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This case is an example of a rare cause of a common clinical presentation (persistent lobar collapse with wheeze). We describe patient management from primary care through to a national thoracic referral centre. We highlight the importance of objective testing to support an asthma diagnosis and the need to consider alternative or additional diagnoses if a patient does not respond to treatment or the clinical course is unexpected. We highlight the importance of follow-up X-ray to determine whether atelectasis has resolved, which was significantly delayed in this case due to COVID-19 restrictions. Though rare, an endobronchial tumour should be considered if atelectasis persists and when planning endoscopy for a presumed foreign body, especially if the clinical history and patient factors make a foreign body less likely. Greater awareness of this as a differential may expedite diagnoses for patients in future. We show how virtual, multicentre, multidisciplinary meetings can aid rapid diagnosis, surgical planning and coordination of follow-up across centres.

Introduction Ward rounds are complex clinical processesthat provide an opportunity for daily review and management of thoracic surgery inpatients (1). The aim of this study was to evaluate the thoracic surgical ward round documentation against the guidelines and recommendations and facilitate a pathway template to improve this process and enhance patient care. Materials and Methods Data for this audit was collected retrospectively and prospectively. Data was collected during three auditing periods and managed on Microsoft Excel. Descriptive statistics were used for its analysis. Chi-square and Fisher’s Exact tests were used to test for difference in reporting rates. Results and Discussion Initially, a total of 199 ward round notes were reviewed. Imaging results (19%) and discharge planning (23%) were not reported. eCARE (electronic Clinical Assessment for Round Evaluation) was developed to ensure that all aspects of patient evaluation recommended by the guidelines were included. Reporting rates significantly improved after such changes. We analysed the effect of the new ward round note on discharge planning (23.3 vs 41%, pConclusion Over a year, we audited the compliance of the Thoracic Surgery Department against national standards for ward round documentation. Several important items were not regularly reported. Using closed-ended questions improved reporting rates, and patient safety was optimised. Further research should explore the impact of this new documentation method on patient care and postoperative outcomes in our Trust as well as other Cardiothoracic centers.

Objectives: The COVID-19 pandemic has generated a new type of acute respiratory distress syndrome (ARDS) arising as a complication of COVID-19 pneumonia. Extreme cases require the support of extracorporeal membrane oxygenation (ECMO). Here we present the outcomes of patients that underwent surgical tracheostomy or thoracic surgery at a single tertiary centre whilst on ECMO support for COVID-19 related ARDS. Methods: 18 patients requiring thoracic input whilst on ECMO support during the first wave of COVID-19 (March–June 2020) were included. Thoracic surgery was required both for performing surgical tracheostomies in the operating theatre and for treating emergencies arising under the ECMO treatment such as bleeding complications. Results: Thirteen patients underwent a surgical tracheostomy, whilst five patients had an invasive thoracic procedure. Anticoagulation was withheld for at least 12 h in the perioperative setting regardless of the indication. One patient was re-operated for haemothorax immediately after the end of the primary operation. 94.5% of the patients were successfully decannulated from ECMO support. Overall 30-day mortality in the cohort was 5.5% (1/18). Conclusions: Thoracic surgeons can play a valuable role in supporting an ECMO unit during the COVID pandemic, by treating ECMO related complications and by safely performing surgical tracheostomies. Withholding anticoagulation in the perioperative window was not associated with increased thromboembolic events and is desirable when interventions or surgery is indicated in this patient cohort to avoid excessive bleeding.

Background SARS-CoV-2 has challenged health service provision worldwide. This work evaluates safe surgical pathways and standard operating procedures implemented in the high volume, global city of London during the first wave of SARS-CoV-2 infection. We also assess the safety of minimally invasive surgery(MIS) for anatomical lung resection. Methods This multicentre cohort study was conducted across all London thoracic surgical units, covering a catchment area of approximately 14.8 Million. A Pan-London Collaborative was created for data sharing and dissemination of protocols. All patients undergoing anatomical lung resection 1st March-1st June 2020 were included. Primary outcomes were SARS-CoV-2 infection, access to minimally invasive surgery, post-operative complication, length of intensive care and hospital stay (LOS), and death during follow up. Findings 352 patients underwent anatomical lung resection with a median age of 69 (IQR: 35–86) years. Self-isolation and pre-operative screening were implemented following the UK national lockdown. Pre-operative SARS-CoV-2 swabs were performed in 63.1% and CT imaging in 54.8%. 61.7% of cases were performed minimally invasively (MIS), compared to 59.9% pre pandemic. Median LOS was 6 days with a 30-day survival of 98.3% (comparable to a median LOS of 6 days and 30-day survival of 98.4% pre-pandemic). Significant complications developed in 7.3% of patients (Clavien-Dindo Grade 3–4) and 12 there were re-admissions(3.4%). Seven patients(2.0%) were diagnosed with SARS-CoV-2 infection, two of whom died (28.5%). Interpretation SARS-CoV-2 infection significantly increases morbidity and mortality in patients undergoing elective anatomical pulmonary resection. However, surgery can be safely undertaken via open and MIS approaches at the peak of a viral pandemic if precautionary measures are implemented. High volume surgery should continue during further viral peaks to minimise health service burden and potential harm to cancer patients. Funding This work did not receive funding.

Der parapneumonische Pleuraerguss ist eine haufige Komplikation nach einer Pneumonie und kann zur Entwicklung eines Pleuraempyems fuhren. Das Pleuraempyem ist eine lebensbedrohliche Infektion, die mit Antibiotika, interventioneller Drainage oder in spateren Stadien operativ versorgt werden kann. Hier beschreiben wir den ersten Fall eines Pleuraempyems nach vorangegangener COVID-19-Infektion ohne respiratorische Insuffizienz bei einem zuvor gesunden, sportlichen Patienten. Der Patient wurde initial mit Antibiotika und interventioneller Drainage versorgt, musste aber aufgrund einer klinischen Verschlechterung erneut stationar aufgenommen werden. Operativ zeigte sich ein Pleuraempyem 3. Grades, das thorakoskopisch erfolgreich mittels Dekortikation versorgt werden konnte. Die praoperative SARS-CoV-2-Testung war negativ. Der Patient hat sich komplett erholt und konnte entlassen werden.

Parapneumonic pleural effusion is a common complication of pneumonia and can progress to empyema. Pleural empyema is a life-threatening infection, which can be treated with antibiotics and interventional drainage but in later stages often requires surgery. Here we describe the first case of pleural empyema following a COVID-19 infection with no respiratory failure in a previously healthy and athletic patient. The patient was initially treated with antibiotics and interventional drainage but was readmitted to hospital with symptom deterioration. He was then referred for surgery and underwent an uneventful thoracoscopic washout with partial decortication. The preoperative SARS-CoV‑2 swab was negative. The patient recovered fully and could be discharged.Der parapneumonische Pleuraerguss ist eine häufige Komplikation nach einer Pneumonie und kann zur Entwicklung eines Pleuraempyems führen. Das Pleuraempyem ist eine lebensbedrohliche Infektion, die mit Antibiotika, interventioneller Drainage oder in späteren Stadien operativ versorgt werden kann. Hier beschreiben wir den ersten Fall eines Pleuraempyems nach vorangegangener COVID-19-Infektion ohne respiratorische Insuffizienz bei einem zuvor gesunden, sportlichen Patienten. Der Patient wurde initial mit Antibiotika und interventioneller Drainage versorgt, musste aber aufgrund einer klinischen Verschlechterung erneut stationär aufgenommen werden. Operativ zeigte sich ein Pleuraempyem 3. Grades, das thorakoskopisch erfolgreich mittels Dekortikation versorgt werden konnte. Die präoperative SARS-CoV-2-Testung war negativ. Der Patient hat sich komplett erholt und konnte entlassen werden.

Summary A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed: Is open window thoracostomy (OWT) the only method to control infection in patients with an empyema following pulmonary resection for primary lung cancer? Altogether 442 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Empyema following anatomical lung resection (excluding pneumonectomy) is an uncommon complication but one that remains a challenge to treat effectively. Chest tube thoracostomy and intravenous antibiotics remain the initial steps to management, but evidence is lacking with regard to the best ongoing strategy. Conservative options including chest cavity irrigation, postural drainage and vacuum-assisted closure have been attempted with some success, even in the presence of a broncho-pleural fistula. However, the very limited number of patients on which these various management strategies have been trialled on prevents recommendations and clear guidance being given.

Ruptured thoracic duct cysts are an extremely rare occurrence that may arise spontaneously or due to trauma. Surgical treatment is needed to provide a definitive diagnosis, drain the chylothorax and ligate the thoracic duct to prevent reoccurrence. We report the case of a woman with a ruptured thoracic duct cyst presenting with abdominal pain and subsequent tension chylothorax. To the best of our knowledge, this is the first such reported case.

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether trimodal therapy [neoadjuvant chemoradiotherapy (nCRT) in addition to surgery] improves survival in patients with resectable oesophageal cancer. Altogether 565 studies were identified using the below-mentioned search. Eleven represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses are tabulated. All 11 studies were randomized controlled trials comparing surgery with trimodal therapy, 5 of which showed a survival advantage with combined treatment. The remaining six randomized controlled trials showed no difference between trimodal therapy and surgery alone. The 3-year survival for trimodal treatment varied between 19.3 and 58% compared with that for surgery alone which varied between 7 and 53%. Five of these studies compared trimodal therapy with surgery in terms of resection margins, three of which showed that trimodal therapy led to increased R0 resection rate. One study focused on the differences between adenocarcinoma and squamous cell tumours, and described equivalent effects of trimodal therapy in terms of survival. One randomized controlled trial showed improved survival in patients with complete regression of their tumour following induction treatment. Two studies suggested that induction treatment may lead to a higher operative mortality; however, an increase in disease-free survival was noted in one of the two studies. We conclude that trimodal therapy for resectable oesophageal cancer offers similar or even improved results compared with surgery alone in terms of survival. Furthermore, it is likely that there is an advantage for those patients who have a complete pathological response following induction treatment.

Immune evasion is a hallmark of cancer. Losing the ability to present neoantigens through human leukocyte antigen (HLA) loss may facilitate immune evasion. However, the polymorphic nature of the locus has precluded accurate HLA copy-number analysis. Here, we present loss of heterozygosity in human leukocyte antigen (LOHHLA), a computational tool to determine HLA allele-specific copy number from sequencing data. Using LOHHLA, we find that HLA LOH occurs in 40% of non-small-cell lung cancers (NSCLCs) and is associated with a high subclonal neoantigen burden, APOBEC-mediated mutagenesis, upregulation of cytolytic activity, and PD-L1 positivity. The focal nature of HLA LOH alterations, their subclonal frequencies, enrichment in metastatic sites, and occurrence as parallel events suggests that HLA LOH is an immune escape mechanism that is subject to strong microenvironmental selection pressures later in tumor evolution. Characterizing HLA LOH with LOHHLA refines neoantigen prediction and may have implications for our understanding of resistance mechanisms and immunotherapeutic approaches targeting neoantigens. VIDEO ABSTRACT.

The aim of this article is to review the evidence and clinical implications of preoperative investigations in assessing hilar tumours. All current available paraclinical investigations, invasive and non-invasive, were analysed in order to establish the predictability of a more extended resection. We concluded the following: it is difficult to exclude the possibility of an extended resection from the current investigations without exploratory thoracotomy.

A 65-year-old woman was referred with hypercalcaemia and found to have a four cm retrotracheal mass on CT. The patient also suffered from neurofibromatosis and a recently diagnosed gastric mass. Tc(99) sestamibi scintigraphy revealed an area of intense uptake in the right upper mediastinum. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was used to confirm the diagnosis of parathyroid adenoma and thoracoscopic resection was subsequently performed. EBUS-TBNA biopsy can be a helpful diagnostic tool to confirm diagnosis of mediastinal parathyroid masses in patients with atypical or complex clinical presentations.