Interlobar Fissure Research Articles

P1.01-031 Does Malignant Pleual Mesothelioma (MPM) Behaviour Differ among Decades?

MPM is extremely aggressive and has a long-latency period. Hence, detected at advanced stages resulting in an unfavorable prognosis (1-2years). However, MPM prognosis has been improving over the past few years with availability of better diagnostic and treatment regimens. We aim to compare clinico-pathologic characteristics of old-MPM cases referred to National Cancer Institute(NCI)-Cairo university between (2002-2003)and new MPM cases (2012-2015) Retrospective review of MPM cases presented to NCI. Data regarding demographics, histology, symptoms and signs, tumor staging and CT-findings were obtained from all patients’ records. Pearson's Chi(X2)and Fisher's Exact t-tests were used for statistical analysis. 1) Old cohort (n=100): 100 patients were encountered. Median age was 46 years. Males were 59% of cases. 30% has PS1. Asbestos exposure was documented in 74 cases. 44 cases were smokers, 25 cases were industrial-workers. Family history was positive in 12 cases. Dyspnea was the presenting symptom in 92 cases, chest pain in 83% and tuberculous pleuritis in 2 cases, effusion in all cases, pleural thickening in 80%, tracheal shift to the opposite-side in 23%, T2 represented 41%. Epithelioid subtype 46.6%. Pathological T2= 34%. 2) New cohort (n=194): 194 patients were encountered. Median age was 53 years. Males and females were nearly equally distributed. Epithelioid subtype was 63.4%. Rt-sided lesions were evident in nearly two-thirds of the cases. Pleural thickening was nodular in 131 (69.7%) cases. Inter-lobar fissure was thickened in 29.4%. Mediastinal Pleura was affected in 37.1%. Nearly, half of our cases had effusion. Ossification & calcification were detected in 8 (4.1%) cases. Contraction of hemithorax was identified in 77 (39.7%) cases. Chest wall invasion (CWI) was present in 18 (9.3%) cases. Pulmonary nodules were detected in one-fifth of the cohort. Metastases were detected in 9 (4.6%) cases (Figure). By comparing both groups, we found that more lymph node involvement(N+), less metastasis(M+),older median age, more females, more epithelial subtype, less pleural effusion presentation, more pleural thickening were detected in group 2(new cases) reflecting better staging ( mediastinoscopy& PET-CT),early detection, more incidence in females and better treatment modalities.

Robotic Lobectomy: Left Lower Lobectomy by Surgery

According to National Comprehensive Cancer Network guidelines concerning non–small cell lung cancer, robotic lobectomy is considered an advisable oncologic procedure for patients with lung cancer, with no anatomic or surgical contraindications. At present, da Vinci is the only available robotic system (Intuitive Surgical, Inc., Sunnyvale, CA), with 2 platforms (da Vinci SI and da Vinci XI) requiring different port-mapping and cart positioning. Robotic left lower lobectomy can be considered one of the most technically simple of all lobectomies. We describe our endoscopic technique, with 4 surgical ports, using CO2 insufflation.

Prevalence of incomplete interlobar fissures of the lung.

Some patients benefit from accurate integrity assessment of pulmonary fissures. There are a number of methods for the assessment of incomplete interlobar fissures: imaging techniques, endobronchial methods measuring collateral air flow, a perioperative view, and autopsies used in research into pulmonary anatomy. We performed a computerized advanced search for primary evidence in the PubMed (Public/Publisher MEDLINE) and Google Scholar electronic databases using the following terms: incomplete and fissure. The search was not restricted to the English literature, nor limited by publication time. The bibliographic search was then extended to the "Related Articles" links and to the list of literature references of each article. Publications have consistently shown that interlobar fissures exhibit high variability and that preoperative or at least detailed perioperative assessment can influence the effect of treatment.

Predicting Lung Volume Reduction after Endobronchial Valve Therapy Is Maximized Using a Combination of Diagnostic Tools

Background: Bronchoscopic lung volume reduction using one-way endobronchial valves (EBVs) has been proven to be effective in patients with severe emphysema. However, the selection of patients without collateral ventilation prior to treatment is critical for procedural success. Collateral ventilation can be assessed directly with the Chartis system or indirectly using computed tomography (CT) fissure analysis. Objectives: We retrospectively evaluated the diagnostic value of a combination of the quantitative CT interlobar fissure completeness score (FCS) and Chartis in predicting responders to EBV therapy. Methods: CT data from four prospective studies were pooled and analyzed using semiautomated software to quantify the completeness of interlobar fissures. These FCSs were compared to a reference standard of achieving ≥350 ml of target lobe volume reduction after EBV treatment. Using a receiver operating characteristic curve, optimal thresholds predictive of complete fissures (responders) and incomplete fissures (non-responders) were determined. A subgroup of patients with partially complete fissures was identified, where software had lower accuracy. The complementary value of Chartis was investigated in this group. Results: A fissure was defined as complete (FCS >95%), incomplete (FCS <80%), or partially complete (80% < FCS < 95%). The positive predictive value (PPV) of complete fissures is 88.1%, and the negative predictive value (NPV) is 92.9%, with an overall accuracy of 89.2%. Chartis was utilized in patients with partially complete fissures, with a PPV of 82.3%, an NPV of 84.6%, and an accuracy of 83.3%. Conclusion: Combining diagnostic tools could reduce the burden on patients and the healthcare system while providing clinicians with a better means for patient selection for EBV therapy.

Pleural irregularities and mediastinal pleural involvement in early stages of malignant pleural mesothelioma and benign asbestos pleural effusion

ObjectiveTo elucidate differences in the level and localization of pleural irregularities in early malignant pleural mesothelioma (eMPM) and benign asbestos pleural effusion (BAPE) using CT. Study designRetrospective assessment of CT findings of consecutive patients with BAPE at a single centre and patients with eMPM reported in Japanese vital statistics. MethodologyThirty-six patients with confirmed diagnoses of BAPE and sixty-six patients with confirmed diagnoses of eMPM (mesothelioma stages T1 or T2) were included. Informed consent, CT scans, and clinical and pathologic details were obtained for all patients and were reviewed by one radiologist, two pathologists, and two pulmonologists. Asbestosis, pleural plaque, rounded atelectasis, and diffuse pleural thickening were assessed in all patients. ResultsPrevalence of asbestosis, pleural plaque, rounded atelectasis, and diffuse pleural thickening was significantly higher in the BAPE group. Low-level irregularity was more common in the BAPE group (p<0.001), whereas high-level irregularity, mediastinal localization, and interlobar fissure were more prevalent in the eMPM group (p<0.001). Interlobar pleural irregularity was not observed in any patients in the BAPE group, although 55% of patients in the eMPM group showed interlobar pleural irregularity. Mediastinal pleural involvement was observed in 74% of patients in the eMPM group and had a positive predictive value of 89%. ConclusionThis study demonstrates that the level and localization of plural irregularities significantly differed between patients with BAPE and eMPM. Large-scale prospective studies are needed to fully establish the diagnostic utility of such differences.

Double-domed horizontal fissure

We read with interest the article entitled “Volumetric thin-section CT: evaluation of pulmonary interlobar fissures” by Guan et al. (1) in the November-December 2015 issue of Diagnostic and Interventional Radiology. The authors gave detailed information about interlobar fissures, their incompleteness, relationship to vascular structures, CT appearance, and defect location. The interlobar fissures and their variations are important for identifying pulmonary lesion locations, evaluating disease progression, and selecting appropriate surgical or interventional approaches. Therefore, it is important to know any detail about fissural anatomy and its variations. All horizontal (minor) interlobar fissures have been described as having one dome in the literature (2, 3). We would like to contribute by noting that they may also have a double dome. During the last five-year period, out of approximately 35 000 thorax CT scans, we came across five patients with double-domed horizontal fissure (Figs. 1, ​,2).2). Those patients did not have any abnormality that might change fissural anatomy like atelectasis or fibrosis. Although double-domed horizontal fissure is a very rare entity, it is important to keep it in mind to avoid misinterpretation. Figure 1 A 35-year-old male patient. Axial CT image, 1 mm slice thickness, shows double-domed horizontal fissure (empty arrows, anterior dome; solid arrows, posterior dome; curved arrows, oblique fissure). Figure 2. a, b A 74-year-old male patient. Axial CT image 1 mm slice thickness (a) and sagittal oblique 2 mm reformatted CT image (b) show double-domed horizontal fissure (empty arrows, anterior dome; solid arrows, posterior dome; curved arrows, oblique fissure).

Management of bleeding from an abnormally located S6 arterial branch in a common origin with S2 branch during live surgery.

In 24th/03/2016 we organized the first uniportal video-assisted thoracic surgery (VATS) live surgery workshop in Jerusalem at our institution with our special guest Dr. Diego Gonzalez-Rivas, more than 30 participants attended this workshop from Israeli and the Palestinian territories (cardiothoracic and vascular surgeons, general surgeons, anesthesiologists and nurses). During the workshop Dr. Gonzalez operated two complex cases while the first case was an anatomical S1 segmentectomy, the second case (the one which we are reporting in this paper) was bilobectomy of right middle and lower lobes, during this case a profuse bleeding appeared while introducing the stapler in the interlobar fissure, the source of this bleeding was an abnormally located arterial branch, however the bleeding managed perfectly by Dr. Gonzalez-Rivas, although this surgery kept all of us in a state, all the attendees were happy to see the way how this bleeding managed and everybody was satisfied with the final result.

Results of surgical treatment and impact on T staging of non-small-cell lung cancer adjacent lobe invasion.

To assess the results of surgical treatment of T-ALI (adjacent lobe invasion) tumours in patients with non-small-cell lung carcinoma. Multicentric retrospective analysis of a prospectively maintained database of 13 065 patients, aged 32-89 years (mean 52.9, median 63 years), who underwent resection between January 2009 and September 2014. In the whole study group, T-ALI was observed in 324 patients (2.5%): 201 patients (62.0%) with a tumour invading the pleura in the inter-lobar fissure (T-ALI-A), and 123 patients (38.0%) with a tumour in the adjacent lobe but without pleural invasion in the fissure (T-ALI-D). With regard to N0 patients, the 3- and 5-year survival rates in the T2 group were significantly higher than that of the T-ALI group (76.1 and 68.4%, P = 0.002 vs 58.3 and 51.0%, P = 0.008, respectively). On the other hand, when the N1 group was analysed, the 5-year survival rates were 54.3 and 48%, respectively (P = 0.041). In the N2 group, the 5-year survival rates in the T2 and T-ALI groups were 40.2 and 35.0%, respectively (P = 0.241). The comparison of the T-ALI and T3 groups for stages N0, N1 and N2 revealed differences in 5-year survival rates as follows: 68.4 vs 62.9% (P = 0.048), 48.0 vs 37.6% (P = 0.08) and 35.0 vs 27.6% (P = 0.121), respectively. In the whole group, the difference in survival rate between T-ALI N0 and T2N0 was statistically significant (P = 0.008) and statistically significant for the T3N0 group (P = 0.048). The 3-year survival rate in the T-ALI N0 group was statistically lower following pneumonectomy than following lobectomy (56.4 vs 61.3%, P = 0.03). The best survival rate was observed following bilobectomy (75.6%). In our study, a tumour with ALI (T-ALI) represented a separate stage of cancer between T2 and T3. The survival rate in the T-ALI-A group was significantly poorer than that in the T-ALI-D group. Overall treatment results were similar for stage T3, suggesting that it may be necessary to divide this group into T3a and T3b. We would suggest that all tumours between 5 and 7 cm be classified as T3b, and any tumour smaller than 5 cm but with ALI be classified as T3a. Treatment of choice should include lobectomy or bilobectomy. Pneumonectomy should be performed only in a selected group of patients.

Fatal pleural mesothelioma in Japan (2003-2008): evaluation of computed tomography findings.

The purpose of this study was to clarify the characteristic findings of mesothelioma at the time of diagnosis, and determine precautions and guidelines for diagnosing mesothelioma early in imaging studies. Overall, 327 patients with pleural mesothelioma were selected from 6030 patients who died of mesothelioma between 2003 and 2008 in Japan. Their imaging findings were examined retrospectively. Plaques were found in 35% of computed tomography (CT) scans. Asbestosis, diffuse pleural thickening, and rounded atelectasis were found in only seven (2%), five (2%), and two cases (1%), respectively. Pleural thickening findings on CT scans were classified into four stages: no irregularity, mild irregularity, high irregularity, and mass formation. Overall, 18% of cases did not show a clear irregularity. Localized thickening was observed in the mediastinal (77%) and basal (76%) pleura and in the interlobar fissure (49%). Eight percent of cases did not have any thickening in these three areas. Upon examination of the CT scans at diagnosis, 18% of mesothelioma cases did not show a clear irregularity. When diagnosing pleural effusion of unknown etiology, it is necessary to consider the possibility of mesothelioma even when no plaque and pleural irregularity are observed.

Macroscopic Anatomy of the Saimaa Ringed Seal (Phoca hispida saimensis) Lower Respiratory Tract.

We studied the macroscopic anatomy of the lower respiratory tract of the endangered Saimaa ringed seal (Phoca hispida saimensis). Examination of one adult and one young individual found dead showed that trachea had 85 and 86 complete cartilage rings. The adjacent cartilages exhibited very few random anastomoses. There was variation in the confirmation of the trachea between the cranial and caudal part of the trachea. The right lung was divided by partly incomplete inter-lobar fissures into cranial, middle, caudal, and accessory lobes. The left lung consisted of cranial, middle, and caudal lobes. The lungs were characterized by a high amount of interlobular connective tissue. Silicone casts were prepared of the two specimens to visualize the tracheobronchial branching which was similar to that of marine ringed seals but in the Saimaa ringed seal the right middle lobar bronchus originated at the same level as the accessory lobar bronchus.

Malignant Mesothelioma Versus Metastatic Carcinoma of the Pleura: A CT Challenge.

Background:Malignant pleural mesothelioma (MPM) is a rare malignant neoplasm of the pleura that typically affects individuals occupationally exposed to asbestos through a variety of industries. MPM presents with several CT features similar to more common pleural diseases such as metastatic pleural malignancy.Objectives:The aim of this study is to differentiate malignant pleural mesothelioma from metastatic carcinoma of the pleura by pathological and radiological assessment in order to investigate accuracy of CT scan in this regard and to compare CT features of these two malignancies.Patients and Methods:Chest CT scans of 55 pleural malignancy patients including MPM and metastatic pleural malignancy were evaluated in this retrospective study. The pathologist made the definite diagnosis based on immunohistochemistry. A chest radiologist unaware of the pathology diagnosis observed all CT scans. Several parameters including pleural thickening, pleural effusion, thickening of inter lobar fissure, contralateral extension, contraction of involved hemithorax, parenchymal involvement (infiltration, nodules, fibrosis), pleural mediastinal involvement, lymphadenopathy, extrapleural invasion (hepatic, chest wall, diaphragm, intraperitoneal), and pericardial involvement were checked. Data analysis was carried out using SPSS version 16, and the ability of CT scan to differentiate malignant pleural mesothelioma and metastatic pleural diseases was investigated.Results:Totally 29 males and 26 females were assessed in this study. Based on pathology, 17 MPM and 38 metastatic pleural malignancies were diagnosed. According to CT study, about 82% of the patients with MPM and about 79% of the patients with metastatic pleural diseases were correctly diagnosed by a radiologist. The most common findings suggestive of MPM were pleural thickening (88.2%), loculated effusion (58.8%), and thickening of the interlobar fissure (47.1%). Whereas free pleural effusion (71.7%), parenchymal infiltration (65.8%) and pleural thickening (63.2%) were most prevalent parameters among metastatic cases.Conclusion:CT scan is highly accurate in differentiating malignant pleural mesothelioma and metastatic pleural diseases. Pleural thickening and thickening of interlobar fissure lead us to the diagnosis of MPM and massive free pleural effusion is more commonly seen in metastatic pleural malignancy.

The role of computed tomography in characterization, diagnosis and staging of malignant pleural mesothelioma in a sample of Iraqi patients

Background: malignant pleural mesothelioma (MPM) is uncommon neoplasm arising from mesothelial cells of the pleura. The most important etiologic agent is typically related to exposure to minerals fibers such as asbestos and erionite. Computed tomography (CT) plays essential role in characterization, diagnosis and staging of MPM.Objectives: to determine the value of CT scan in characterization of MPM and its impact on diagnosis, and staging of the disease with histopathological correlation.Patients and methods: the CT scan of 27 patients who had diagnosed of MPM were retrospectively evaluated, additionally CT findings of histopathological subtypes were compared and determine staging of the disease according to their documented CT findings. The study was performed at Medical City Teaching Hospitals and Hospital of Radiation &amp; Nuclear Medicine in Baghdad from period of 2008 to 2014.Results: Fifteen patients were male and twelve patients were female with percentage of (55.5%, 44.4%) respectively with age range of 36-66 years, 37% of patients were coming from area closed to asbestos manufacture in Baghdad, but only 14.8% of them had history of exposure to asbestos. histological subtypes analysis revealed that epitheliod types is the most frequent type occurred in 63% of patients, sarcomatoid type in 22.2% of patients and mixed (biphasic) type in 14.8% of patients. The statistical analysis of CT findings of different histological subtypes reveal that the interlobar fissure involved in 100% of patients, paranchymal lung involvement in 67%, chest wall involvement in 67%, pericardial involvement in 67%, mediastinal lymphadenopathy in 67% which are more significant with p-value &lt;0.05 in sarcomatoid subtypes than alternate histological subtypes. Regarding the staging of MPM, the study show stage I in 11.1% of cases, stage II in 37.1, stage III in 25.9%, and stage IV in 25.9%.Conclusion: This study show that contrast-enhanced CT of the chest and upper abdomen plays a fundamental role in characterization and categorization of key findings of malignant pleural mesothelioma and convert it into the updated staging system to guide appropriate evaluation and management.

Multidetector CT Findings and Differential Diagnoses of Malignant Pleural Mesothelioma and Metastatic Pleural Diseases in Korea.

ObjectiveTo compare the multidetector CT (MDCT) features of malignant pleural mesothelioma (MPM) and metastatic pleural disease (MPD).Materials and MethodsThe authors reviewed the MDCT images of 167 patients, 103 patients with MPM and 64 patients with MPD. All 167 cases were pathologically confirmed by sonography-guided needle biopsy of pleura, thoracoscopic pleural biopsy, or open thoracotomy. CT features were evaluated with respect to pleural effusion, pleural thickening, invasion of other organs, lung abnormality, lymphadenopathy, mediastinal shifting, thoracic volume decrease, asbestosis, and the presence of pleural plaque.ResultsPleural thickening was the most common CT finding in MPM (96.1%) and MPD (93.8%). Circumferential pleural thickening (31.1% vs. 10.9%, odds ratio [OR] 3.670), thickening of fissural pleura (83.5% vs. 67.2%, OR 2.471), thickening of diaphragmatic pleura (90.3% vs. 73.4%, OR 3.364), pleural mass (38.8% vs. 23.4%, OR 2.074), pericardial involvement (56.3% vs. 20.3%, OR 5.056), and pleural plaque (66.0% vs. 21.9%, OR 6.939) were more frequently seen in MPM than in MPD. On the other hand, nodular pleural thickening (59.2% vs. 76.6%, OR 0.445), hilar lymph node metastasis (5.8% vs. 20.3%, OR 0.243), mediastinal lymph node metastasis (10.7% vs. 37.5%, OR 0.199), and hematogenous lung metastasis (9.7% vs. 29.2%, OR 0.261) were less frequent in MPM than in MPD. When we analyzed MPD from extrathoracic malignancy (EMPD) separately and compared them to MPM, circumferential pleural thickening, thickening of interlobar fissure, pericardial involvement and presence of pleural plaque were significant findings indicating MPM than EMPD. MPM had significantly lower occurrence of hematogenous lung metastasis, as compared with EMPD.ConclusionAwareness of frequent and infrequent CT findings could aid in distinguishing MPM from MPD.

Surgical treatment of pulmonary aspergillosis: A single center experience.

Background:Aspergillus fumigatus is a saprophytic fungus which colonizes in the cavitary lesions in the lungs. In our part of the world, where tuberculosis is endemic, the healed tubercular cavities form a good nidus for this fungus. The fungus forms a fungal ball or aspergilloma within the cavity, which erodes the walls of the cavity and causes hemoptysis by erosion of the bronchial vessels. Hemoptysis is the main symptom. Antifungal agents are not useful against the fungal ball. Surgery in the form of lobectomy is the primary treatment. Surgery for aspergilloma is known to be risky because of intra-pleural adhesions, obliteration of the interlobar fissures, massive hemorrhage during dissection and poor pulmonary reserve of the patient due to the underlying disease.Materials and Methods:Clinical presentation, radiological investigations, operative techniques, postoperative outcome, and follow-up of 24 cases of pulmonary aspergilloma treated surgically were studied prospectively between August 2010 and July 2013 at IPGMER and SSKM Hospital, Kolkata.Results:There were 15 male (62.5%) and 9 female (37.5%) patients. Mean age of the study population was 34.54 years. All the patients had complex aspergilloma. Tuberculosis was the underlying disease in 22 patients (91%). Hemoptysis was the main symptom in 79.16% cases. Chest X-ray was the first investigation, which gave a clue to the diagnosis. Computed tomography scan was diagnostic in all cases. Lobectomy was done in 16 patients (66.67%). There was one mortality and the overall complication was 33.33%. The average follow-up period was 21.65 months, during which there was no mortality and no recurrence of hemoptysis in these patients.Conclusions:Though surgery for aspergilloma is considered to be risky, excision of the cavity along with the involved lobe can be done with acceptable morbidity and mortality to provide the patient complete cure and symptom-free survival.

Short linear shadows connecting pulmonary segmental arteries to oblique fissures in volumetric thin-section CT images: comparing CT, micro-CT and histopathology.

To retrospectively evaluate short linear shadows connecting pulmonary segmental arteries to oblique fissures in thin-section CT images and determine their anatomical basis. CT scanning was performed on 108 patients and 11 lung specimens with no lung diseases around the oblique fissures or hila. Two radiologists evaluated the imaging. The parameters included length, thickness of short linear shadows, pulmonary segmental artery variations, and traction interlobar fissures, etc. The short linear shadows were not related to sex, age, or smoking history. The lengths of the short linear shadows were generally within 10mm. The thicknesses of the short linear shadows ranged from 1 to 2mm. Of the patients, 26.9% showed pulmonary segmental artery variations; 66.7% of short linear shadows pulled oblique fissures. In three-dimensional images, the short linear shadows appeared as arc planes, with one side edge connected to the oblique fissure, one side edge connected to a pulmonary segmental artery. On the tissue slices, the short linear shadow exhibited a band structure composed of connective tissues, small blood vessels, and small lymphatic vessels. Short linear shadows are a type of normal intrapulmonary membranes and can maintain the integrity of the oblique fissures and hilar structure. • Volumetric thin-section CT scanning is commonly used to study lung anatomy. • Short linear shadows are a common intrapulmonary structure in thin-section CT. • Short linear shadows correlate with band structures on the correlative tissue slices.

Volumetric thin-section CT: evaluation of pulmonaryinterlobar fissures.

We aimed to perform an imaging analysis of interlobar fissures and their variations using thin-section computed tomography (CT). Volumetric thin-section CT scanning was performed in 208 subjects. Interlobar fissures were observed on axial images, and reconstructed coronal and sagittal images were observed by multiplanar reformatting (MPR). The vessel distributions were verified by maximal intensity projection (MIP). On the axial images, the interlobar fissures were characterized by lines of hyperattenuation, bands of hyperattenuation, avascular zones, and mixed imaging. The interlobar fissures were divided into seven grades according to the percentage of defects over the entire fissure. On the axial images, of all interlobar fissures without avascular zones, 70.2% of the right oblique fissures (ROFs) and 94.2% of the left oblique fissures (LOFs) appeared as lines, and 83.2% of the horizontal fissures (HFs) appeared as bands. All of the interlobar fissures appeared as lines on the coronal and sagittal images. Of all cases, 17.8% showed fully complete interlobar fissures for all three fissures. Incomplete fissures included 41.3% of ROFs, 58.2% of HFs, and 45.2% of LOFs. In ROFs and LOFs, discontinuity was most frequently below 20%, while in HFs discontinuity was most frequently 41%-60%. The most common classification of incomplete interlobar fissures was a discontinuous avascular zone. Incomplete interlobar fissures are common variations of interlobar fissures. Techniques including volumetric thin-section CT, MPR, and MIP can assist in the diagnosis of incomplete interlobar fissures.

A randomised controlled study of Bronchoscopic Lung Volume Reduction with endobronchial valves for patients with Heterogeneous emphysema and Intact interlobar Fissures: the BeLieVeR-HIFi study

BackgroundDespite optimal therapy many patients with emphysema remain significantly breathless and limited. Bronchoscopic lung volume reduction (BLVR), using valves placed to allow air to leave but not enter the worst-affected areas of the lung, has been proposed as a way to improve lung function in these patients, but response is variable because interlobar collateral ventilation prevents the devices from working. Based on retrospective analysis of clinical trials, patients with heterogeneous emphysema and intact interlobar fissures are most likely to benefit.ObjectivesTo establish whether or not it is possible to identify patients prospectively who will reliably benefit from endobronchial valve placement.DesignProspective, randomised, parallel-group, double-blind, sham-controlled trial.SettingThe study was performed at a single specialist centre.ParticipantsAdult patients with heterogeneous emphysema and a target lobe with intact interlobar fissures were eligible if they had significant gas trapping (total lung capacity &gt; 100% predicted, residual volume &gt; 150% predicted), breathlessness [Medical Research Council (MRC) dyspnoea score of ≥ 3] and exercise limitation (6-minute walk distance of &lt; 450 m). Participants were on optimised pharmacotherapy and were non-smokers.InterventionsStudy participants were randomised to either unilateral lobar endobronchial valve placement aiming to achieve lobar atelectasis or bronchoscopy and ‘sham’ valve placement.Main outcome measuresThe primary end point was improvement in forced expiratory volume in 1 second (FEV1) in the treatment arm compared with the control arm measured 90 days post procedure. Secondary end points were change in lung volumes, gas transfer, exercise capacity (both walking and endurance cycle ergometry) and health-related quality of life.ResultsIn total, 50 patients were recruited, 25 to each arm; 62% were male and mean (standard deviation) FEV1% predicted was 31.7% (10.2%). The primary end point of the study was met as FEV1increased by 24.8% [95% confidence interval (CI) 8.0% to 41.5%] in the treatment arm and by 3.9% (95% CI 0.7% to 7.1%) in the control arm [between-group difference 20.9% (95% CI 4.3% to 37.5%);p = 0.033]. There were both statistically and clinically significant improvements in lung volumes and carbon monoxide gas transfer as well as endurance time and dynamic hyperinflation during cycle ergometry. Two deaths occurred in the treatment arm and one control patient was unable to attend for follow-up assessment because of a prolonged pneumothorax. Two pneumothoraces occurred in the treatment arm.ConclusionsWith appropriate selection of patients through a multidisciplinary team it is possible to produce a significant improvement in lung function through lobar occlusion with endobronchial valves in heterogeneous emphysema. Prospective trials are needed to compare the effect of BLVR with surgical approaches in terms of magnitude and duration of benefit.Trial registrationCurrent Controlled Trials ISRCTN04761234.FundingThis project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a MRC and NIHR partnership.

Analysis of Unexpected Conversion to Thoracotomy During Thoracoscopic Lobectomy in Lung Cancer

Since anatomical lung resection by video-assisted thoracoscopic surgery (VATS) was first introduced, VATS has played a major role in lung cancer. However, conversion to thoracotomy is a major concern because an unexpected thoracotomy increases the risk of potentially adverse outcomes. Therefore, we compared patients who were and were not converted to thoracotomy and identified the risk factors for thoracotomy conversion. Between January 2005 and December 2013, 69 of 1,110 VATS lobectomies for lung cancer required an unexpected conversion to thoracotomy. Each converted patient was individually matched to 3 randomly selected nonconverted patients based on date of operation, type of operation, and pathologic stage. The most common cause of conversion was fibrocalcified lymph nodes, found in 28 patients (40.6%), followed by vascular injury in 20, tumor invasion or extension in 11, pleural adhesion in 5, incomplete interlobar fissure in 3, and failure of single-lung ventilation in 2. The differences in overall postoperative complications and in-hospital deaths were not significant; however, respiratory complications were significantly more common in the conversion group (p = 0.012). The independent risk factors for conversion were age 65 years and older, forced expiratory volume in 1 second of less than 1.8 L, and the presence of fibrocalcified lymph nodes on preoperative chest computed tomography. Unexpected conversion to thoracotomy during VATS lobectomy in lung cancer does not appear to increase overall surgical morbidity and mortality. However, with high-risk patients, the surgeon requires careful selection for VATS candidate. Also, if necessary, the decision to convert must be made promptly to reduce possible critical respiratory complications.

Bronchoscopic lung volume reduction with endobronchial valves for patients with heterogeneous emphysema and intact interlobar fissures (the BeLieVeR-HIFi study): a randomised controlled trial

Lung volume reduction surgery improves survival in selected patients with emphysema, and has generated interest in bronchoscopic approaches that might achieve the same effect with less morbidity and mortality. Previous trials with endobronchial valves have yielded modest group benefits because when collateral ventilation is present it prevents lobar atelectasis. We did a single-centre, double-blind sham-controlled trial in patients with both heterogeneous emphysema and a target lobe with intact interlobar fissures on CT of the thorax. We enrolled stable outpatients with chronic obstructive pulmonary disease who had a forced expiratory volume in 1 s (FEV1) of less than 50% predicted, significant hyperinflation (total lung capacity >100% and residual volume >150%), a restricted exercise capacity (6 min walking distance <450 m), and substantial breathlessness (MRC dyspnoea score ≥3). Participants were randomised (1:1) by computer-generated sequence to receive either valves placed to achieve unilateral lobar occlusion (bronchoscopic lung volume reduction) or a bronchoscopy with sham valve placement (control). Patients and researchers were masked to treatment allocation. The study was powered to detect a 15% improvement in the primary endpoint, the FEV1 3 months after the procedure. Analysis was on an intention-to-treat basis. The trial is registered at controlled-trials.com, ISRCTN04761234. 50 patients (62% male, FEV1 [% predicted] mean 31·7% [SD 10·2]) were enrolled to receive valves (n=25) or sham valve placement (control, n=25) between March 1, 2012, and Sept 30, 2013. In the bronchoscopic lung volume reduction group, FEV1 increased by a median 8·77% (IQR 2·27-35·85) versus 2·88% (0-8·51) in the control group (Mann-Whitney p=0·0326). There were two deaths in the bronchoscopic lung volume reduction group and one control patient was unable to attend for follow-up assessment because of a prolonged pneumothorax. Unilateral lobar occlusion with endobronchial valves in patients with heterogeneous emphysema and intact interlobar fissures produces significant improvements in lung function. There is a risk of significant complications and further trials are needed that compare valve placement with lung volume reduction surgery. Efficacy and Mechanism Evaluation Programme, funded by the Medical Research Council (MRC) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership.

EXPERIENCE OF VIDEOTHORACOSCOPY (VTS) IN THORACIC ONCOLOGY DIAGNOSIS AND TREATMENT OF SMALL LUNG NEOPLASMS

Hyperdiagnosis of lung cancer in recent years is of concern because of the emergence of new screening methods that detect small nodules, which clinical significance is unknown. The incidence of lung cancer ranged from 0.4% to 2.7% according to the results of screening studies, depending on the size of the population surveyed. The large number of false-positive diagnoses is unsolved problem yet. At the initial stage of the examination in the groups with high risk the number of false diagnoses is in the range of 10-20%, but can reach 50%, with positive predictive values of 2.8% to 11.6%. It is found that pathological nodules less than5 mmare unlikely malignant, and nodules from 5 to10 mmin diameter are undefined, 25-40% of which contain calcifications. Management of patients with such nodules, as a rule, is to perform repeated CT scans over time and if the growth of nodules is detected then fine-needle aspiration biopsy or surgical resection must be performed. Videothoracoscopy with biopsy provides a high efficiency in differential diagnosis of single tumors located in the cortical and subcortical regions of the lung or near the interlobar fissure. Presented here results indicate that the current VTS in peripheral tumors and metastatic lesions of the lung is the only minimally invasive method to verify the process with 100% accuracy.