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BACKGROUND: The intraoperative localization of nonpalpable pulmonary nodules for thoracoscopic wedge resection is technically challenging. Current preoperative image-guided localization techniques require additional time, costs, procedural risks, advanced facilities, and well-trained operators. In this study, we explored a cost-effective method of well-matched interaction between virtuality and reality for accurate intraoperative localization. METHODS: Through the integration of techniques involving preoperative 3-dimensional (3D) reconstruction, temporary clamping of target vessel and the modified inflation-deflation method, the segment on the 3D virtual model and the segment under the thoracoscopic monitor were well matched in the inflated state. Then the spatial relationships of target nodule to the virtual segment could be applied to the actual segment. The well-matched interaction between virtuality and reality would facilitate nodule localization. RESULTS: A total of 53 nodules were successfully localized. The median maximum diameter of the nodules was 9.0 mm (interquartile range [IQR], 7.0-12.5 mm). The median depth(min) and depth(max) were 10.0 mm and 18.2 mm, respectively. The median macroscopic resection margin was 16 mm (IQR, 7.0-12.5 mm). The median duration of chest tube drainage was 27 hours, with a median total drainage of 170 mL. The median postoperative length of hospital stay was 2 days. CONCLUSIONS: The well-matched interaction between virtuality and reality is safe and feasible for intraoperative localization of nonpalpable pulmonary nodules. It may be proposed as a preferred alternative to traditional localization methods.

The main contents of the Clinical Practice Guidelines on Image-Guided Thermal Ablation (IGTA) of Primary and Metastatic Lung Tumors (2022 Edition) include the following: epidemiology of primary and metastatic lung tumors; the concepts of the IGTA and common technical features; procedures, indications, contraindications, outcomes evaluation, and related complications of IGTA on primary and metastatic lung tumors; and limitations and future development.

Background Despite recent improvements in treatment technologies, such as surgical resection and chemoradiotherapy, the prognosis of patients with esophagogastric junction adenocarcinoma (EJA) remains poor due to early lymph node metastasis. Since few studies have investigated genes associated with lymph node metastasis in EJA, we aimed to screen lymph node metastasis‐associated genes and clarify their expression status and prognostic significance in EJA. Methods The differential frequency of mutations between carcinoma and para‐carcinoma tissues from 199 cases with EJA was detected using targeted next‐generation sequencing (tNGS). Following a stratified analysis to determine that gender has no effect on the frequency of gene mutations, lymph node metastasis‐related genes, including CDK6, MET, NOTCH1, and LRP1B, were screened, and CDK6 and LRP1B were selected for further study as they displayed significant differences in mutation rates. Differences in their expression status were verified using immunohistochemical (IHC) staining in 18 CDK6‐ and 17 LRP1B‐mutated samples and a randomly matched control group. Results tNGS revealed that CDK6 and LRP1B mutation frequencies were significantly different between EJA cases with (N ≥ 1) or without (N = 0) lymph node metastasis. In particular, CDK6 mutation frequency was expected less, whereas that of LRP1B was remarkably higher in cases with stage N0 than in those with stage N ≥ 1. IHC staining confirmed significant differences in CDK6 and LRP1B expression status between the study and control cohorts. Chi‐square tests revealed that a high CDK6 expression status correlated significantly with smoking history (p = 0.044), T stage (p = 0.035), N stage (p = 0.000), and advanced TNM stage (p = 0.001) in EJA, whereas a high LRP1B expression status only correlated with BMI (p = 0.013) and N stage (p = 0.000). Furthermore, as confirmed by survival status investigation, a high LRP1B expression status predicted good prognosis, and a high CDK6 expression status was an independent predictor of poor prognosis in patients with EJA. Conclusions Taken together, the findings of this study demonstrate that a high CDK6 and LRP1B expression status promotes and inhibits lymph node metastasis in patients with EJA, respectively, suggesting that both CDK6 and LRP1B are significantly potential predictors of lymph node metastasis and prognosis in EJA., Screening of lymph node metastasis‐related genes by targeted next‐generation sequencing in of esophagogastric junction adenocarcinoma. CDK6 and LRP1B were selected for further study to clarify their expression and prognostic significance in AEG.

Background Tracheomalacia may be caused by long-standing compression of retrosternal goitre because of destruction of support of tracheal cartilages. Life-threatening airway collapses may occur after surgical removal of goitre. However, available literature on management methods of tracheomalacia is sparse. Our study highlights prolonged endotracheal intubation as a feasible treatment method. Methods This retrospective study analysed 106 thyroidectomies for retrosternal goitre performed between 1994 and 2019. We recorded each patient's clinical profile. Severe tracheomalacia was confirmed through the following: soft and floppy trachea on intra-operative palpation and the collapse of cross-sectional tracheal area measured in computed tomography (CT) images by >80%. We assessed the extent of airway stenosis of these cases. All severe cases were treated by prolonged endotracheal intubation. Results Surgical treatment was successfully performed in all 106 retrosternal goitre patients with no mortality. Seventeen severe tracheomalacia cases were confirmed. The extent of airway stenosis was assessed: the minimal tracheal diameter of compressed trachea was 0.2-0.4 [mean 0.31, standard deviation (SD) 0.06] cm, and the narrow tracheal length was 4-6.7 (mean 5.1, SD 0.6) cm. These patients underwent endotracheal intubation for 17-47 h after surgery. All patients were transferred to the general ward after extubation and successfully discharged. There were no cases of tracheal stenosis on follow-up. Conclusions Tracheomalacia is a rare but serious complication of retrosternal goitre surgery. Based on our experience, prolonged endotracheal intubation is a feasible treatment for tracheomalacia after retrosternal goitre surgery.

The Expert Consensus reviews current literatures and provides clinical practice guidelines for thermal ablation of pulmonary subsolid nodules or ground-glass nodule (GGN). The main contents include the following: (1) clinical evaluation of GGN; (2) procedures, indications, contraindications, outcomes evaluation, and related complications of thermal ablation for GGN; and (3) future development directions.

Background Research on the impact of examined lymph node (ELN) count on node‐negative esophageal cancer (EC) especially pT1N0M0 EC is inadequate. This study was designed to analyze the prognostic impact of ELN count on pT1N0M0 EC. Methods Data of resected pT1N0M0 EC patients between 1988 and 2015 were extracted from the United States Surveillance, Epidemiology, and End Results (SEER) database. The association between ELN count and overall survival (OS) or esophageal cancer‐specific survival (ECSS) were investigated. Factors that may predict the outcome were identified using the Kaplan‐Meier method and the Cox proportional‐hazards model. Results A total of 906 patients who underwent resection with at least one lymph node (LN) retrieved met our criteria. The cumulative 5‐year OS was 67.6%, while the cumulative 5‐year ECSS was 75.4%. X‐Tile analysis showed that 12 was the optimal cutoff value for ELN count in terms of both OS (χ2 = 28.764, P 12 was significantly associated with better OS (HR, 0.532; 95% CI, 0.421–0.672; P

Background: As one of the most common malignant tumors of the digestive tract, esophageal squamous cell carcinoma (ESCC) is an advanced metastatic cancer with an extremely high mortality rate and the highest prevalence rate in China. Spindle- and kinetochore-associated protein 1 (SKA1), an essential member involved in chromosome separation during mitosis, has been indicated as a potential biomarker in the pathogenesis and development of various types of malignant tumors; however, the exact functions of SKA1 in ESCC are still unclear. Patients and Methods: SKA1 expression was explored in stage IIA ESCC and corresponding healthy esophageal mucosa tissues through immunohistochemistry and reverse transcription–quantitative polymerase chain reaction and was further validated using The Cancer Genome Atlas (TCGA) database of the online tool UALCAN. Then, the clinicopathological correlations of SKA1 were analyzed based on the follow-up data. Furthermore, using the online tool LinkedOmics, the correlation test, gene ontology (GO), and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analysis of SKA1 were analyzed using high-throughput sequencing data of ESCC patients from TCGA dataset. Results: The expression level of SKA1 was markedly upregulated in ESCC tissues. Upregulation of SKA1 significantly correlated with higher pathological T stage (P = 0.003) and poorer overall survival (P = 0.013). GO and pathway enrichment analyses of SKA1 in ESCC revealed that SKA1 was involved in a number of classical cell cycle-related pathways that contribute to special biological processes in tumorigenesis and development of ESCC. Conclusion: The results of this study demonstrate that SKA1 may act as a prognostic biomarker for stage IIA ESCC. Combined with the bioinformatic analysis, SKA1 could potentially serve as a therapeutic target for ESCC. Conclusion: The results coming from the present study demonstrated that SKA1 may act as a prognostic biomarker for stage IIA ESCC. Combined with the bioinformatic analysis, SKA1 could serve as a potential therapeutic target for ESCC.

Background Currently, methods for identifying the intersegmental plane during anatomical segmentectomy can be classified into 2 categories: the bronchial method and the vascular method. One of the vascular methods, the arterial-ligation-alone method, has not yet been validated or objectively evaluated in a large case series. We thus aimed to confirm that the arterial-ligation-alone method could effectively and accurately identify the intersegmental plane. Methods We retrospectively reviewed the records of 104 patients who were scheduled for thoracoscopic anatomic segmentectomy. Preoperative three-dimensional (3D) reconstruction was performed on all the affected lungs to distinguish the targeted segmental arteries, veins and bronchi. The procedure was as follows: first, based on the 3D reconstruction of the lung, the targeted segmental arteries were distinguished and ligated. Second, bilateral pulmonary ventilation was performed with pure oxygen. When the affected lung had completely inflated, contralateral pulmonary ventilation was performed. After waiting for some time, the first intersegmental plane could be obtained, and the time was recorded as T1, with an electric coagulation hook being used for marking. Thirdly, when the targeted segmental veins and bronchi had been ligated, the second intersegmental plane could be obtained by the inflation-deflation method as before, with the waiting time being recorded as T2. The differences between the 2 intersegmental planes were evaluated by 2 experienced chief thoracic surgeons. Result In a total of 99 (95.2%) patients, the intersegmental planes were successfully and accurately identified by the arterial-ligation-alone method. Ultimately, 85 (81.7%) patients underwent thoracoscopic anatomic segmentectomy. The results for evaluating the differences between the 2 planes were as follows: completely consistent (94 cases, 94.9%), basically consistent (5 cases, 5.1%), and discrepant (0 cases, 0%). The mean T1 was 13.6±2.7 minutes (range, 8-25 minutes), and the mean T2 was 13.0±2.6 minutes (range, 8-23 minutes), with P=0.100 (95% CI). For 99 patients, the mean nodule size was 1.1±0.34 cm. In the 85 patients who underwent segmentectomy, the mean margin width was 2.84±0.51 cm, the mean operative duration was 165.6±18.3 minutes, the mean operative hemorrhage was 52.1±20.2 mL, and the mean duration of chest tube drainage was 3.9±1.3 days. Postoperative complications related to operative procedures occurred in 2 cases. Conclusions The arterial-ligation-only method can effectively, accurately and inexpensively identify the intersegmental plane, and is especially suitable for the patients whose veins or bronchi are difficult to anatomize. Whether the target bronchus is ligated has no effect on the intersegmental plane.

Non-small cell lung cancer (NSCLC) is the most common and fatal tumor worldwide, with 2.1 million new cases and 1.77 million deaths per year (1). With the wider application of examination approaches and the improvement of health awareness, higher proportions of surgically resectable early and mid-stage lung cancers have been detected. In overall, only 50% of patients have been cured after radical resection. In other cases, however, NSCLC is highly active and recurrence and/or metastasis can easily occur after surgery. In these patients, systemic therapy as a postoperative adjuvant therapy is required to eliminate or reduce residual micro-lesions to lower the risk of recurrence; meanwhile, the patients should be closely monitored to detect early recurrence. EGFR mutation is a major mutation type in lung cancer, and is seen in about 40% of lung cancer cases in Asia (2). Compared with wild types and other mutation types, EGFR-mutant NSCLC has its unique biological properties and drug susceptibilities, and thus requires specific diagnosis and treatment strategies. This expert consensus aims to review the current evidence and provide recommendations on key issues. A consensus and guideline development panel, with its members including top thoracic surgeons and oncologists all around the world, was established to decide the methodologies, processes, levels of evidence, and related recommendations. The panel members proposed the core clinical issues in the consensus document and wrote and submitted the outlines to the panel for approval. The panel carried out a problem-oriented literature search for articles published since 1997 in Chinese and foreign databases. The level of evidence was defined using the following criteria: Categories of Evidence and Consensus, Category 1: based upon high-level evidence, there is uniform consensus that the intervention is appropriate; Category 2A: based upon lower-level evidence, there is uniform consensus that the intervention is appropriate; Category 2B: based upon lower-level evidence, there is consensus that the intervention is appropriate; Category 3: based upon any level of evidence, there is major disagreement that the intervention is appropriate. The strength of recommendations was classified as strong or weak according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system (3), and the recommendation statement was composed based on the real-world evidence. A “strong” recommendation generally refers to recommendations based on high-level evidence with consistency between clinical behavior and outcome expectancy; in contrast, a “weak” recommendation is typically based on low-level evidence with uncertainty between clinical behavior and outcome expectancy. After the first draft had been completed, all the panel members were involved in revising and finalizing this document.

Background The superior efficacy of first-line treatment with gefitinib over that of standard chemotherapy was demonstrated in patients with advanced non–small-cell lung cancer (NSCLC) harboring sensitive mutation of epidermal growth factor receptor (EGFR). However, scarce evidence showing the superiority of gefitinib to chemotherapy exists regarding the postoperative adjuvant therapy of EGFR mutation–positive patients with stage II-IIIA NSCLC. To address this important gap, we undertook a retrospective study to assess the efficacy of adjuvant gefitinib versus adjuvant chemotherapy (AC) in patients with completely resected EGFR-mutant stage II-IIIA NSCLC. Patients and Methods A total of 116 patients with completely resected II-IIIA NSCLC and confirmed positive EGFR mutation (exon 19 deletion or exon 21 Leu858Arg) between January 2013 and March 2017 were included in our study. Disease-free survival (DFS) was analyzed in 55 patients treated with gefitinib and 61 patients treated with a platinum-based 2-drug-combination AC. Propensity score matching allowed the generation of best matched pairs for the 2 categories (1:1 ratio). Factors affecting survival were assessed by the Kaplan-Meier method and Cox regression analysis. Results The matched cohort consisted of 52 gefitinib and 52 AC patients with a median follow-up of 37.1 and 31.5 months, respectively. DFS was significantly longer in the gefitinib group than that in the AC group (34.9 months [95% confidence interval (CI), 21.1-48.7] versus 19.3 months [95% CI, 13.3-25.3]; hazard ratio = 0.36 [95% CI, 0.19-0.68], log-rank P = .001). In the gefitinib group the most common adverse events (AEs) were rash (76.9%), aminotransferase elevation (53.8%), and diarrhea (46.2%), whereas in the AC group the most common AEs were neutropenia (67.3%), nausea or vomiting (63.5%), and anemia (44.2%). Less frequent grade 3 or higher AEs were observed in the gefitinib group (15.4% vs. 38.5% in the AC group). After receiving gefitinib for 3 months, one patient was diagnosed with interstitial lung disease, which was regarded as the most severe treatment-related AE. No deaths were treatment related. Conclusion In this retrospective study, compared to AC, gefitinib provided a statistically significant DFS benefit, reduced toxicity in EGFR mutation–positive patients with resected II-IIIA NSCLC. These results require further validation by prospective randomized trials.

Although surgical resection with curative intent is the main therapy for both primary and metastatic lung tumors, about 80% of lung cancers cannot be removed by surgery. Because most patients with unresectable lung cancer only receive limited benefits from traditional radiotherapy and chemotherapy, many novel local treatment modalities have emerged including local ablation therapy. The Minimally Invasive Treatment of Lung Cancer Branch, Professional Committee of Minimally Invasive Treatment of Cancer of the Chinese Anti-Cancer Association and Committee on Tumor Ablations, Chinese College of Interventionalists have organized multidisciplinary experts to develop guidelines for this treatment modality. These guidelines aim at standardizing thermal ablation procedures, describing the indications for candidates, assessing outcomes, and preventing postablation complications.

Background A giant thoracic neoplasm is extremely rare and poorly understood. Our systemic study introduced computed tomography angiography (CTA) with three-dimensional (3D) reconstruction imaging and evaluated correlations between imaging, pathology, and surgical management. Methods Data from 45 patients undergoing surgery for giant thoracic neoplasm in our institution between May 2007 and November 2015 were collected. The clinical characteristics, imaging manifestations, preoperative biopsy, surgical management, postoperative pathology, and prognosis and their correlation were analyzed. Results The clinical characteristics, imaging manifestations, and pathological types were complicated. Four patients underwent CTA with 3D reconstruction imaging and feeding vessels were found in three cases. Twenty-four selected patients accepted preoperative biopsy, eight of which were inconsistent with postoperative pathology. Complete resection was performed in 39 cases, 20 of which underwent extended excision. The median survival duration of all patients was 58 months (range 3.0–118.0). The one, three, and five-year survival rates were 86.0%, 64.4%, and 47.0%, respectively. Univariate analyses showed tumor size and resection status were prognostic factors for survival (P = 0.003 and P < 0.001, respectively). Conclusions A giant thoracic neoplasm should preferably be treated in experienced centers for precise diagnosis and optimal therapy schemes with comprehensive consideration of clinical characters, imaging manifestations, pathology, surgical management, and prognosis. Innovative CTA with 3D reconstruction imaging together with preoperative biopsy are feasible and effective in therapeutic decision-making and surgical planning. Complete surgical resection remains the mainstay of curative therapy for all resectable tumors.

Objective: The detection rate of synchronous multiple primary lung cancers (SMPLC) showed an increasing trend year by year. In an attempt to identify the optimal treatment strategy for SMPLC, we retrospectively analyzed our surgical treatment outcomes of a series of patients with SMPLC. Materials and Methods: A total of 43 SMPLC patients who met the modified Martini-Melamed criteria and with clinical data retained between November 2012 and July 2016 underwent complete resection without any preoperative induction therapy at the Department of Thoracic Surgery, Shandong Provincial Hospital. The relationships between gender, age, family history of cancer, the number of tumors, the location of tumors, tumor size, tumor histology, regional lymph node metastasis, type of surgery, pathological stage, epidermal growth factor receptor (EGFR) mutation, mortality, and survival were further analyzed. Results: Among the 43 patients, 29 (67.4%) patients had ipsilateral tumors, whereas 14 (32.6%) patients had contralateral tumors. Nine patients with contralateral tumors underwent one-stage surgical treatment, with mean postoperative hospitalization days of 9.8. EGFR mutations were detected in 5 patients with synchronous multiple primary lung adenocarcinomas (SMPLA) for each lesion independently. The results showed different tumors in the same patient could carry different EGFR mutations. The 1- and 3-year overall survival (OS) rates were 97.0% and 76.7%, respectively. Larger maximal tumor dimension (P = 0.015), advanced pN stage (P = 0.002), advanced pT stage (P = 0.046), advanced TNM stage (P = 0.013), and postoperative adjuvant chemotherapy (P = 0.025) were correlated with poor OS. Conclusions: SMPLC could be considered to be a local disease rather than the systemic disease. Surgical treatment is an effective approach for patients with SMPLC. Mutational status of EGFR could be used as a diagnostic criterion, especially in patients with SMPLA.

Objective: Chyle test is widely used to identify chylothorax after pulmonary resection and lymph node dissection for primary non-small cell lung cancer (NSCLC). Low accuracy of chyle test in identifying chylothorax is rarely reported. This observational study was designed to identify the diagnostic value of chyle test. Patients and Methods: From September 2016 to March 2017, 185 consecutive patients either suspected or histologically documented lung cancer were screened for this observational study. Except exclusion, 108 patients were eligible for further analysis. Daily chest-tube output as well as the postoperative day of chest tube removal was documented. Chyle test was analyzed with 108 cases, and the results were blinded to the thoracic surgeons. Chest tube was timely removed regardless of the results of chyle test. A high-output pleural effusion and an associated change in quality of the pleural fluid, from serous to milky yellowish after normal diet, led to the diagnosis of chylothorax. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of chyle test in identifying chylothorax were calculated. Results: Of 108 patients, 4 (3.7%) were observed with chylothorax after pulmonary resection and lymph node dissection for primary NSCLC. Postoperative chylothorax was conservatively managed in three patients and chest tubes were removed 12 days (from 10 to 16) after surgery. Failed in conservative treatment, one patient underwent thoracic duct ligation performed by video-assisted thoracic surgery. For patients without chylothorax, the median day of chest tube removal was postoperative day 4. Among the 108 patients, 75.9% (82/108) was found with a positive chyle test result, of which 95.1% (78/82) was false positive in identifying chylothorax. The sensitivity and specificity of chyle test in identifying chylothorax were 100% and 25%, respectively. The positive predictive value, negative predictive value, and accuracy of chyle test for chylothorax diagnosis were 4.9%, 100%, and 27.8%, respectively. Conclusions: It was suggested that the specificity and accuracy of chyle test in identifying chylothorax were relatively low. Chyle test is not a good laboratory index in identifying chylothorax. With highly positive result, chyle test should not preclude the removal of chest tube in patients after pulmonary resection and lymph node dissection for primary NSCLC.

Background Epidermal growth factor receptor-tyrosine kinase inhibitors (TKI-EGFRs) present a new prospect for the treatment of lung cancer. However, in clinical application, the majority of patients become TKI resistant within a year. More and more studies have shown that a loss of phosphatase and tensin homolog (PTEN) expression is associated with TKI resistance. An alternative method of upregulating PTEN expression may reverse TKI resistance. Methods We designed five candidate small activating ribonucleic acids (saRNAs) to target PTEN, and transfected them into H-157 cells to screen out functional saRNA. We used reverse transcriptase-polymerase chain reaction and Western blot to evaluate the effect of saRNA to PTEN expression. We then analyzed the growth and apoptosis of cells transfected with saRNA under the treatment of TKI to investigate whether saRNAs can reverse TKI resistance by upregulating PTEN expression. Results The functional saRNA we designed could upregulate PTEN expression. The H-157 cells transfected with saRNA grew slower in the presence of TKI drugs than the cells that were not transfected with saRNA. The apoptosis rate was also obviously higher. Conclusions Our study proves that loss of PTEN expression is an important mechanism of TKI resistance. It is possible to control TKI resistance by upregulating PTEN expression using RNA activation technology.

Background CMTM6 was identified as an important regulator of the PD-L1 protein. The role of CMTM6 in lung adenocarcinoma (LUAD) has so far remained unclear. We aimed at investigating the role of CMTM6 in LUAD at transcriptome and genomic levels and its relationship with tumor-infiltrating immune cells (TIICs). Methods We downloaded the data sets of LUAD from TCGA. The genomic profiles containing somatic mutations were analyzed and the transcriptome level of CMTM6 was also obtained. Gene set variation analysis (GSVA) was used to predict the pathway change. In addition, we explored the association between CMTM6 and LUAD immune infiltrates by means of CIBERSORT. The association between CMTM6 and PD-L1 mRNA was analyzed using an integrated repository portal for tumor-immune system interactions (TISIDB) and was further validated in 80 LUAD patients. Kaplan-Meier survival curve and the log-rank test was used to analyze the survival significance of CMTM6. Results We found that CMTM6 was downregulated in LUAD. Patients with low CMTM6 expression were more likely to be frequent with somatic mutations. Moreover, GSVA analysis exhibited that CMTM6 was associated with immune responses and inflammatory activities. Specifically, a positive correlation between increased CMTM6 expression and immune infiltrating level of Dendritic cells resting, Eosinophils, Macrophages M1, Macrophages M2, Neutrophils, T cells CD4 memory activated and T cells CD4 memory resting was established. The CMTM6 expression was positively correlated with PD-L1 in both mRNA and protein level. Clinically, patients with high expression of CMTM6 tended to have a better survival. Conclusion CMTM6 expression likely had an important effect on TIICs composition and prognosis in LUAD patients. The CMTM6 expression was positively correlated with PD-L1 in LUAD. These findings establish CMTM6 as a promising target for immunotherapeutic prospects.

Background: Even with the use of contrast-enhanced thin-layer chest computed tomography (CT) and endoscopic ultrasonography (EUS), the likelihood of cT2N0M0 squamous cell esophageal cancer correlating with the final pathologic outcome is exceedingly low. We therefore sought to investigate the associations between different risk factors and pathologic upstaging in stage T2N0M0 esophageal cancer patients who underwent esophagectomy. Materials and Methods: We retrospectively reviewed the clinicopathological characteristics of 224 stage T2N0M0 squamous cell esophageal cancer patients who underwent complete resection over a 2-year period (October 2016–September 2018). The tumor volume (TV) was automatically measured from thin-layer chest CT scans using imaging software. Univariate and multivariate analyses were performed to identify the risk factors associated with upstaging. A receiver operating characteristic (ROC) curve was plotted, and its ability to identify pathological upstaging was assessed. Results: A total of 224 patients with clinical stage T2N0M0 squamous cell esophageal carcinoma (SCEC) underwent esophagectomy; of these patients, 96 (42.86%) had a more advanced stage during the final pathologic review than during the initial diagnosis. The risk factors for pathologic upstaging included a large TV, high total cholesterol (TC), high triglycerides (TGs), high platelet-to-lymphocyte ratio (PLR), and high number of lymph nodes examined. The ROC analysis demonstrated an area under the curve of 0.845 (95% confidence interval 0.794–0.895). Conclusions: In SECC diagnosed as stage T2N0M0 by CT and EUS, the incidence of postoperative pathologic upstaging increases with a large TV, high TC, high TGs, high PLR, and high number of lymph nodes examined.

Rationale: Aorto-esophageal fistula (AEF), a postoperative complication of esophagectomy, constitutes a very small percentage of all cases presenting with AEF; however, it is associated with a high mortality rate. Acute massive hemorrhage is the single largest cause of death in patients developing AEF. There is a lack of consensus on the optimal treatment of AEF. Patient concerns: We present 3 cases secondary to esophagectomy due to lower thoracic esophageal carcinoma. All 3 patients presented with similar acute symptoms including a critical and life-threatening course with dead feeling, thoracic pain, and projectile hematemesis, and also hypovolemic shock. Diagnoses: Digital subtraction angiography identified AEF as the diagnosis of these 3 cases. Interventions: All patients were treated with emergency thoracic endovascular aortic repair, the aortic fistulas were repaired. Outcomes: All patients successfully survived the perioperative period. Lessons: Thoracic endovascular aortic repair, a minimally invasive technique, is a better method to achieve faster and safer hemodynamic stability in patients with AEF compared with open thoracic aortic repair.

Background A giant thoracic neoplasm is extremely rare and poorly understood. Our systemic study introduced computed tomography angiography (CTA) with three‐dimensional (3D) reconstruction imaging and evaluated correlations between imaging, pathology, and surgical management. Methods Data from 45 patients undergoing surgery for giant thoracic neoplasm in our institution between May 2007 and November 2015 were collected. The clinical characteristics, imaging manifestations, preoperative biopsy, surgical management, postoperative pathology, and prognosis and their correlation were analyzed. Results The clinical characteristics, imaging manifestations, and pathological types were complicated. Four patients underwent CTA with 3D reconstruction imaging and feeding vessels were found in three cases. Twenty‐four selected patients accepted preoperative biopsy, eight of which were inconsistent with postoperative pathology. Complete resection was performed in 39 cases, 20 of which underwent extended excision. The median survival duration of all patients was 58 months (range 3.0–118.0). The one, three, and five‐year survival rates were 86.0%, 64.4%, and 47.0%, respectively. Univariate analyses showed tumor size and resection status were prognostic factors for survival (P = 0.003 and P < 0.001, respectively). Conclusions A giant thoracic neoplasm should preferably be treated in experienced centers for precise diagnosis and optimal therapy schemes with comprehensive consideration of clinical characters, imaging manifestations, pathology, surgical management, and prognosis. Innovative CTA with 3D reconstruction imaging together with preoperative biopsy are feasible and effective in therapeutic decision‐making and surgical planning. Complete surgical resection remains the mainstay of curative therapy for all resectable tumors.

Lung cancer is one of the most common types of malignant tumor worldwide. The etiology of lung cancer is complex and, although significant progress has been made in previous investigations, the molecular mechanism responsible for lung cancer remains to be fully elucidated. In the present study, the association between lung cancer and transmembrane 7 superfamily member 4 (TM7SF4) was investigated. Reverse transcription‑quantitative polymerase chain reaction technology was used to detect the expression of TM7SF4, and it was expressed at a high level in lung cancer. Furthermore, by overexpressing and inhibiting the expression of TM7SF4, the present study compared cell proliferation and migration rates. It was confirmed that TM7SF4 promoted lung cancer cell proliferation and migration. TM7SF4 was also confirmed to promote cancer cell migration and invasion by modulating the activation of the phosphatidylinositol 3‑kinase/Akt pathway in the A549 cells. Correspondingly, the inhibition of TM7SF4 decreased the expression of proteins associated with AKT, whereas the overexpression of TM7SF4 promoted the expression of the relevant proteins. Therefore, the present study confirmed that TM7SF4 was involved in the progression of lung cancer via regulating the activation of AKT. These findings suggested that TM7SF4 may be involved in the progression of lung cancer and may be a novel therapeutic target for this disease.

Objective: We investigated the outcomes of patients with multiple ground-glass nodules (GGNs) to identify the role of video-assisted thoracoscopic surgery (VATS) in diagnosis and treatment. Patients and Methods: We included patients with multiple GGNs who were qualified for thoracoscopic surgery resection and analyzed the statistics. Results: Fifty-one GGNs were detected in 21 patients. There were 40 pure GGNs and 11 part-solid ones. Around 46 of the 51 lesions were resected via VATS. Four pure GGNs

The aim of this study was to investigate the efficacy of 11C-choline PET/CT imaging for lung cancer and the correlation between choline uptake of lung cancer tissue and the expression of choline kinase (ChoK), phosphorylcholine-cytidyl transferase and Ki-67 index. Between March 2008 and June 2010, 53 patients diagnosed or suspected of having lung cancer underwent integrated 11C-choline PET/CT and contrast-enhanced CT scans before surgery. After surgery, specimens from 42 patients diagnosed with lung cancer were used to detect the expression of ChoK, phosphorylcholine-cytidyl transferase and the Ki-67 index. The PET/CT results were analyzed using visual methods and the standardized uptake value (SUV) of lesions was measured using semi-quantitative methods. Finally, the analyzed results were compared to the histopathological results. The accuracy of the 11C-choline PET/CT for diagnosing lung cancer was 81.13% (43/53), compared with 71.70% (38/53) for CT scanning. The difference was not statistically significant (P=0.61). The accuracy of 11C-choline PET/CT for diagnosing lymph nodes was 83.76% (227/271), compared with 66.79% (181/271) for CT scanning. This difference was statistically significant (P=0.04); the SUVmean value of lesions correlated positively with the Ki-67 index (r=0.51, p=0.002). Of the 35 patients with positive 11C-choline PET results, 29 (82.86%) overexpressed ChoK, 26 (74.29%) overexpressed phosphorylcholine-cytidyl transferase. The seven patients with negative 11C-choline PET results did not exhibit overexpression of ChoK or phosphorylcholine-cytidyl transferase; the SUVmean value correlated positively with the expression of both ChoK and phosphorylcholine-cytidyl transferase (r=0.52, p=0.001; r=0.37, p=0.029). In conclusion, compared with contrast-enhanced CT, 11C-choline PET offers nodal staging with higher accuracy. The SUV value of PET is correlated with the proliferation of tumor cells and the mechanism of PET imaging is associated with the overexpression of ChoK and phosphorylcholine-cytidyl transferase.

Carbon-11 ((11)C)-choline positron emission tomography/computed tomography (PET/CT) is a new diagnostic method for detecting lung cancer. To prove whether it is superior to enhanced CT, we compared the diagnostic efficacy of these 2 approaches in 108 patients with pulmonary lesions and drew the conclusion that (11)C-choline PET/CT is not better at diagnosing primary lesions but is better at lymph node staging. This helps us to fully understand (11)C-choline PET/CT.This study compares the diagnostic abilities of integrated (11)C-choline PET/CT imaging and contrast-enhanced helical CT imaging in pulmonary lesions and locoregional lymph node metastases in patients with lung cancer.One hundred eight patients with proven or suspected lung cancer underwent integrated (11)C-choline PET/CT and contrast-enhanced CT, followed by surgical resection and nodal staging.The (11)C-choline PET/CT and CT diagnoses of pulmonary lesions and locoregional lymph node metastases were compared with pathologic findings, which revealed benign lesions in 26 patients (tuberculoma [8 patients], inflammatory pseudotumor [7 patients], hamartoma [6 patients], sclerosing hemangioma [4 patients], and pulmonary sequestration [1 patient]) and lung cancers in 82 patients (adenocarcinoma [39 patients], squamous cell carcinoma [23 patients], carcinoid [7 patients], small-cell lung cancer [5 patients], adenosquamous carcinoma [5 patients], and large-cell lung cancer [3 patients]). The accuracy, sensitivity, and specificity of (11)C-choline PET/CT for diagnosing lung cancer were 82.4%, 85.4%, and 73.1%, respectively, compared with 73.1%, 76.8%, and 61.5%, respectively, for CT. Differences between (11)C-choline PET/CT and CT in diagnosing lung cancer were not statistically significant (p = .503, .118, and .375, respectively). We used receiver operating characteristic (ROC) curve for analysis, finding the ROC of standard uptake value (SUV(max)) for diagnosing lung cancer. The cutoff value of SUV(max) was 3.54. Preoperative nodal staging was compared with postoperative histopathologic staging. (11)C-choline PET/CT correctly staged 80.5% of patients, 12.2% were overstaged, and 7.3% were understaged; for CT these values were 58.5%, 24.4%, and 17.1%, respectively. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of (11)C-choline PET/CT for lymph nodes were 83.8%, 82.4%, 84.1%, 50.3%, and 96.1%, respectively, compared with 69.3%, 63.7%, 71.2%, 30.2%, 91.0%, respectively, for CT.Differences in the accuracy, sensitivity, specificity, PPV, and NPV between (11)C-choline PET/CT and CT are thus statistically significant for nodal staging (p = .003, .007, .000, .000, and .004, respectively). Although (11)C-choline PET/CT is not significantly better at diagnosing pulmonary lesions than is enhanced CT, (11)C-choline PET/CT has improved sensitivity, specificity, accuracy, PPV, and NPV relative to enhanced CT in the evaluation of locoregional lymph nodes.

To investigate the expression of vascular endothelial growth factor (VEGF) and CD44v6 in non-small cell lung cancer (NSCLC) and to explore their association with invasion, metastasis and prognosis of NSCLC.A rapid immunohistochemical method (streptoavidin-peroxidase, SP) was used to detect VEGF and CD44v6 proteins expression in 43 paraffin-embedded resected NSCLC tissues retrospectively. All the patients were initially treated.The expression rates of VEGF in squamous cell carcinoma and adenocarcinoma were 62.5% (15/24) and 68.42% (13/19) respectively. The positive rates of CD44v6 expression in squamous cell carcinoma and adenocarcinoma were 58.33% (15/24) and 68.42% (13/19) respectively. The positive expressions of VEGF and CD44v6 were significantly correlated with lymph node metastasis and TNM stage (P0.05), and also significantly correlated with postoperative hematogenous metastasis (P0.05). The 3- and 5-year survival rates of patients with VEGF positive expression were 19.23% and 6.41% respectively, whereas those with negative expression were 67.41% and 58.82%, there was signi-ficant difference of survival rate between the two groups (P0.05). The 3- and 5-year survival rates of CD44v6 positive expression group and negative expression group were 18.67%, 10.67% and 67.83%, 53.50%, there was also significance difference of survival rate between two groups (P0.05). The positive expression of VEGF was significantly correated with the positive expression of CD44v6 (P0.05).Detection of VEGF and CD44v6 expression in NSCLC is helpful to evaluate the lymph node metastasis, TNM stage and prognosis. It is also helpful to guide postoperative multiple modality therapy.

To investigate the relationship between micrometastasis of bone marrow and neoadjuvant chemotherapy and prognosis in patients with stage III non-small cell lung cancer (NSCLC).Sixty-five patients with stage III NSCLC were randomly divided into group A (32 patients treated with preoperative neoadjuvant chemotherapy plus operation) and group B (33 patients treated with operation and postoperative chemotherapy as control group). Expression of CK19 mRNA and CEA mRNA was detected in bone marrow samples from the rib segments of all patients obtained from operation by RT-PCR. The relationship between survival duration and CK19 and CEA expression was analyzed.The positive rates of CK19 mRNA expression were 18.8%(6/32) and 45.5%(15/33) in group A and B, respectively (P=0.033), and the positive rates of CEA were 25.0%(8/32) and 51.5% (17/33) in group A and B, respectively (P= 0.041). A significant positive correlation was observed between CK19 and CEA expression (r s=0.671,P0.001). The response rates of neoadjuvant chemotherapy were 0%(0/5) and 56.5%(13/23) in patients with CK19(+)/CEA(+) and CK19(-)/CEA(-), respectively (P=0.044), and the median survival duration were 11 and 27 months, respectively (P=0.000 6). Cox's model showed that the response to neoadjuvant chemotherapy and the expression of CK19 or CEA were significantly prognostic factors in group A.Neoadjuvant chemotherapy can reduce the possibility of bone marrow micrometastasis in stage III NSCLC patients. Bone marrow micrometastasis may indicate a poorer prognosis for NSCLC.

Neoadjuvant chemotheropy can improve the survival rate of patients with stage III non-small cell lung cancer (NSCLC), whose chemotherapy is valid. The value of P53 expression in stage III NSCLC has not been reported. This study is to investigate the value of P53 expression on neoadjuvant chemotherapy sensitivity and prognosis in stage III NSCLC and to investigate the relationship between P53 expression and the result from thoracic CT examination.By immunohistochemical technique, the expression of P53 in 51 patients with stage III NSCLC who received neoadjuvant chemotherapy was determined in contrast with 49 patients with stage III NSCLC without neoadjuvant chemotherapy. Every patient who received neoadjuvant chemotherapy was examined by thoracic CT before and after neoadjuvant chemotherapy.(1) There was no significant difference in the positive rate of P53 and the median survival time between neoadjuvant group and control group (48.98% vs 49.02% and 18 months vs 19 months). In neoadjuvant chemotherapy group, the median survival time was significantly different between P53 positive patients and P53 negative ones (13 months vs 31 months). (2) The expression of P53 was related to the neoadjuvant chemotherapeutic response by the results from thoracic CT examination (r=0.537, P0.01).(1)Detection of P53 expression might be helpful to predict the effect of neoadjuvant chemotherapy. (2)The expression of P53 and the neoadjuvant chemotherapeutic results from thoracic CT examination are correlated.

Lung cancer invading left atrium or base of pulmonary vein belongs to locally advanced lung cancer (T4). The prognosis of treatment without surgery is poor. The aim of this study is to explore the feasibility and the value of surgical method in the treatment of this disease.From April, 1993 to April, 2005, lobectomy or pneumonectomy combined with extended resection of left atrium were carried out in 46 patients with locally advanced lung cancer. The operations included left low lobectomy in 20 cases, left pneumonectomy in 6 cases, right middle and low lobectomy in 12 cases, right low lobectomy in 3 cases and right pueumonectomy in 5 cases respectively. The base of the pulmonary vein was invaded by the tumor in 34 patients, while left atriums were invaded obviously in 12 patients. Two patients were operated using extracoporeal circulation because of main pulmonary artery and left atrium being invaded. The Kaplan-Meier method (Log rank test) and a COX model were used to analyse the survival and the prognosis.There was no operative mortality in this series, 15 patients had operative complication, including arrhythmia in 13 cases, pneumonia in 8 cases and heart failure in 1 case. The median survival was 35 months. The 1-, 3-, 5-year survival rates were 84.2%, 43.7%, 30.5% respectively. The survival of patients with N0/1 was better than that of patients with N2 disease, the median survival of them were 38 months and 19 months respectively (P=0.002). Using a Cox model analysis, lymph node stage (N0/1 or N2) was independent prognostic factor, while preoperative chemotherapy, sex, age and the pathologic type were not independent prognostic factors.Surgical treatment for lung cancer invading the left atrium or the base of pulmonary vein is feasible, especially for N0 patients.

To research the effect and practicalbility of lobectomy with bronchoplasty and reconstruction of pulmonary artery by minitrauma-technique for lung cancer.We retrospectibely reviewed our experience on 61 cases being lobectomy with bronchoplasty and bronchoplasty with or without video assisted thoracic small incision surgery for lung cancer from July 2005 to June 2009 from Shandong Provincal Hospital and 46 cases simultaneously by routine posterolateral incision. All patients whose bronchus and/or pulmonary artery were involved underwent the operation and experienced the bronchial sleeve/wedge resection or reconstruction of the pulmonary artery.All patients were done operation successfully and there were no operative mortality and no occurrence of anastomosis stenosis as well as fistula. The small incisions' length was from 8 cm-15 cm while the routine posterolateral incision's length was 25 cm-35 cm. The patients done the operation of small incision had less postoperative shoulder joint dysfunction and had better quality of life compaired to the patients done the routine posterolateral incision.Lobectomy with bronchoplasty and reconstruction of pulmonary artery by minitrauma-technique for lung cancer could finished the same work with the traditional thoracic lateral incision and had less trauma, less pain, less recovery time.