading to mortality remains too common. Melatonin has shown promise for the treatment of patients with lung cancer; however, its effect following cancer resection has not been studied. We evaluated if melatonin taken after complete resection reduces lung cancer recurrence and mortality, or impacts quality of life (QOL), symptomatology or immune function. Methods Participants received melatonin (20 mg) or placebo nightly for one year following surgical resection of primary NSCLC. The primary outcome was two-year disease-free survival (DFS). Secondary outcomes included five-year DFS, adverse events, QOL, fatigue, sleep, depression, anxiety, pain, and biomarkers assessing for immune function/inflammation. This study is registered at https://clinicaltrials.gov NCT00668707. Findings 709 patients across eight centres were randomized to melatonin (n = 356) versus placebo (n = 353). At two years, melatonin showed a relative risk of 1·01 (95% CI 0·83–1·22), p = 0·94 for DFS. At five years, melatonin showed a hazard ratio of 0·97 (95% CI 0·86–1·09), p = 0·84 for DFS. When stratified by cancer stage (I/II and III/IV), a hazard reduction of 25% (HR 0·75, 95% CI 0·61–0·92, p = 0·005) in five-year DFS was seen for participants in the treatment arm with advanced cancer (stage III/IV). No meaningful differences were seen in any other outcomes. Interpretation Adjuvant melatonin following resection of NSCLC does not affect DFS for patients with resected early stage NSCLC, yet may increase DFS in patients with late stage disease. Further study is needed to confirm this positive result. No beneficial effects were seen in QOL, symptoms, or immune function. Funding This study was funded by the Lotte and John Hecht Memorial Foundation and the Gateway for Cancer Research Foundation.

Background Ex vivo lung perfusion (EVLP) presents a unique therapeutic opportunity to administer mesenchymal stromal cells (MSCs) to lung grafts before transplantation. We sought to determine the optimal route and dose of viable human umbilical cord–derived MSCs to be delivered into ex vivo–perfused damaged swine lungs, and to measure their effect on concentration of growth factors and inflammatory mediators. Methods Pig lungs were conventionally retrieved, cold preserved for 18 hours, and perfused normothermically ex vivo for 12 hours. Physiologic data were recorded. No cells were administered to a control group of animals ( n = 5). To examine the routes of administration, lungs were administered 50 × 10 6 MSCs endobronchially ( n = 3) or via the pulmonary artery ( n = 3). To determine the doses, a dose-escalation study was performed wherein lungs were administered 50 × 10 6 ( n = 3), 150 × 10 6 ( n = 5) and 300 × 10 6 ( n = 3) MSCs via the pulmonary artery. Concentrations of human growth factors and pig cytokines were measured in lung biopsies and perfusate. Results Intravascular administration of 50 × 10 6 MSCs was associated with significant and sustained retention of MSCs in lung parenchyma, whereas intrabronchial administration was not. Intravascular administration of 150 × 10 6 MSCs was the optimal tolerated dose and was associated with increased concentrations of human vascular endothelial growth factor (VEGF) in lung biopsies and decreased concentrations of pig interleukin-8 (IL-8) in the perfusate during 12 hours of EVLP. Conclusions Intravascular delivery of 150 × 10 6 MSCs showed preferred outcome compared with intrabronchial delivery to damaged lungs perfused ex vivo. The method was well tolerated and associated with an increased concentration of human VEGF in the lung tissue and a decreased concentration of pig IL-8 in the perfusate.

Background The translation of novel drugs in lung transplantation is challenged by different physiologic conditions between small animals and humans. Large-animal models provide important pre-clinical evidence and the next step that best informs clinical trials. In the present study, we used a pig lung transplant model to determine whether human α 1 -antitrypsin (A1AT), a medication shown to prevent pulmonary ischemia-reperfusion injury in rats, could attenuate reperfusion injury after prolonged hypothermic preservation in a large-animal lung transplant model. Methods Donor lungs were preserved for 24 hours at 4°C, followed by lung transplantation. In a randomized and blinded fashion, intravenous A1AT (240 mg/kg; n = 5) or human albumin ( n = 5) was administered to the recipient before reperfusion. Allograft gas exchange function and lung mechanics were monitored during a 4-hour reperfusion period. Microscopic lung injury, inflammatory response, coagulation activity, and cell death were assessed. Results Pulmonary gas exchange was significantly better during the 4-hour reperfusion period in the A1AT group. Treatment with A1AT improved static pulmonary compliance and significantly reduced pulmonary edema and lung permeability. A1AT treatment inhibited inflammatory mediators in the circulation, with reduced activation of nuclear factor-κB and inflammasome, reduced formation of thrombin-antithrombin complex in plasma, and reduced apoptosis in the allografts. Conclusions Administration of human A1AT before reperfusion in recipients improved immediate post-transplant lung function in pigs. A large-animal survival model should be considered to support further advancement toward a clinical trial of A1AT to prevent primary graft dysfunction in lung transplantation.

Background In vivo lung perfusion (IVLP) is a promising adjuvant treatment of lung metastases, allowing the localized delivery of drugs to the lungs without systemic exposure. Previous experimental and clinical data resulted in variable efficacy and frequent toxicity. Our objectives were to demonstrate the feasibility and safety of a novel protective IVLP technique coupled with the delivery of sarcoma-based chemotherapy to the lung. Methods The left pulmonary artery and veins in pigs were cannulated and clamped. Left lung IVLP was performed for 4 hours. Doxorubicin (Dox) at a standard clinical dose of 75 mg/m 2 was used, followed by 150 and 225 mg/m 2 . Dox 75 mg/m 2 combined with ifosfamide (Ifos) 6 g/m 2 was also tested. After IVLP, blood reperfusion was allowed for 4 hours. Lung physiology was assessed and biopsy samples were obtained for histologic assessment of acute lung injury (ALI), inflammatory profile, and cell death. Lung tissue levels, perfusate, and plasma levels of Dox were measured during the procedure. Results Lungs treated with Dox 75 mg/m 2 alone or combined with Ifos showed stable function throughout the procedure, without evidence of ALI ( p = 0.12 and p = 0.36, respectively). Tissue levels of Dox were 70.3 μg/g homogeneously distributed in the lung ( p = 0.12). No drug was detected systemically. Dox 150 mg/m 2 and 225 mg/m 2 showed incremental ALI. Conclusions IVLP for 4 hours with Dox 75 mg/m 2 alone or combined with Ifos was well tolerated, without measurable ALI. High drug levels in perfusate and lung tissue were found without systemic leakage. A dose-related toxicity was observed with increases in Dox doses.

Ex vivo lung perfusion (EVLP) is a platform to treat infected donor lungs with antibiotic therapy before lung transplantation. Human donor lungs that were rejected for transplantation because of clinical concern regarding infection were randomly assigned to two groups. In the antibiotic group (n = 8), lungs underwent EVLP for 12 h with high-dose antibiotics (ciprofloxacin 400 mg or azithromycin 500 mg, vancomycin 15 mg/kg, and meropenem 2 g). In the control group (n = 7), lungs underwent EVLP for 12 h without antibiotics. A quantitative decrease in bacterial counts in bronchoalveolar lavage (BAL) was found in all antibiotic-treated cases but in only two control cases. Perfusate endotoxin levels at 12 h were significantly lower in the antibiotic group compared with the control group. EVLP with broad-spectrum antibiotic therapy significantly improved pulmonary oxygenation and compliance and reduced pulmonary vascular resistance. Perfusate endotoxin levels at 12 h were strongly correlated with levels of perfusates tumor necrosis factor α, IL-1β and macrophage inflammatory proteins 1α and 1β at 12 h. In conclusion, EVLP treatment of infected donor lungs with broad-spectrum antibiotics significantly reduced BAL bacterial counts and endotoxin levels and improved donor lung function.

Objective We hypothesized that administration of a homodimer of recombinant annexin V, diannexin, could shield phosphatidylserine on the endothelium, and inhibit leukocyte and platelet adhesion, thereby potentially reducing ischemia reperfusion injury (IRI) in lung transplantation. This hypothesis was tested using a rat syngeneic single left-lung transplant model. Methods Rats were randomly assigned to receive diannexin (DN group; n = 10) or normal saline (control group; n = 10). Diannexin (1000 μg/kg) was administered to the donor lung in the pulmonary flush solution, and to the recipient intravenously, 5 minutes after initiation of reperfusion. Grafts were reperfused for 2 hours. Results The transplanted grafts in the DN group performed significantly better in gas exchange with higher partial pressure of oxygen (control group: 179 ± 121 vs DN group: 330 ± 54 mm Hg; P = .007) and lower partial pressure of carbon dioxide (control: 55.1 ± 26 vs DN: 34.2 ± 11 mm Hg; P = .04), as well as lower peak airway pressure (control: 20.5 ± 8.5 vs DN: 12.0 ± 7.9 cm H 2 O; P = .035) after 2 hours of reperfusion. Wet-to-dry lung weight ratio ( P = .054), and alveolar fibrin deposition score ( P = .04), were reduced in the DN group. Caspase-cleaved cytokeratin 18 in plasma (a marker of epithelial apoptosis) was significantly reduced in the DN group ( P = .013). Furthermore, gene-expression levels of proinflammatory cytokines in the transplanted graft, including interleukin-6 ( P = .04) and macrophage inflammatory protein 2 ( P = .03) were significantly decreased in the DN group. Conclusions A homodimer of recombinant annexin V reduced ischemia reperfusion injury in a lung transplant animal model, by reducing cell death and tissue inflammation.

Objective To evaluate a new protocol of accelerated hemithoracic intensity-modulated radiation therapy (IMRT) followed by extrapleural pneumonectomy (EPP) for patients with resectable malignant pleural mesothelioma (MPM). Methods A total of 25 Gy of radiation was delivered in 5 daily fractions over 1 week to the entire ipsilateral hemithorax with concomitant boost of 5 Gy to volumes at high risk based on computed tomography and positron emission tomography scan findings. EPP was performed at 6 ± 2 days after the end of radiation therapy. Adjuvant chemotherapy was offered to patients with ypN2 disease. Results A total of 62 patients were included between November 2008 and October 2014. One patient died in the hospital 2 months after EPP, for an operative mortality of 1.6%, and 2 died after discharged from the hospital for an overall treatment-related mortality (grade 5 toxicity) of 4.8%. Twenty-four patients (39%) developed grade 3 to 5 (grade 3+) complications. On final pathology, 94% of the patients were stage III or IV, and 52% had ypN2 disease. The median survival for all patients as an intention-to-treat analysis was 36 months. The median overall survival and disease-free survival was 51 and 47 months, respectively, in epithelial subtypes, compared with 10 and 8 months in biphasic subtypes ( P = .001). Ipsilateral chest recurrence occurred in 8 patients. Conclusions Accelerated hemithoracic IMRT followed by EPP has become our preferred approach for resectable MPM. The results have been encouraging in patients with epithelial subtype.

Background Ex vivo lung perfusion (EVLP) allows normothermic evaluation and treatment of donor lungs not currently acceptable for transplant and improves organ use. Donor lungs undergo a period of cold preservation before (cold ischemic time [CIT]-1) and after (CIT-2) EVLP. We investigated the effect of an extended CIT-2 on lung function after transplantation. Methods Explanted pig lungs, preserved in low-potassium dextran flush (Perfadex) at 4°C for 10 hours, were subjected to 6 hours of EVLP. They were subsequently allocated to 2 groups: short CIT-2 (CIT-2 = 2 hours; n = 5), and long CIT-2 (CIT-2 = 10 hours; n = 5). In a control group ( n = 6), explanted lungs were placed in cold static preservation for 24 hours without EVLP. After the total preservation period, the left lung was transplanted in all groups. Results After 4 hours of reperfusion, oxygenation function, acute lung injury score, inflammatory markers, and cell death pathway markers were similar between short and long CIT-2 groups. Both EVLP groups fared significantly better than the control group in oxygenation function ( p Conclusions The intervention of EVLP improved lung function after transplantation, and this was not affected by a prolonged cold static preservation time after EVLP. These results provide the basis for a practical prolonged lung preservation strategy using a combination of cold and warm preservation techniques, which may improve lung transplantation logistics and outcomes.

The primary objective of this study is to systematically review all pertinent literature related to robotic-assisted lung resection. Robotic-assisted thoracic surgery (RATS) case series and studies comparing RATS with video-assisted thoracoscopic surgery (VATS) or thoracotomy were included in the search. In accordance with preferred reporting items for systematic reviews and meta-analyses guidelines, 2 independent reviewers performed the search and review of resulting titles and abstracts. Following full-text screening, a total of 20 articles met the inclusion criteria and are presented in the review. Amenable results were pooled and presented as a single outcome, and meta-analyses were performed for outcomes having more than 3 comparative analyses. Data are presented in the following 4 categories: technical outcomes, perioperative outcomes, oncological outcomes, and cost comparison. RATS was associated with longer operative time, but did not result in a greater rate of conversion to thoracotomy than VATS. RATS was superior to thoracotomy and equivalent to VATS for the incidence of prolonged air leak and hospital length-of-stay. Oncological outcomes like nodal upstaging and survival were no different between VATS and RATS. RATS was more costly than VATS, with most of the costs attributed to capital and disposable expenses of the robotic platform. Although limited by a lack of prospective analysis, lung resection via RATS compares favorably with thoracotomy and appears to be no different than VATS. Prospective studies are required to determine if there are outcome differences between RATS and VATS.

Lung transplantation using RNA+ hepatitis C (HCV+) donors to seronegative recipients is not currently performed due to the very high risk of transmission. Previous reports have shown poor survival when this practice was applied. The emergence of new direct-acting antiviral drugs (DAA) suggests a high chance of sustained virologic response in immunocompetent patients. We report here successful transplantation of lungs from HCV+ donor to HCV- recipient. The recipient was an HCV- patient with chronic lung allograft dysfunction. Viral transmission occurred early posttransplant but excellent clinical outcomes were observed including elimination of HCV after 12 weeks of treatment using DAAs.

Purpose We have recently showed the superiority of 10°C cold static preservation (CSP) compared to standard 4°C. Despite that, CSP cannot be prolonged unlimited. Here, we hypothesized that combining CSP at 10°C with 2 short cycles of normothermic EVLP (a “recharge” period) would further extend donor lung preservation. Methods Donor lungs (n=3) from Yorkshire pigs (28-35kg) were flushed with 4°C LPD and subsequently preserved using 10°C CSP and intermittent normothermic EVLP (Fig 1A). After a total of 72h of preservation, a left lung transplant was performed followed by 4h of reperfusion. At 4h of reperfusion, isolated graft assessment was performed by clamping the contralateral pulmonary artery and bronchus. To evaluate the contribution of the EVLP recharge periods, 2 control lungs were preserved solely with 10°C CSP for 72h and assessed using normothermic EVLP. Results After 3-days of preservation, post-transplant graft function was excellent. Systemic P/F ratio after excluding the contra-lateral lung was 430 ± 57 mmHg. Lung function was also stable during the intermittent EVLP periods (Fig 1B) and after transplantation (Fig 1C). No pulmonary edema was observed in the bronchoscopic assessment after transplant. Lungs preserved purely in CSP for 72h were assessed on EVLP and failed immediately with the development of massive pulmonary edema. Conclusion We demonstrate for the first time the feasibility of 3-day lung preservation leading to excellent early post-transplant outcomes. Further experiments are being performed to confirm these positive findings and underlying mechanisms. The combination of a modified CSP method (10°C) and intermittent EVLP can open new opportunities to further prolong organ preservation and provide time for advanced lung treatments and repair.

Purpose Despite remote reports indicating 10°C to be the optimal temperature for cold static organ preservation (CSP), preservation of lungs in an ice cooler at 4°C remains the standard strategy in clinical transplantation. Here, we used a commercially available device that can keep a donor lung at 10°C conveniently and compared 10°C vs. 4°C during a prolonged period of CSP followed by functional and biological assessment of lung grafts. Methods Lungs were procured from Yorkshire pigs (28-35kg), flushed with a low-potassium dextran solution and randomized into two groups (n=5 each): CSP at 4°C vs. CSP at 10°C (MyTemp Mini Incubator, Benchmark Scientific). After 36h of CSP, lungs were subjected to 12h of normothermic ex vivo lung perfusion (EVLP) with hourly functional assessment. Lung biopsies and perfusate samples were taken for biological and metabolic evaluation. Results During 12h of EVLP, lungs stored at 10°C presented superior physiological parameters compared to 4°C (Fig 1A). Reduced edema formation was seen as represented by a lower lung weight gain during EVLP (30 ± 34.1 vs. 201 ± 33.2 g, p = 0.0159). Metabolic profiles of the EVLP perfusate were significantly more favorable in the 10°C group compared to 4°C (Fig 1B). Furthermore, the 10°C group had significantly less inflammation demonstrated by lower levels of pro-inflammatory cytokines IL-1β (p = Conclusion With simple controllable refrigerators, 10°C preservation is easily achievable and provides significantly superior CSP in comparison to conventional 4°C storage. This could potentially remarkably improve the clinical and transportation logistics in lung transplantation.

Purpose In pre-clinical studies we have demonstrated the ability of light-based therapies - UVC and photodynamic therapy (PDT) during EVLP to inactivate HCV in donor lungs. In a step-wise application of this technology to clinical transplantation, we designed a clinical trial to evaluate to effects of UVC treatment using NAT+ HCV donor lungs followed by transplantation. Methods Twenty patients receiving NAT+ HCV lungs were included in the study. In the control group, lungs were subjected to 5-6h of EVLP whereas in UVC group, lungs were subjected perfusate irradiation with UVC (254 nm, 31mW/cm²) followed by transplantation. Results 11 patients received lungs subjected to EVLP alone, and 9 patients received lungs subjected to EVLP+UVC. Donor viral loads were similar between the 2 groups (3585000 IU/ml vs. 3480000 IU/mL, p=0.56). During EVLP, lung function was stable and similar between the 2 groups. 19/20 patients developed viremia. Perfusate and tissue levels of HCV by PCR during EVLP were not significantly affected by UVC treatment (Fig.1A), however, the UVC group showed a marked delay in developing viremia post-transplantation (Fig 1B). Median day 7 viral loads were 4390 vs. 168 IU/ml; p=0.27 in control vs. UVC group respectively. The proportion of patients with viral loads less than 3-log copies at day 7 was 2/11 (18%) in control vs. 5/8 (62.5%) in UVC group; p=0.07. Survival post lung transplantation is 100% in both groups with a mean follow up of 162 (14-385) days. Conclusion This is the first clinical trial evaluating a therapeutic intervention during EVLP. As in our pre-clinical studies, UVC does not alter virus quantities measured by PCR (virus fragments) during EVLP, however it does appear to confer impairment in virus infectivity. The combination of UVC therapy with an ultra-short course of direct anti-virus agents may provide the ability to prevent transmission altogether, allowing expansion of transplantation using HCV+ organs.

Purpose Ex vivo lung perfusion (EVLP) enables novel therapeutic approaches to repair damaged lungs for transplantation. We investigated the concept and feasibility of elective cell therapy for donor lungs. Dosing, efficacy and transgene expression kinetics of engineered mesenchymal stromal cell therapy were examined in pig EVLP and transplantation. Methods Human umbilical cord perivascular mesenchymal stromal/stem cells were transduced with an adenoviral vector encoding human IL-10 (MSC-hIL-10 cells), cryopreserved and recovered 1h before use. Pig lungs with 4 to 24-hour cold ischemia (n=5) were connected to EVLP for 6 (n=3) or 12 hours (n=2) and MSC-hIL-10 cells (40-150 × 106) were administered through the pulmonary artery after 1h of EVLP. Left single lung transplantation was performed after EVLP and the grafts were monitored up to 4h (n=4) and 3d (n=1) after reperfusion. Human IL-10 levels were determined by ELISA and fluorescence in situ hybridization with human-specific ALU probes was used to track MSC-hIL-10 cells. Results Supra-therapeutic levels of hIL-10 were present in EVLP perfusate within minutes after MSC-hIL10 cell administration and the levels consistently increased during EVLP (Figure 1A). Recipient plasma hIL-10 levels were elevated 1h after lung transplantation, remained high for 4h and gradually decreased to low levels by 3d after transplantation (Figure 1C). Elevated tissue and bronchoalveolar lavage hIL-10 levels were observed in the transplanted lung and remained low in the recipient native lung. MSC-hIL-10 cells were detected in the donor lung during EVLP and after transplantation (Figure 1B). Conclusion Engineered mesenchymal stromal cell therapy during EVLP is a novel and practical “off-the-shelf” strategy to achieve rapid transient therapeutic levels of soluble cytokines such as IL-10 for pre-transplant lung repair and protection. Ongoing studies will determine the therapeutic effect and longer-term fate of MSC-hIL-10 cells delivered during EVLP.

Background Normothermic ex vivo lung perfusion (EVLP) is a preservation technique that allows reassessment of donor lungs before transplantation. We hypothesized that the endothelin-1 (ET-1) axis would be associated with donor lung performance during EVLP and recipient outcomes after transplantation. Methods ET-1, Big ET-1, endothelin-converting enzyme (ECE), and nitric oxide (NO) metabolites were quantified in the perfusates of donor lungs enrolled in a clinical EVLP trial. Lungs were divided into 3 groups: (I) Control: bilateral transplantation with good early outcomes defined as absence of primary graft dysfunction (PGD) Grade 3 (PGD3) ; (II) PGD3: bilateral lung transplantation with PGD3 any time within 72 hours; and (III) Declined: lungs rejected after EVLP. Results There were 25 lungs in Group I, 7 in Group II, and 16 in Group III. At 1 and 4 hours of EVLP, the perfusates of Declined lungs had significantly higher levels of ET-1 (3.1 ± 2.1 vs 1.8±2.3 pg/ml, p=0.01; 2.7 ± 2.2 vs 1.3 ± 1.1 pg/ml, p=0.007) and Big ET-1 (15.8 ± 14.2 vs 7.0 ± 6.5 pg/ml, p=0.001; 31.7 ± 17.4 vs 19.4 ± 9.5 pg/ml, p=0.007) compared with Controls. Nitric oxide metabolite concentrations were significantly higher in Declined and PGD3 lungs than in Controls. For cases of donation after cardiac death, PGD3 and Declined lungs had higher ET-1 and Big ET-1 levels at 4 hours of perfusion compared with Controls. At this time point, Big ET-1 had excellent accuracy to distinguish PGD3 (96%) and Declined (92%) from Control lungs. Conclusions In donation after cardiac death lungs, perfusate ET-1 and Big ET-1 are potential predictors of lung function during EVLP and after lung transplantation. They were also associated with non-use of lungs after EVLP and thus could represent useful biomarkers to improve the accuracy of donor lungs selection.