Chest Wall Invasion Research Articles

Differences of Clinicopathological Features between Metaplastic Breast Carcinoma and Nonspecific Invasive Breast Carcinoma and Prognostic Profile of Metaplastic Breast Carcinoma.

Introduction Metaplastic breast carcinoma is a rare special type of breast cancer, which has distinguished clinical characteristics. We aimed to evaluate the clinicopathological features of metaplastic breast carcinoma compared with nonspecific invasive breast carcinoma and study the prognosis of metaplastic breast carcinoma. Methods We reviewed metaplastic breast carcinoma cases (n = 37) from January 2000 to December 2021 and nonspecific invasive breast carcinoma cases (n = 433) from January 2019 to December 2020 extracted from our institution retrospectively. The following variables were recorded, including the patients' general information, complications, T stage, expression of estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2, Ki-67, molecular subtyping, lymph node status, skin or chest wall involvement, vessel carcinoma embolus, therapy modality (surgical treatments, chemotherapy, and radiotherapy), and survival. Results Patients with metaplastic breast carcinoma had more advanced disease than patients with nonspecific invasive breast carcinoma (T stage: P=0.0011). A greater proportion of metaplastic breast carcinoma presented with triple-negative breast cancer than nonspecific invasive breast carcinoma (79.41% vs. 12.47%, P ≤ 0.001). Our study showed that the skin or chest wall invasion was more frequent in metaplastic breast carcinoma patients (11.76% vs. 1.62%, P=0.005). The 5-year survival rate for metaplastic breast carcinoma patients was 57.66% (95% CI: 0.3195∼0.7667). No local recurrence was observed while distant metastasis occurred in 33.33% of patients with metaplastic breast carcinoma. Death due to disease occurred in 24.24% of patients with metaplastic breast carcinoma. Conclusion The majority of metaplastic breast carcinoma patients had more advanced disease and triple-negative disease than nonspecific invasive breast carcinoma patients. Also, metaplastic breast carcinoma patients had frequent skin or chest wall invasion and a high rate of distant metastasis and mortality.

The role of sentinel lymph nodes in breast cancer

Introduction. The problem of improving early diagnosis and prognosis of breast cancer remains one of the most actual for current oncological practice. Taking into account a close correlation between the general prevalence of breast neoplasms and mortality from breast cancer, this problem is not only of professional interest, but also has medical-social and socio-economic significance.
 The purpose of the study is to improve the quality of the sentinel lymph node detection in patients with breast cancer using ICG.
 Material and methods. At the period 2009–2016, 400 patients with T1-T3N0M0 breast cancer were operated on. All the patients were divided into two groups using two dyes – Patent Blue and ICG. The patients after mastectomy with a sentinel lymph node biopsy had a clinical diagnosis of T2-T3N0M0 breast cancer more often.
 In group I, 100 patients had the sentinel lymph node biopsy. Lymph node staining was performed using Patent Blue dye.
 In group II, sentinel lymph nodes biopsy was conducted with the Patent Blue dye and another fluorescent dye — ICG, which was also injected on the affected side of the breast. After ICG dye introduction, in 15 minutes the stained green lymph nodes were detected using special equipment.
 Criteria for inclusion of patients in the clinical trial:
 1) breast cancer patients of any age with T1-3N0M0, I-II AB disease stage;
 2) patients with clinically unaffected lymph nodes N0 after examination.
 Criteria for exclusion of patients from the clinical trial:
 The exceptions were T3-T4 tumors > 5 cm in diameter, or the skin and chest wall invasion, as well as palpable axillary lymph nodes, 3 or more affected lymph nodes with sentinel lymph node biopsy;
 3) patients after radiation therapy.
 Results. The tumor histology was performed after the node trephine biopsy. The main aims of sentinel nodes detection were staging and improving the breast cancer patients’ life quality after surgical treatment. The post-mastectomy syndrome, the main manifestation of which is swelling of the upper extremity is a big problem for patients because it affects their life quality and disturbs their usual lifestyle. The sentinel lymph node detection, in contrast to axillary lymph node dissection of I-II level, significantly minimizes all the risks of postmastectomy syndrome, in particular, impaired lymphatic drainage in the form of lymphatic edema of the upper extremity, impaired venous outflow in the form of stenoses or the axillary and/or subclavian veins occlusion, rough scars which limit the function of the extremity in the shoulder joint, and brachioplexitis.
 Conclusions. The study of sentinel lymph nodes significantly improves the results of surgical treatment of breast cancer patients. Based on the clinical-laboratory and histological examinations, new data were obtained concerning the sentinel lymph node detection using two dyes, the choice of the surgical intervention volume and reduction of complications rate at the postoperative period. We found that fluorescent lymphography is highly effective, which allows to recommend it for implementation into the clinical practice. The frequency of sentinel lymph node detection in breast cancer patients is 98% in the control group, 100% – in the main group.
 On the basis of the obtained results, the sentinel lymph node detection algorithm and the surgical management of patients with breast cancer was developed and implemented into practice, which allowed to reduce the number of complications with using two dyes for the sentinel lymph node detection from 19% to 2% (χ2 =15.37, p<0.001). Recurrence of breast cancer fell from 13% to 8%.

Heterogeneity of stage IIIA non-small cell lung cancer—different tumours, different nodal status, different treatment, different prognosis: a narrative review

: Stage IIIA non-small cell lung cancer (NSCLC) consists of a heterogeneous group of disease, ranging from small T1a tumours with ipsilateral mediastinal lymph node involvement over T3 tumours with chest wall invasion, up to T4 tumours with mediastinal invasion with or without positive hilar lymph nodes. Based on this heterogeneity, treatment approaches as well as prognosis are very dependent on specific subgroups. Therapy recommendations should be based on multidisciplinary case discussions in high volume centres including medical and radiation oncologists, pneumologists and experienced thoracic surgeons specialized in thoracic cancer surgery. Recommendations may differ from standards in highly selected cases. Therefore, independent of age, in medically fit (operable) patients with resectable stage IIIA tumours, an aggressive approach in a curative setting is key to obtain good overall survival rates. Moreover, maintaining quality of life is essential. In this narrative review, the different aspects of all the subgroups of stage IIIA NSCLC and their heterogeneity as well as the variety of treatment modalities, their combined treatment approaches and survival rates are discussed. Again, the reported 5-year survival rates, ranging from 5% in patients with bulky N2 disease, up to 50% for patients with superior sulcus tumours with hilar lymph node disease, reflect the heterogeneity of stage IIIA NSCLC.

The Difference and Significance of Parietal Pleura Invasion and Rib Invasion in Pathological T Classification With Non-Small Cell Lung Cancer.

ObjectiveThis study was to explore the difference and significance of parietal pleura invasion and rib invasion in pathological T classification with non-small cell lung cancer.MethodsA total of 8681 patients after lung resection were selected to perform analyses. Multivariable Cox analysis was used to identify the mortality differences in patients between parietal pleura invasion and rib invasion. Eligible patients with chest wall invasion were re-categorized according to the prognosis. Cancer-specific survival curves for different pathological T (pT) classifications were presented.ResultsThere were 466 patients considered parietal pleura invasion, and 237 patients served as rib invasion. Cases with rib invasion had poorer survival than those with the invasion of parietal pleura (adjusted hazard ratio [HR]= 1.627, P =0.004). In the cohort for parietal pleura invasion, patients with tumor size ≤5cm reached more satisfactory survival outcomes than patients with tumor size >5cm (unadjusted HR =1.598, P =0.006). However, there was no predictive difference in the cohort of rib invasion. The results of the multivariable analysis revealed that the mortality with parietal pleura invasion plus tumor size ≤5cm were similar to patients with classification pT3 (P =0.761), and patients for parietal pleura invasion plus tumor size >5cm and pT4 had no stratified survival outcome (P =0.809). Patients identified as rib invasion had a poorer prognosis than patients for pT4 (P =0.037).ConclusionsRib invasion has a poorer prognosis than pT4. Patients with parietal pleura invasion and tumor size with 5.1-7.0cm could be appropriately up-classified from pT3 to pT4.

Pancoast tumor presenting with multiple joint pains: a case report

BackgroundPancoast tumors represent a unique subset of lung cancers wherein a primary neoplasm arises in the lung’s apex and invades the surrounding soft tissues. One of the main challenges in the diagnosis and treatment of these apical lung cancers is that they are usually not visualized on initial chest x-ray and, by the time the patient presents with symptoms, the tumor has almost always invaded nearby structures.Case presentationHerein we report a case of a 58-year-old nonsmoking African American male who presented to the neurology clinic with a history of multiple chronic joint pains. The patient complained of shoulder pain that traveled into his right arm and right finger and had worsened over the past 9 months. The patient also reported decreased right proximal strength and swelling of his right hand. Magnetic resonance imaging of the shoulder and cervical region showed mild cervical spondylosis and a questionable right apical mass. A subsequent high-resolution computed tomography scan of the chest revealed a large right apical lung mass, with chest wall invasion and erosion of the adjacent ribs. Biopsy of the mass confirmed poorly differentiated non-small cell lung cancer. Radiation therapy was initiated, and the patient’s pain improved significantly. Given the size of the tumor, chemotherapy was recommended by the oncology team. The patient decided against chemotherapy.ConclusionThis case highlights the importance of early diagnosis by expanding the differential diagnosis in patients presenting with weakness, sensory loss, and shoulder pain beyond radiculopathy or joint-related diseases. A comprehensive history and careful examination may lead to an earlier diagnosis, more appropriate treatment, and better outcome in cases of Pancoast tumor presenting with neuropathic or musculoskeletal pain.

A huge metaplastic breast carcinoma with chest wall invasion and pulmonary metastasis: a rare case report

ABSTRACTMetaplastic breast carcinoma (MBC) is a diverse group of invasive breast carcinoma, in which the neoplastic epithelium differentiates toward squamous cells or mesenchymal looking elements, including but not restricted to spindle, osseous and chondroid cells. MBC was formally considered a distinct pathological pattern by WHO classification of breast tumors in 2000. We report the case of a 49-year-old Syrian female who presented to our hospital due to a painful huge mass in her right breast. Radiographic and clinical findings were highly indicative of breast carcinoma. Therefore, a core needle biopsy was performed, and surprisingly, microscopic examination suggested the diagnosis of soft tissue sarcoma, whereas immune stains confirmed the diagnosis of metaplastic carcinoma. We aim to introduce a challenging case that clarifies the rarity of this tumor, and the methods we used in diagnosing, examining and treating this malignancy.

Adhering to guideline concordant care improves survival among the different subtypes of T3 N2 non–small cell lung cancer

ObjectivesT3 disease comprises heterogeneous morphologic characteristics, a variation only further complicated when in the context of N2-confirmed involvement. This study aims to examine whether or not specific features of T3 N2 non–small cell lung cancer are associated with improved 5-year overall survival when using a multimodal therapeutic approach consistent with guideline recommendations compared with definitive surgery alone. MethodsPatients with pathologic T3 N2 non–small cell lung cancer were identified in the National Cancer Database. Therapy modality, as defined by surgery alone versus surgery with adjuvant therapy, and T3 disease descriptors were compared for differences in 5-year overall survival using Kaplan-Meier analysis and log-rank tests. Multivariable Cox regression was used to determine prognostic factors for survival. ResultsA total of 1924 patients met the inclusion criteria. Of these, 80.0% (n = 1539) received adjuvant chemotherapy with or without radiation therapy following surgery and 20.0% (n = 385) underwent definitive surgery alone. Patients in the 2 cohorts differed significantly in age, race, insurance status, and Charlson-Deyo score (P < .05). The overall survival for patients who underwent surgery followed by chemotherapy with or without radiation therapy compared with those who underwent surgery alone was 31.7% and 11.1%, respectively (P < .0001). Multivariable analysis demonstrated a lower risk of death with multimodal therapeutic intervention compared with surgery alone for patients with disease marked by chest wall invasion, additional ipsilateral pulmonary nodules, tumor size, and the presence of multiple T3 features. ConclusionsThe utilization of a multimodal approach to treating pathologic T3 N2 NSCLC, compared with surgery alone, is associated with superior overall survival and lower risk of death for many subtypes of T3 disease.

Video-Assisted Thoracic Surgery Technique for Chest Wall Resection

Chest wall resection is indicated in the management of operable primary chest wall tumors and lung cancers with chest wall invasion in carefully selected patients. Traditionally, chest wall resection has been performed via open thoracotomy, which is associated with significant postoperative pain and other associated morbidities. Furthermore, depending on the size and location of the resulting chest wall defect, chest wall reconstruction is warranted to maintain overall chest wall integrity, preserve inherent respiratory mechanics, and protect underlying intrathoracic structures. Video assisted thoracic surgery (VATS) techniques are an emerging and alternative technique to open chest wall resection, and have the potential benefit of minimizing the overall incision size, avoiding extensive rib spreading, and reducing tissue trauma. Given the technical challenges and lack of robust prospective outcomes data, VATS chest wall resection has not been widely adopted, but early reports appear to demonstrate its feasibility without apparent detriment to safety in selected patient populations. In this review, we detail relevant operative steps related to patient positioning and strategic port placement, anatomical dissection, and reconstruction options, as well as provide useful trouble shooting tips and tricks to help optimize outcomes following VATS chest wall resection. Chest wall resection is indicated in the management of operable primary chest wall tumors and lung cancers with chest wall invasion in carefully selected patients. Traditionally, chest wall resection has been performed via open thoracotomy, which is associated with significant postoperative pain and other associated morbidities. Furthermore, depending on the size and location of the resulting chest wall defect, chest wall reconstruction is warranted to maintain overall chest wall integrity, preserve inherent respiratory mechanics, and protect underlying intrathoracic structures. Video assisted thoracic surgery (VATS) techniques are an emerging and alternative technique to open chest wall resection, and have the potential benefit of minimizing the overall incision size, avoiding extensive rib spreading, and reducing tissue trauma. Given the technical challenges and lack of robust prospective outcomes data, VATS chest wall resection has not been widely adopted, but early reports appear to demonstrate its feasibility without apparent detriment to safety in selected patient populations. In this review, we detail relevant operative steps related to patient positioning and strategic port placement, anatomical dissection, and reconstruction options, as well as provide useful trouble shooting tips and tricks to help optimize outcomes following VATS chest wall resection. Commentary: Reasons to BotherOperative Techniques in Thoracic and Cardiovascular SurgeryVol. 27Issue 3PreviewThe article by Hirji and colleagues is a well-illustrated primer for those wishing to embark on minimally invasive chest wall resection.1 Arguably, the popularity of this approach compared to VATS lobectomy has been tempered by the reasonable question, “Why bother avoiding thoracotomies if cutting through ribs anyway?” Full-Text PDF

Conversion Surgery for Advanced Thoracic SMARCA4-Deficient Undifferentiated Tumor With Atezolizumab in Combination With Bevacizumab, Paclitaxel, and Carboplatin Treatment: A Case Report

A SMARCA4-deficient undifferentiated tumor (SMARCA4-UT) is a rapidly progressing subtype of lung cancer with a poor prognosis and causes early postoperative recurrence among operable patients. In this study, we present a case of SMARCA4-UT with vertebral and chest wall invasion that successfully underwent conversion surgery after treatment with atezolizumab in combination with bevacizumab, paclitaxel, and carboplatin. The surgical specimen comprised SMARCA4-deficient and SMARCA2-positive adenocarcinoma, confirming intratumor heterogeneity. Gene panel analysis revealed no substantial differences in mutant gene profiles among tumors and no differences in SMARCA2 mutations. Furthermore, no recurrence occurred for 9 months after surgery. Thus, this case illustrates the possibility of multidisciplinary treatment including neoadjuvant therapy with immunotherapy and conversion surgery for SMARCA4-UT.

DOES THICKNESS REALLY MATTER? DIAGNOSTIC DILEMMAS IN CAVITARY LESIONS

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: A pulmonary cavity is a gas-filled space seen as a lucency within a pulmonary consolidation, a mass, or a nodule. The differential for a solitary cavity of the lung includes anaerobic lung abscess, fungal infections, tuberculosis and malignancy. Wall thickness <4 mm has been shown to be caused by benign processes while thickness >15 mm are usually malignant. We describe the case of a former smoker in whom an infection was masking a cavitary squamous cell carcinoma of the lung. CASE PRESENTATION: A 75 year-old former smoker presented to the ER with hemoptysis for 1 week. He was afebrile with BP 90/50 and HR 124. WBC count was 17.8K/L. CT Chest revealed a 9.7 cm irregular cavitary mass in the right upper lobe of the lung with thick walls measuring 29 mm and evidence of invasion into the right hilum and chest wall causing rib fractures. Exam was significant for foul-smelling breath and poor dentition with gross aspiration while lying flat. Bronchoscopy demonstrated thick purulent secretions in the RUL and advancement into RUL takeoff with the bronchoscope led directly inside the cavity, revealing thick, friable walls. BAL and endobronchial brushings were obtained. Given patient's risk factors for aspiration and imaging findings, there was concern for possible anaerobic lung abscess. BAL cultures were polymicrobial. He received antibiotics and improved. However, BAL cytology and endobronchial brushing demonstrated malignant cells. Pathology from a CT-guided biopsy of the lesion confirmed squamous cell carcinoma of the lung. DISCUSSION: Several features of our patient's clinical presentation were suggestive of anaerobic lung abscess including aspiration, poor dentition, halitosis and leukocytosis. However, primary lung cancer remains the most frequent cause of a solitary cavitary lung lesion. Squamous cell carcinoma is the most common subtype to cavitate due to tumoral necrosis, in up-to 82% of patients. Features that can raise suspicion for malignancy as an etiology of a lung cavity include thickness of cavity wall >15 mm with irregular internal contours, upper lobe location and chest wall invasion, all of which were present in our patient. Our case highlights the importance of maintaining a high index of suspicion for underlying malignancy in smokers with cavitary lesions, despite an overwhelming clinical picture of infection. CONCLUSIONS: Cavitary lung lesions with high-risk radiological features such as wall thickness>15 mm should prompt accelerated work-up for malignancy to minimize high morbidity and mortality. REFERENCE #1: Gafoor K, Patel S, Girvin F, Gupta N, Naidich D, Machnicki S, Brown KK, Mehta A, Husta B, Ryu JH, Sarosi GA, Franquet T, Verschakelen J, Johkoh T, Travis W, Raoof S. Cavitary Lung Diseases: A Clinical-Radiologic Algorithmic Approach. Chest. 2018 Jun;153(6):1443-1465. doi: 10.1016/j.chest.2018.02.026. Epub 2018 Mar 6. PMID: 29518379. DISCLOSURES: No relevant relationships by Roxanne GarciaOrr, source=Web Response No relevant relationships by Sumit Patel, source=Web Response No relevant relationships by Nehan Sher, source=Web Response

Role of delayed phase contrast-enhanced CT in the intra-thoracic staging of non-small cell lung cancer (NSCLC): What does it add?

PurposeThe aim of the study was to investigate differences in non-small cell lung cancer (NSCLC) intra-thoracic staging by using contrast-enhanced computed tomography (ce-CT) at the arterial phase (AP), at the arterial plus delayed phases (AP + DEP), and at the delayed phase (DEP), and to evaluate their potential impact on disease staging. Materials and methodsTwo chest radiologists with different level of expertise and a general radiologist independently reviewed the chest CT exams of 150 patients with NSCLC; CT scans were performed 40 s (AP) and 60 s (DEP) after contrast material injection. Image assessment included three reading sessions: session A (AP), session B (AP + DEP) and session C (DEP). CT descriptors for the primary tumour (T), regional nodal involvement (N), and intra-thoracic metastases (M) were evaluated in each reading session. Readers had to assign a confidence level (CL) for the assessment of each descriptor and define the TNM stage. Friedman and Cochran Q test was used to compare the assessments of the 3 reading sessions; inter-reader agreement was determined (Intraclass Correlation Coefficient – ICC). ResultsThe CL was significantly higher in sessions B and C than in session A for all descriptors, with the exception of pulmonary arterial invasion. Primary tumour inner necrosis and regional nodal involvement were detected in a significantly higher number of cases in sessions B and C as compared to session A (p ≤ 0.001). DEP significantly changed N stage determination (p < 0.001), particularly N3, and excluded chest wall invasion (p = 0.05) and venous invasion (p = 0.001). The agreement was good among the 3 readers (ICC = 0.761) and excellent between the 2 chest radiologists (ICC ≥ 0.940), regardless of the contrast phase. ConclusionsThe 60-second DEP ce-CT for staging NSCLC significantly increased the readers’ CL, changed the N stage determination, and helped excluding chest wall invasion and venous invasion.

Combined approach for NSCLC with chest wall invasion: the role of VATS

Combined approach for NSCLC with chest wall invasion: the role of VATS

Management of Malignant Chest Wall Tumors.

To analyse the malignant chest wall tumors in terms of histological types and confer option for resection, stabilisation and reconstruction, along with postoperative morbidity and mortality. Observational study. Department of Thoracic Surgery, CMH Rawalpindi, Lahore and Multan from January, 2010 to October, 2018. Patients who had histologically proven malignant tumors of chest wall and breast with bone involvement, and required resection, stabilisation, mesh reinforcement and muscle flap reconstruction, were included. Small soft tissue tumors without bony involvement which did not require reconstruction, primary tumors of spine, pancoast tumors and lung tumors involving chest wall were excluded from the study. Record of these patients including age, gender, histopathological type, reconstruction method used, postoperative complications, mortality and recurrence were noted. Data was analysed using descriptive statistics. The study included 86 patients with 61 (70.9%) males and 25 (29.1%) females; age ranging from 18 to 77 years with mean age of 47.84 ± 12.9 years. Palpable mass was the most common symptom occurring in 61 (70.9%) patients. Twenty-one (24.4%) had breast tumor with chest wall invasion. In the remaining cases, most common histological type was chondrosarcoma occurring in 13 (15.1%) patients, followed by Ewing sarcoma in 12 (14%) patients. The most common complication was post-thoracotomy neuralgia (PTN), occurring in 25 (29.1%) patients. Malignant tumors of the chest wall are rare entity which can be effectively treated with chest wall resection, mesh reinforcement for stabilisation and muscle flaps for reconstruction with acceptable postoperative complications, morbidity and mortality. Key Words: Primary, Malignant, Chest wall, Tumors, Chest wall reconstruction, Stability of chest wall.

Clinicopathological predictors of survival in resected primary lung adenocarcinoma

AimsPrimary lung adenocarcinoma consists of a spectrum of clinical and pathological subtypes that may impact on overall survival (OS). Our study aims to evaluate the impact of adenocarcinoma subtype and...

Video-Assisted Thoracoscopic En Bloc Vertebrectomy for Spine Tumors: Technique and Outcomes in a Series of 33 Patients.

In en bloc vertebrectomy, the posterior approach is associated with limited access to anterior structures (vertebral body, esophagus, aorta, azygos vein). Video-assisted thoracoscopic surgery (VATS) might prove to be advantageous during thoracic en bloc vertebrectomy by allowing a combined anterior-posterior access in the prone position. We describe the technique and review the outcomes of 33 cases of video-assisted thoracoscopic en bloc vertebrectomy. A retrospective, single-center cohort study included all cases of VATS with a minimum follow-up of 1 year. A team of thoracic and orthopaedic surgeons performed the surgical procedure with the patient in a single, prone position. Anterior release was carried out thoracoscopically, followed by posterior en bloc tumor removal. From 2003 to 2019, 33 patients were included. Nine patients underwent total vertebrectomy (8 had single-level and 1 had 3-level), and 24 patients underwent partial vertebrectomy (1 had single-level, 8 had 2-level, 13 had 3-level, and 2 had 4-level). Ten patients had pulmonary resection. Histology revealed 18 cases (55%) of primary bone tumors, 6 cases (18%) of lung cancer invading the spine, 6 cases (18%) of solitary metastasis, and 3 other cases (9%). The margins were tumor-free in 28 cases (85%). The median operative time was 240 minutes (range, 150 to 510 minutes), with a median blood loss of 1,200 mL (range, 400 to 6,700 mL), and there were 2 cases of conversion to thoracotomy. A total of 33 complications occurred in 18 patients (55%), and these were predominantly pulmonary. One death was surgery-related (infection). One patient had a persistent monoplegia. At a median follow-up of 63 months (range, 12 to 156 months), there were 21 surviving patients (64%) with 2 local recurrences and 1 distant recurrence, and 2 patients (6%) were lost to follow-up. The survival rates were 94% at 1 year, 71% at 2 years, and 68% at 5 years. VATS en bloc vertebrectomy may be indicated for T2-to-T11 spine tumors with the exception of massive tumors, substantial chest wall and/or mediastinal invasion, and lung cancer exceeding 7 cm. The technique yielded satisfactory surgical and oncologic outcomes. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Risk factors of chest wall invasion in non-small cell lung cancer.

BackgroundThe risk factors for the development of chest wall invasion (CWI) in non-small cell lung cancer (NSCLC) patients are unclear. If the risk factors for the development of CWI can be clarified, surgical treatment might be able to be performed before CWI development, thus improving the prognosis.MethodsIn the present study, we enrolled patients who received surgery for NSCLC between January 2008 and December 2019 with available data on the maximum standardized uptake value (SUVmax) on positron emission tomography (PET) with lesions adjacent to the visceral pleura. Furthermore, the preoperative white blood cell (WBC) count, the preoperative neutrophil-to-lymphocyte ratio (NLR), platelet (Plt) count, levels of lactate dehydrogenase (LDH) and C-reactive protein (CRP) were analyzed as predictive factors of CWI.ResultsThe relationships between CWI and clinicopathological variables were analyzed, and there were significant differences between patients with and without CWI in the age (P=0.02), maximum tumor diameter on computed tomography (CT) (P<0.01), diameter of tumors adjacent to the visceral pleura (Pmax) (P<0.01), SUVmax (P<0.01), maximum tumor diameter on a pathological examination (P<0.01), WBC count (P=0.03), Plt count (P=0.04), and levels of LDH (P<0.01) and CRP (P=0.01). Logistic regression analyses of the risk factors related to CWI showed that the age (P=0.02), Pmax (P=0.02), SUVmax (P=0.01), and LDH (P<0.01) were significant risk factors.ConclusionsThe age, Pmax, SUVmax, and LDH levels might be associated with CWI.

Depth of chest wall invasion and lymph node metastasis in non-small cell lung cancer

Depth of chest wall invasion and lymph node metastasis in non-small cell lung cancer

Infección pulmonar y torácica por Fusobacterium nucleatum

Fusobacterium nucleatum is an anaerobic bacillus that is part of the oral microbiota and dental plaque. This can cause local and potentially remote infections, which are exceptional in pediatrics. Objective: To present the case of a patient with lung injury with chest wall invasion by Fusobacterium nucleatum. Clinical Case: An 11-year-old female immunocompetent patient who consulted due to a two-week history of cough, night sweats, without fever or weight loss, and increased volume at the left spleen thoracic level. There was no history of chest wall trauma or travel outside the country. Two weeks before the onset of symptoms, she was treated for dental caries. Imaging studies and CT scan showed left spleen pneumonia, which invades the pleura and the chest wall. A minimal thoracotomy was performed, releasing a thick, foul-smelling liquid. The studies for common germs and tuberculosis were negative. Hematology ruled out tumor lesions. The anaerobic study reported the development of Fusobacterium nucleatum. The patient was treated with penicillin followed by amoxicillin presenting good clinical and radiological responses. The dental procedure was suspected as the cause of infection. Conclusions: Fusobacterium nucleatum can occasionally cause remote or extra-oral infections in immunocompetent patients, such as pneumonia with chest wall invasion, therefore it is necessary to bear it in mind.

Latissimus dorsi flap: safe, reliable and versatile workhorse flap in the era of minimally invasive breast surgery—a case series

: Breast reconstruction in Asian women differ from their western counterparts as most Asian ladies have small to moderate sized breast with limited adiposity for abdominal flap reconstruction. Latissimus dorsi (LD) flap is an extremely useful reconstruction option for this particular group of women. Minimally invasive breast surgery is surgery performed via small aesthetically placed incision(s) whilst maintaining oncological principles. As LD flap is conventionally harvested as a myocutaneous flap, it results in a long unsightly donor site scar. Hence, the use of conventional LD flap harvest in combination with minimally invasive oncological resection have raised doubts over its value. To the best of our knowledge, this is the first series to describe our initial experience in using minimally invasive oncological resection techniques in combination with multiple variations of minimally invasive LD flap reconstruction. Consecutive patients who underwent breast reconstruction using LD flap between January to March 2020 were included in this case series and analyzed. Data collection included clinicopathological characteristics of tumor, types of surgery and reconstruction, operative time, blood loss, length of hospital stay, surgical outcomes and complications. Aesthetic outcomes evaluations with clinical and post-operative photography-based assessments were performed, in which patients’ consent was obtained. The mean age of patients was 56 years old (range, 45–69). All had early non-metastatic breast cancer, no evidence of skin or chest wall invasion and no clinical evidence of lymph node metastases. Mean pathological tumor size was 2.8 cm (range, 8 mm to 7 cm). Specimen weight ranged from 34 to 51 g for wide excision cases and 117 to 309 g for mastectomy specimens. The mean blood loss for all was less than 15 mL and mean hospitalization was 1 day. Aesthetic outcome assessed by the performing surgeon and patients graded it to be between good and excellent. All patients were satisfied with their scar appearance, wound length and location. Our initial experience demonstrated the safety and versatility of endoscopically harvested LD flap in combination with minimally invasive breast surgery, which offers an attractive alternative for oncological resection in breast cancer management.

Prognostic Impact of Single and Multiple Descriptors in Pathologically Staged T3N0M0 NSCLC

IntroductionT components of the current eighth edition of lung cancer American Joint Commission on Cancer (AJCC) staging assignment include size of primary tumor and others such as chest wall invasion. The role of the presence of multiple T3 descriptors in prognosis remains unknown. MethodsUsing the National Cancer Database and the AJCC seventh edition, pathologically staged (R0) N0M0 NSCLC cases diagnosed in 2010 to 2016 were analyzed. The selected cases had primary size larger than 5 cm or staged as T3 by the AJCC seventh edition despite the size of less than 5 cm. T3 descriptor status according to the eighth edition was defined as single descriptor (“T3-single”) with primary size of 5 to 7 cm or size less than 5 cm and T3 based on the seventh edition (“T3-other”) or multiple descriptor (“T3-multi”) with presence of both descriptors. Survival analysis was performed with validation of multivariate analyses. ResultsOf the 108,632 surgically resected pathologically staged N0M0R0 NSCLC cases, 9931 met the following criteria: 8955 as T3-single (4381 as T3-size, 4574 as T3-other) and 884 as T3-multi. Univariate and multivariate analyses revealed that T3-multi had significantly worse overall survival than T3-single with a median survival of 37.3 versus 69.3 months, respectively. Propensity score matching analysis validated the statistical significance. Exploratory analysis also revealed that the survival of the T3-multi group is similar to that of the T4 groups. ConclusionsOur retrospective analysis using the National Cancer Database suggests that prognosis of patients with multiple T3 descriptors is substantially worse than those with single descriptors. Further research may be required to accurately define the prognosis of NSCLC for future staging update.