Patients Undergoing Wedge Resection Research Articles

Wedge Resection versus Stereotactic Body Radiation Therapy for Non-Small Cell Lung Cancer Tumors ≤8 mm.

The objective of this study was to evaluate the overall survival of patients with ≤8 mm non-small cell lung cancer (NSCLC) who undergo wedge resection versus stereotactic body radiation therapy (SBRT). Kaplan-Meier analysis, multivariable Cox proportional hazards modeling, and propensity score-matched analysis were performed to evaluate the overall survival of patients with ≤8 mm NSCLC in the National Cancer Database (NCDB) from 2004 to 2017 who underwent wedge resection versus patients who underwent SBRT. The above-mentioned matched analyses were repeated for patients with no comorbidities. Patients who were coded in the NCDB as having undergone radiation because surgery was contraindicated due to patient risk factors (e.g., comorbid conditions, advance age, etc.) and those with a history of prior malignancy were excluded from analysis. Of the 1505 patients who had NSCLC ≤8 mm during the study period, 1339 (89%) patients underwent wedge resection, and 166 (11%) patients underwent SBRT. In the unadjusted analysis, multivariable Cox modeling and propensity score-matched analysis, wedge resection was associated with improved survival when compared to SBRT. These results were consistent in a sensitivity analysis limited to patients with no comorbidities.

Wedge resection, segmentectomy, and lobectomy: oncologic outcomes based on extent of surgical resection for ≤2 cm stage IA non-small cell lung cancer.

Long-standing controversy has existed over whether sublobar resection is an adequate oncological procedure for clinical stage IA non-small cell lung cancer (NSCLC) ≤2 cm, despite the recent randomized trial reports of Japanese Clinical Oncology Group (JCOG) 0802 and Cancer and Leukemia Group B (CALGB) 140503 demonstrating non-inferior outcomes with sublobar resection compared to lobectomy. As practice patterns shift, we sought to compare oncologic outcomes in patients with these early-stage tumors after wedge resection, segmentectomy, or lobectomy in a contemporary, real-world, cohort. A retrospective review of a prospectively maintained database from a single institution was conducted from 2011 to 2020 to identify all patients with clinically staged IA1 or IA2 NSCLC (tumors ≤2 cm with no nodal involvement). The primary outcomes of interest were overall survival (OS) and disease-free survival (DFS), with secondary outcomes of lung cancer-specific survival (LCSS), recurrence patterns, and perioperative morbidity and mortality. A total of 480 patients were identified; 93 (19.4%) patients underwent wedge resection, 90 (18.7%) received segmentectomy, and 297 (61.9%) underwent lobectomy. Patients who underwent wedge resection had worse Eastern Cooperative Oncology Group (ECOG) performance status (23.7% ECOG 1 or 2 vs. 5.6% among segmentectomy and 5.4% among lobectomy, P<0.05). Both wedge resection and segmentectomy patients had lower preoperative mean percentage of predicted forced expiratory volume in one second (%FEV1) compared to the lobectomy group (81.8% and 82.6% vs. 89.6%, P=0.002), a higher proportion of patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD), and a higher Charlson Comorbidity Index. There were no statistically significant differences in 5-year OS, DFS, or LCSS between groups: 90%, 61%, 78% for wedge resections compared with 85%, 75%, 86% for segmentectomy, and 87%, 77%, 87% for lobectomy, respectively. Recurrence was observed in 17 patients who underwent wedge resection (18.3%, 8 local, 9 distant), 12 patients who received segmentectomy (13.4%, 6 local, 6 distant), and 38 patients who underwent lobectomy (12.8%, 11 local, 27 distant), which was not significantly different (P=0.36). Patients with inferior performance status or lower baseline pulmonary function are more likely to receive wedge resection for clinical stage IA NSCLC ≤2 cm in size. For these small tumors, lobectomy, segmentectomy, and wedge resection provide comparable oncologic outcomes.

Is VATS suitable for lung diseases with hemoptysis? Experience from a hemoptysis treatment center in China

BackgroundSurgery is crucial in the treatment of the potentially fatal pulmonary hemoptysis condition. Currently, most patients with hemoptysis are treated by traditional open surgery (OS). To illustrate the effectiveness of video-assisted thoracic surgery (VATS) for hemoptysis, we developed a retrospective study of surgical interventions for lung disease with hemoptysis.MethodsWe collected and then analysed the data, including general information and post-operative outcomes, from 102 patients who underwent surgery for a variety of lung diseases with hemoptysis in our hospital between December 2018 and June 2022.ResultsSixty three cases underwent VATS and 39 cases underwent OS. 76.5% of patients were male (78/102). Comorbidities with diabetes and hypertension were 16.7% (17/102) and 15.7% (16/102) respectively. The diagnoses based on postoperative pathology included aspergilloma in 63 cases (61.8%), tuberculosis in 38 cases (37.4%) and bronchiectasis in 1 case (0.8%). 8 patients underwent wedge resection, 12 patients underwent segmentectomy, 73 patients underwent lobectomy and 9 patients underwent pneumonectomy. There were 23 cases of postoperative complications, of which 7 (30.4%) were in the VATS group, significantly fewer than 16 (69.6%) in the OS group (p = 0.001). The OS procedure was identified as the only independent risk factor for postoperative complications. The median (IQR) of postoperative drainage volume in the first 24 h was 400 (195–665) ml, which was 250 (130–500) ml of the VATS group, significantly less than the 550 (460–820) ml of the OS group (p < 0.05). The median (IQR) of pain scores 24 h after surgery was 5 (4–9). The median (IQR) of postoperative drainage tube removal time was 9.5 (6–17) days for all patients, and it was 7 (5–14) days for the VATS group, which was less than 15 (9–20) days for the OS group.ConclusionVATS for patients with lung disease presenting with hemoptysis is an effective and safe option that may be preferred when the hemoptysis is uncomplicated and the patient's vital signs are stable.

Clinicopathological Properties of Mesenchymal Tumors of the Stomach and Surgical Treatment Outcomes

Background: Mesenchymal tumors are part of a heterogeneous group of neoplasms. Objectives: The present study investigated the clinicopathological properties and surgical outcomes of patients with gastric mesenchymal tumors who underwent surgical treatment. Methods: This study included all cases who underwent surgical treatment for mesenchymal tumors in Başakşehir Çam and Sakura City Hospital, Turkey, between August 2020 and August 2022. The demographic data and clinical properties of the patients, operative details, postoperative assessments, pathological specifications of the tumor, and immunohistochemical analysis results were evaluated. Results: The study included 14 patients, 57% of whom were male. Patients had a mean age of 59.7±9.3 years. The most frequent American Society of Anesthesiologists (ASA) score was ASA 2 in 10 (72%) patients, and the mean hemoglobin level was 12±1.9 g/dl. All patients underwent wedge resection, 5 (35.7%) by a minimally invasive method. The mean duration of operation was 98.9±29.4 min. There were no intraoperative complications, conversions, or postoperative mortalities, and the mean duration of hospital stay was 6.2±3.2 days. One patient made an unplanned re-admission to the hospital due to inadequate oral intake. As an adjuvant treatment, three patients were prescribed imatinib. The tumor location was most frequently the corpus in 5 (36%) patients, and the mean tumor diameter was 62±35.2 mm. Stromal tumors were the most common histological type in 10 (72%) patients, and the other histological types were leiomyoma in 3 (21%) and pancreatoblastoma in 1 (7%) patient. The median and maximum Ki-67 index were 3 and 80, respectively, and the median and maximum mitotic index were 3 and 18, respectively. The number of dissected lymph nodes was nine in one patient and five in another. The surgical margin was positive in one patient, and no patient had a perforated tumor. Conclusion: Among the different types of mesenchymal tumors of the gastrointestinal system, which are rare, stromal tumors are the most common histological type. Gastric mesenchymal tumors can be safely treated with wedge resection, an approach that is associated with low postoperative morbidity and mortality.

A Rare Case and Atypical Metastatic Regions, Pulmonary Giant Cell Carcinoma.

Sixty two years old man referred to our clinic due to suspicion of thymic mass. The hypermetabolic nodular lesion in the right lung upper lobe was seen in 18F-fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography (PET/CT) in addition to the mass in the anterior mediastinum which was found to without malignancy. The patient underwent wedge resection and final diagnosis was pulmonary giant cell carcinoma. In follow-up 18F-FDG PET/CT multiple lesions with pathological activity were observed in the cerebrum, right postauricular region, bilateral adrenal, stomach, pancreas, pelvic soft tissue, mesenteric, left femur and bilateral lung parenchyma 6 months after. The pathology results of the right frontal, pelvic mass and the postauricular region were metastasis.

Pulmonary function changes after sublobar resection in patients with peripheral non-subpleural nodules

BackgroundIn the treatment of peripheral early-staged lung cancer and benign lesions, segmentectomy and wedge resection are both reliable treatment methods. It is debatable that how much pulmonary function will be lost after different sublobar resection in the treatment of early-staged deep-located peripheral NSCLC (non-small cell lung cancer). The purpose of this study was to explore postoperative pulmonary function changes of sublobar resection in enrolled patients with non-subpleural peripheral nodules.MethodsWe collected clinical data of patients undergoing VATS (video-assisted thoracoscopic surgery) segmentectomy or wedge resection for single nodule. These nodules were confirmed as peripheral non-subpleural nodules by preoperative 3D imaging. Patients were divided into two groups according to the operation procedure. Demographic characteristics, pulmonary function, postoperative outcomes, and others were collected. All data was gathered at the First Affiliated Hospital of Soochow University. Outcomes after wedge resection were compared with those after segmentectomy resection.ResultsA total of 88 patients were included in this study, including 46 patients with VATS wedge resection and 42 patients with VATS segmentectomy. No difference was detected when comparing FEV1 (forced expiratory volume in 1 s) loss between these two groups (17.6 ± 2.1%, wedge resection vs. 19.4 ± 5.4%, segmentectomy, P = 0.176). FVC (forced vital capacity) loss (8.7 ± 2.3%, wedge resection vs. 17.1 ± 2.2%, segmentectomy, P < 0.001) and MVV (maximum ventilatory volume) loss (11.5 ± 3.1%, wedge resection vs. 20.6 ± 7.8%, segmentectomy, P < 0.001) in segmentectomy group was significantly higher than those in wedge resection group. Discrepancies were investigated when comparing duration of surgery (70 ± 22 min, wedge resection vs. 111 ± 52 min, segmentectomy, P = 0.0002), postoperative drainage (85 ± 45 mL, wedge resection vs. 287 ± 672 mL, segmentectomy, P = 0.0123), and treatment hospitalization expenses [35148 ± 889CNY, wedge resection vs. 52,502 (38,276–57,772) CNY, segmentectomy, P < 0.0002]. No significant difference was found between air leak time (1.7 ± 0.7 days, wedge resection vs. 2.5 ± 1.7 days, segmentectomy, P = 0.062) and hospitalization time (2.7 ± 0.7 days, wedge resection vs. 3.5 ± 1.7 days, segmentectomy, P = 0.051).ConclusionsFor patients with peripheral non-subpleural nodules, we observed that patients who underwent wedge resection had less lung function loss than those who underwent segmentectomy when their lung function was reviewed at the 6th month after surgery. Patients undergoing wedge resection had partial advantages over patients with segmental resection in terms of hospitalization cost, operation time and postoperative drainage, etc. Wedge resection, as a treatment for peripheral non-subpleural pulmonary nodules, seemed to have more advantages in preserving patients’ pulmonary function.

Wedge resection plus adequate lymph nodes resection is comparable to lobectomy for small-sized non-small cell lung cancer.

The study investigated whether wedge resection plus adequate lymph nodes resection conferred comparable survival to lobectomy for node-negative non-small cell lung cancer (NSCLC) ≤2 cm. The Surveillance, Epidemiology, and End Results database was used to identify patients diagnosed with node-negative NSCLC ≤2 cm and underwent wedge resection or lobectomy (2004-2015). Patients were stratified by the procedure (wedge resection, lobectomy) and the size of NSCLC (≤1 cm, 1-2 cm). We assessed survival between patients undergoing wedge resection and lobectomy. The optimal number of lymph nodes resected which made those two procedures comparable was explored by using Kaplan-Meier analysis and Cox regression analysis. Propensity score matching was performed to minimize the effect of confounding factors. 7893 patients with lobectomy and 2536 patients with wedge resection were identified. Wedge resection was associated with worse survival either in the ≤1 cm or 1-2 cm NSCLC before and after matching. For lesions 1-2 cm and receiving lobectomy, more lymph nodes resected conferred statistically significant increase on survival and six nodes were optimal. For lesions ≤1 cm and receiving lobectomy, lymph nodes resection had no impact on survival. Wedge resection and lobectomy were comparable when one or more nodes for lesions ≤1 cm and six or more nodes for lesions 1-2 cm were resected. Wedge resection was inferior to lobectomy for NSCLC ≤1 cm and 1-2 cm. Wedge resection plus adequate lymph nodes resection was comparable to lobectomy.

PSAT009 Cushing's Syndrome Developing 42 Years After Successful Treatment for Metastatic Adrenocortical Carcinoma

Abstract Introduction ACC is a rare malignancy with poor prognosis. ACC is associated with CS in about 10% of the cases. Herein we report a case of a patient with metastatic ACC who developed contralateral functional adrenal adenoma causing Cushing's syndrome 42 years later. Clinical Case A 72-year-old female presented for evaluation of right adrenal incidentaloma, measuring 4.4×3 cm, on CT abdomen and pelvis (CTAP), done as part of the evaluation for hip pain. In addition to the adrenal incidentaloma, a large left adnexal mass (8×7 cm) was also observed. Her past medical history was significant for left adrenal ACC diagnosed at the age of 30, The patient's initial presentation included virilization and menstrual abnormalities. Laboratory evaluation revealed hyperandrogenism and hypercortisolism. There was no evidence of metastatic disease, and the patient was managed surgically (total left adrenalectomy) with normalization of laboratory abnormalities and resolution of symptoms. Four years later, patient pulmonary metastasis were observed in a surveillance scan and the patient underwent wedge resection and chemotherapy. The patient did not have any evidence of recurrent disease thereafter. At the current presentation, there were no symptoms or signs of adrenal hormone excess. Hormonal workup revealed borderline elevation of plasma metanephrines, with normal 24 h urinary metanephrines and catecholamines. DHEA-S and testosterone levels, as well as other androgens, were normal. 1 mg dexamethasone suppression (DST) was abnormal, with cortisol of 5.5 mcg/dL 8 h after dexamethasone administration (normal &amp;lt;1.8 mcg/dL). High dose DST was repeatedly abnormal, with cortisol levels at 4.0 and 4.4 mcg/dL (normal &amp;lt;1.8 mcg/dL). AM cortisol was elevated, at 23.4 mcg/dL (normal 4-22 mcg/dL) with ACTH at 12 pg/mL (normal &amp;lt;45 pg/dL). 24 h urinary free cortisol (UFC) was repeatedly elevated at 123.2 and 83.8 mcg/d (normal &amp;lt;45.0 mcg/d). CA 125 was normal. As there are case reports of ectopic Cushing's syndrome related to ovarian malignancies, and the patient had a large adnexal mass, adrenal and ovarian vein sampling was performed. Cortisol levels were higher in the right adrenal vein compared to the periphery, and the gradient was normal for the left ovarian vein. The right ovary was not visualized, and it was not possible to catheterize the right ovarian vein. Whole body FDG scan revealed intermediate uptake by right adrenal mass and normal uptake by left adnexal mass. Based on these results, it was determined that the right adrenal was the source of excess cortisol, and the patient underwent laparoscopic right adrenalectomy. Pathology evaluation showed adrenal adenoma, without evidence of ACC. The patient was started on physiologic replacement doses of hydrocortisone and fludrocortisone. The patient has been doing very well clinically. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Pulmonary Hamartomas: A Single-Center Analysis of 59 Cases.

This study investigated the clinical, radiological, and surgical treatment results of patients who underwent surgical treatment for pulmonary hamartomas. Fifty-nine consecutive patients who underwent surgical treatment for pulmonary hamartomas in our clinic between January 2001 and February 2021 were analyzed retrospectively. Forty-three out of 59 (72.9%) of the cases were male and 16 (27.1%) were female. The average age was 52.0 ± 15.0 (between 5 years and 80 years). While pulmonary hamartoma was in the form of a solitary pulmonary nodule in 55 (93.2%) of the cases, there were multiple lesions in 4 (6.8%) cases. Simultaneous gastric adenocarcinoma was detected in 1 patient. One case had been operated on for Wilms tumor. Twenty-two (37.3%) of the cases were asymptomatic and were detected incidentally. Locations of pulmonary hamartomas were 18 (29.0%) in the left lower lobe, 16 (25.8%) in the right upper lobe, 12 (19.4%) in the right lower lobe, 9 (14.5%) in the left upper lobe, and 7 (11.3%) in the right middle lobe. The mean lesion diameter was 22.0 ± 9.5 mm (between 10 mm and 56 mm). Mild to moderate fluorodeoxyglucose (FDG) uptake was observed in 11 of 15 cases that were evaluated with positron emission tomography/computed tomography. Surgically, 44 (74.6%) patients underwent wedge resection, 13 (22.0%) patients underwent enucleation and two (3.4%) patients underwent lobectomy. Perioperative morbidity and mortality were not observed in any of the cases. The cases were followed up for an average of 40.6 ± 38.7 months (between 1 month and 151 months). No recurrence was observed in any of the cases during follow-up. Pulmonary hamartomas are usually detected incidentally and as a solitary pulmonary nodule. Although radiological findings provide important information, a definitive diagnosis is usually made during surgery. Parenchyma-sparing surgery should be preferred in these cases whenever possible.

Liver metastases 2 years after resection of a very-low-risk duodenal gastrointestinal stromal tumor: a case report

BackgroundGastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors, but are the most common mesenchymal tumors of the gastrointestinal tract. The risk classification of GISTs is based on the tumor size, mitotic index, tumor site, and presence of tumor rupture. Recurrence in the very-low-risk group is extremely rare. We herein report a case of liver metastases 2 years after resection of a very-low-risk duodenal GIST.Case presentationA 57-year-old woman presented to the hospital for evaluation of melena. Esophagogastroduodenoscopy showed bleeding from the exposed blood vessels at the top of a submucosal tumor approximately 20 mm in size located in the second (descending) part of the duodenum, and the bleeding was controlled with electrocoagulation. A GIST was suspected, and the patient underwent wedge resection of the duodenum. The resected specimen contained a 16- × 12-mm (< 20-mm) white submucosal tumor composed of spindle cells with a mitotic count of 4 per 50 high-power fields, and a histologically negative margin was achieved. Immunochemical analysis revealed positive tumor staining for c-kit protein and alpha-smooth muscle actin and negative staining for CD34, desmin, and S-100 protein. Therefore, the tumor was diagnosed as a very-low-risk duodenal GIST based on the Fletcher classification and modified Fletcher classification (Joensuu classification). The postoperative course was uneventful, and the patient was discharged on postoperative day 11. At the follow-up visit 2 years postoperatively, contrast-enhanced computed tomography revealed liver tumors in S8 and S6 measuring 26 × 24 and 10 × 10 mm, respectively. Both lesions showed peripheral dominant hyperenhancement with hypoenhancement inside, indicating tissue degeneration within the tumors. These imaging findings closely resembled those of the duodenal GIST. Hence, the patient was diagnosed with liver metastases of GIST 2 years postoperatively. She was subsequently started on treatment with 400 mg of imatinib. At the time of this writing (2 months after diagnosis), the patient was clinically well and asymptomatic and was continuing imatinib therapy.ConclusionsRecurrence of very-low-risk GISTs is extremely rare. Even a small GIST with low mitotic activity can never be considered completely benign, and long-term follow-up is necessary.

METASTATIC MELANOMA TO THE LUNG CURED WITH LOBECTOMY: A CASE REPORT

SESSION TITLE: Cardiovascular Surgery Case Report PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/19/2022 12:45 pm - 01:45 pmINTRODUCTION: Cutaneous Melanoma is the malignant version of the melanocytes. It can have both hematogenous and lymphatogenous spread, sites of metastasis include liver, brain and bone. Lung is the most visceral site affected by melanoma metastasis. We herein present a case of a female patient with history of cutaneous melanoma that relapsed 14 years later as a solitary pulmonary nodule.CASE PRESENTATION: 79-year-old Caucasian female, with a history of chronic obstructive pulmonary disease and right forearm melanoma resected at age of 57 presents for follow up. Patient, back when she was diagnosed with BRAF V600 mutated-positive cutaneous melanoma, underwent wide local excision. Regular follow-ups, of her stage II melanoma did not prove any local or distant recurrences. In July 2014, while undergoing pre-operative work up for bladder polyp removal, patient was found to have a solitary pulmonary nodule that warranted further work up. For a better assessment of the lesion, full body positron emission tomography was obtained; it confirmed a pathological fludeoxyglucose uptake within a 2 x 2 x 1.7 cm left lower lobe pulmonary nodule (Figure 1 and 2). The maximum standardized uptake value recorded was 41. PET scan failed to show any other suspicious lesions. Thorough cutaneous exam did not reveal any skin pathology. Computed tomography (CT) guided needle biopsy was performed, revealing an aggressive melanotic tumor. The patient underwent wedge resection of the left lower lobe. The tumor was tested positive for the same BRAF mutation the previously resected melanoma harbored. Since resection, routine work-up was negative for recurrence, and CT scans of the chest did not demonstrate interval changes from previous studies.DISCUSSION: Melanoma is most commonly cutaneous, and early detection is crucial in preventing disease spread. Primary melanoma of the lung has been rarely described and results supposedly from the embryogenic migration of neural crest cells to the lungs; however, these lesions could have been easily mistaken for primary especially that cutaneous lesions are not always identified. Pulmonary metastasis from melanoma mostly occur peripherally and present as solid nodules. The peripheral location in the lung renders the wedge resection a possible and successful therapeutic option. Melanoma therapeutic approach has changed drastically with targeted therapy. Immunotherapy , as proven, has increased the 10-year survival rate in Stage IV melanoma to 20%. In a randomized clinically trial on melanoma patients with brain metastasis, immunotherapy was shown to be an alternative option.CONCLUSIONS: Melanoma is one of the most virulent cancers that has a wide clinical presentation and portrays a high mortality rate. Recently emerged therapy has changed disease course and was successful in an advanced stage of the illness.Reference #1: Prieto-Granada C, Howe N, McCardle T. Melanoma Pathology. Melanoma. 2016;1012:10–30.Reference #2: Stadelmann SA, Blüthgen C, Milanese G, Nguyen-Kim TDL, Maul JT, Dummer R, et al. Lung nodules in melanoma patients: Morphologic criteria to differentiate non-metastatic and metastatic lesions. Diagnostics. 2021;11(5).Reference #3: Tsaknis G, Naeem M, Singh A, Vijayakumar S. Malignant melanoma without primary, presenting as solitary pulmonary nodule: a case report. J Med Case Rep [Internet]. 2021;15(1):1–4. Available from: https://doi.org/10.1186/s13256-021-02933-zDISCLOSURES: No relevant relationships by Racha Abi MelhemNo relevant relationships by Ahmad Abou YassineNo relevant relationships by Marc AssaadNo relevant relationships by Loai DahabraNo relevant relationships by Khalil El Gharibno disclosure on file for Dany Elsayegh;No relevant relationships by Ahmad ItaniNo relevant relationships by Ali KassemNo relevant relationships by Hussein Rabah SESSION TITLE: Cardiovascular Surgery Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Cutaneous Melanoma is the malignant version of the melanocytes. It can have both hematogenous and lymphatogenous spread, sites of metastasis include liver, brain and bone. Lung is the most visceral site affected by melanoma metastasis. We herein present a case of a female patient with history of cutaneous melanoma that relapsed 14 years later as a solitary pulmonary nodule. CASE PRESENTATION: 79-year-old Caucasian female, with a history of chronic obstructive pulmonary disease and right forearm melanoma resected at age of 57 presents for follow up. Patient, back when she was diagnosed with BRAF V600 mutated-positive cutaneous melanoma, underwent wide local excision. Regular follow-ups, of her stage II melanoma did not prove any local or distant recurrences. In July 2014, while undergoing pre-operative work up for bladder polyp removal, patient was found to have a solitary pulmonary nodule that warranted further work up. For a better assessment of the lesion, full body positron emission tomography was obtained; it confirmed a pathological fludeoxyglucose uptake within a 2 x 2 x 1.7 cm left lower lobe pulmonary nodule (Figure 1 and 2). The maximum standardized uptake value recorded was 41. PET scan failed to show any other suspicious lesions. Thorough cutaneous exam did not reveal any skin pathology. Computed tomography (CT) guided needle biopsy was performed, revealing an aggressive melanotic tumor. The patient underwent wedge resection of the left lower lobe. The tumor was tested positive for the same BRAF mutation the previously resected melanoma harbored. Since resection, routine work-up was negative for recurrence, and CT scans of the chest did not demonstrate interval changes from previous studies. DISCUSSION: Melanoma is most commonly cutaneous, and early detection is crucial in preventing disease spread. Primary melanoma of the lung has been rarely described and results supposedly from the embryogenic migration of neural crest cells to the lungs; however, these lesions could have been easily mistaken for primary especially that cutaneous lesions are not always identified. Pulmonary metastasis from melanoma mostly occur peripherally and present as solid nodules. The peripheral location in the lung renders the wedge resection a possible and successful therapeutic option. Melanoma therapeutic approach has changed drastically with targeted therapy. Immunotherapy , as proven, has increased the 10-year survival rate in Stage IV melanoma to 20%. In a randomized clinically trial on melanoma patients with brain metastasis, immunotherapy was shown to be an alternative option. CONCLUSIONS: Melanoma is one of the most virulent cancers that has a wide clinical presentation and portrays a high mortality rate. Recently emerged therapy has changed disease course and was successful in an advanced stage of the illness. Reference #1: Prieto-Granada C, Howe N, McCardle T. Melanoma Pathology. Melanoma. 2016;1012:10–30. Reference #2: Stadelmann SA, Blüthgen C, Milanese G, Nguyen-Kim TDL, Maul JT, Dummer R, et al. Lung nodules in melanoma patients: Morphologic criteria to differentiate non-metastatic and metastatic lesions. Diagnostics. 2021;11(5). Reference #3: Tsaknis G, Naeem M, Singh A, Vijayakumar S. Malignant melanoma without primary, presenting as solitary pulmonary nodule: a case report. J Med Case Rep [Internet]. 2021;15(1):1–4. Available from: https://doi.org/10.1186/s13256-021-02933-z DISCLOSURES: No relevant relationships by Racha Abi Melhem No relevant relationships by Ahmad Abou Yassine No relevant relationships by Marc Assaad No relevant relationships by Loai Dahabra No relevant relationships by Khalil El Gharib no disclosure on file for Dany Elsayegh; No relevant relationships by Ahmad Itani No relevant relationships by Ali Kassem No relevant relationships by Hussein Rabah

Safety, efficacy, and selection strategy of laparoscopic local gastrectomy for gastrointestinal stromal tumors in the esophagogastric junction.

ObjectiveTo investigate the safety, efficacy, and selection strategy of laparoscopic local gastrectomy for stromal tumors in the esophagogastric junction.MethodsThirty-eight patients with mesenchymal tumors in the esophagogastric junction were retrospectively enrolled from April 2018 to July 2021 in which the upper edge of the tumor is less than 2 cm from the Z-line or has invaded the Z-line <1/2 circumference. Surgical outcomes, complications, recover, and postoperative gastroesophageal reflux of both groups were compared.Results27 patients underwent wedge resection, and 11 underwent resection by opening all of the layers of the stomach wall. Operative time (90.0 vs. 181.8 min, respectively, P = 0.001) was shorter for the WR group vs. RASW. Blood loss (20 vs. 50 ml, respectively, P = 0.012) was less for the WR group vs. RASW. Recovery of the RASW group was slower in terms of time to pass gas (2 vs. 3 days, P = 0.034), time to oral intake (2 vs. 4 days, P = 0.007), time to semi-liquid food intake (4 vs. 8 days, P = 0.003), and postoperative hospitalization (5 vs. 8 days, P = 0.001) vs. WR. In terms of short-term complications (≤30 days), no significant between-group differences were observed. Cardia stenosis did not occur in either group. In the WR group, one patient experienced mild reflux at 6 months and recovered 1 year after surgery. In the RASW group, one patient experienced severe gastroesophageal reflux at 6 months and 1 year after surgery, which was not entirely relieved by taking antacids. No other patients have gastroesophageal reflux.ConclusionLaparoscopic local gastrectomy is safe and feasible for mesenchymal tumors in the esophagogastric junction in which the upper edge of the tumor is less than 2 cm from the Z-line or has invaded the Z-line <1/2 circumference, and has achieved an excellent short-term effect. The choice of surgery is based on the relationship between the tumor and the position of the cardia.

Measuring the margin distance in pulmonary wedge resection.

Margin distance contributes to survival and recurrence during wedge resections for early-stage non-small cell lung cancer. The Initiative for Early Lung Cancer Research on Treatment sought to standardize a surgeon-measured margin intraoperatively. Lung cancer patients who underwent wedge resection were reviewed. Margins were measured by the surgeon twice as per a standardized protocol. Intraobserver variability as well as surgeon-pathologist variability were compared. Forty-five patients underwent wedge resection. Same-surgeon measurement analysis indicated good reliability with a small mean difference and narrow limit of agreement for the two measures. The median surgeon-measured margin was 18.0 mm, median pathologist-measured margin was 16.0 mm and the median difference between the surgeon-pathologist margin was -1.0 mm, ranging from -18.0 to 12.0 mm. Bland-Altman analysis for margin measurements demonstrated a mean difference of 0.65 mm. The limit of agreement for the two approaches were wide, with the difference lying between -16.25 and 14.96 mm. A novel protocol of surgeon-measured margin was evaluated and compared with pathologist-measured margin. High intraobserver agreement for repeat surgeon measurements yet low-to-moderate correlation or directionality between surgeon and pathologic measurements were found. A standardized protocol may reduce variability in pathologic assessment. These findings have critical implications considering the impact of margin distance on outcomes.

Survival after wedge resection versus lobectomy for stage IA second primary NSCLC with previous lung cancer-directed surgery.

BackgroundThe surgical procedure for early-stage second primary non-small cell lung cancer (SP-NSCLC) remains controversial, especially for patients with previous lung cancer-directed surgery. This study aims to compare the survival after wedge resection and lobectomy for these patients.MethodsStage IA SP-NSCLC patients with clear clinical information were searched from the Surveillance, Epidemiology, and End Results (SEER) database. The Cox proportional hazard model, the competing risk model, and the Kaplan–Meier survival curve were used to describe the survival difference between wedge resection and lobectomy. A 1:1 propensity score matching (PSM) method was also performed to reduce the potential impact of confounding factors between the two groups.ResultsOf the 320 eligible stage IA SP-NSCLC patients included in this study, 238 (74.4%) patients underwent wedge resection and 82 (25.6%) patients received lobectomy. The 5-year overall survival (OS) was 61.3% with wedge resection and was 66.1% with lobectomy. Both before and after PSM, wedge resection showed similar OS and lung cancer-specific mortality as lobectomy in the entire cohort. Additionally, in all subgroup analyses, wedge resection demonstrated equivalent survival to lobectomy. However, in the female, sublobectomy for the first primary lung cancer, and interval ≤ 24 months subgroups, wedge resection displayed a higher lung cancer-specific mortality than lobectomy (fine-gray test, all p < 0.05).ConclusionOverall, wedge resection is comparable to lobectomy in OS for stage IA SP-NSCLC patients with previous lung cancer-directed surgery. Therefore, we believe that wedge resection may be sufficient for these patients, although, in some cases, wedge resection has a higher lung cancer-specific mortality rate than lobectomy.

Unexpected pulmonary edema and cardiac arrest following wedge resection of spontaneous pneumothorax -A case report-

BackgroundReexpansion pulmonary edema is a rare but potentially lethal complication. We report a case of suspected reexpansion pulmonary edema that led to cardiac arrest.CaseA 16-year-old male patient underwent wedge resection due to right pneumothorax. The patient showed pink frothy sputum three hours following surgery, and a chest x-ray showed right unilateral pulmonary edema. Thirteen hours following surgery, the patient continuously showed pink frothy sputum and presented with severe hypoxemia, tachypnea, and tachycardia. After transferring to the intensive care unit (ICU), he developed ventricular tachycardia. Cardiopulmonary resuscitation was performed for 32 min. Chest X-ray showed diffuse bilateral pulmonary edema. Extracorporeal membrane oxygenation was performed. During the 65 days of ICU care, the patient became mentally alert. However, follow-up echocardiography revealed severe heart failure.ConclusionsRexpansion pulmonary edema can rapidly progress to diffuse bilateral pulmonary edema. Therefore, careful observation is required for the patients who show signs of pulmonary edema after reexpansion.

Assessment of the Operative Feasibility and Ventilation Distribution during Nonintubation Thoracoscopic Surgery Using Electrical Impedance Tomography.

Background: To investigate the feasibility, ventilation distribution, and physiological effect of iatrogenic pneumothorax generated during nonintubated thoracoscopic surgery using electrical impedance tomography. Methods: Patients who underwent resections for pulmonary nodules between April 2016 and April 2019 were enrolled prospectively. Electrical impedance tomography was performed, and the measurements were recorded at five different timepoints. The patient characteristics, pathological characteristics, surgical procedures, operation times, and intraoperative parameters were recorded and analyzed. Results: Two hundred sixty-five perioperative electrical impedance tomography measurements during nonintubated thoracoscopic surgery were recorded in fifty-three patients. Fifty-one patients underwent wedge resections, and two patients underwent segmentectomies. The preoperative lateral decubitus position time point showed greater ventilation in the right lung than in the left lung. For left-sided surgery, the nonoperative lung had better ventilation (64.5% ± 14.1% for the right side vs. 35.5% ± 14.1% for the left side, p < 0.0001). For right-sided surgery, the nonoperative lung did not have better ventilation (52.4% ± 16.1% for the right side vs. 47.6% ± 16.1% for the left side, p = 0.44). The center of ventilation was significantly increased after surgery (p < 0.001). The global index of ventilation showed no difference after surgery. Conclusions: The nonintubated thoracoscopic surgical side had different ventilation distributions but reached ventilation equilibrium after the operation. Electrical impedance tomography is feasible and safe for monitoring ventilation without adverse effects.

Rescue Surgery after Immunotherapy/Tyrosine Kinase Inhibitors for Initially Unresectable Lung Cancer

Simple SummaryLocally advanced or metastatic non-small cell lung cancer (NSCLC) has been considered for a long time as an unresectable disease. Chemotherapy was considered the only therapeutic option for these conditions and the results were unsatisfactory. Recent advances in biology and immunology have led to the use of personalized treatments by using tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICIs), which produce significant and durable treatment responses. Large trials explored the utility of TKIs and ICIs in neoadjuvant or adjuvant settings, showing good results in terms of radiological response and long-term outcomes. Retrospective case series in patients with the previously unresectable disease who received treatment with TKIs, or ICIs showed important clinical changes that consider the possibility of pulmonary resection of the residual disease. They showed an overall feasibility for pulmonary resection but also raised concerns about the technical challenges. In the present study, we analyzed and reported the surgical and long-term outcomes of patients with initial unresectable, locally advanced, or oligometastatic NSCLC who were treated with TKIs or ICIs achieving a clinical downstaging so as to re-enter resectability.Background: We report the outcomes for unresectable patients with locally advanced or oligometastatic non-small cell lung cancer (NSCLC) treated with tyrosine kinase inhibitor (TKI) or immunotherapy who achieved a clinical downstaging so as to re-enter resectability. Methods: We retrospectively reviewed the clinical, surgical, and pathological data of 42 patients with histologically proven, inoperable NSCLC who received rescue surgery after a good response to TKI or immunotherapy between March 2014 and December 2021. Results: Of 42 patients, 39 underwent pulmonary resection with therapeutic intent (three explorative thoracotomies). There were 26 males, with a median age of 64 years (range, 41–78 years). Twenty-three patients received TKIs and 19 immunotherapies. Anatomic resection was performed in 97.4% of resected patients (38/39) including 30 lobectomies, one right upper sleeve lobectomy, five pneumonectomies, one tracheal sleeve pneumonectomy, and one bilobectomy; a patient underwent wedge resection. Of 10 procedures attempted via a robotic approach, two required conversion to thoracotomy. No intraoperative morbidity/mortality occurred. The median operative time was 190 (range, 80–426) minutes; estimated blood loss was 200 mL (range, 35–780 mL). Morbidity occurred in 13/39 (33.3%). The median length of hospital stay was 6.5 days (range, 4–23 days). Pathologic downstaging was 74.4% (29/39). With a median follow-up of 28.7 months, the 5-year disease-free interval was 46.5%, and the 5-year overall survival was 66.0%; 32/39 patients (82.1%) are alive, 10 with the disease. Conclusions: Lung resection for suspected residual disease after immunotherapy or TKIs is feasible, with encouraging pathological downstaging. Surgical operation may be technically challenging due to the presence of fibrosis, but significant morbidity appears to be rare. Outcomes are encouraging, with reasonable survival during the short-interval follow-up.

Clinical characteristics and surgical treatment of congenital cystic adenomatoid malformation in adults: the largest cohort of 46 patients.

BackgroundCongenital cystic adenomatoid malformation (CCAM) is a rare congenital malformation of the lungs, however it lacks a summary of pathognomonic clinical and imaging features in adults. Our study aims to evaluate clinical characteristics and surgical treatment in the largest case series of adult CCAM.MethodsThe records of 46 adult patients with CCAM admitted to West China Hospital between February 2009 and March 2019 were reviewed. All patients accepted the surgery and get fully recovered. Data were collected and analyzed regarding patient demographics, medical history, preoperative investigations, intraoperative findings, and postoperative outcomes.ResultsThe records of 22 men and 24 women were examined. The main systemic and respiratory symptoms included fever, productive cough, hemoptysis, and chest pain. Twenty lesions were found in the right pulmonary lobes and 26 in the left lobes. All CCAM lesions were successfully resected by surgery (35 patients had lobectomies, and the remaining 11 patients underwent wedge resections). Twenty-nine patients underwent video-assisted thoracic surgery (VATS), while 17 patients received posterolateral thoracotomy (PLT). The pathological analysis of surgical specimens revealed 26 cases of pure CCAM lesions and 20 cases of CCAM mixed with other diseases. More than 10% of patients had coexisting pre-malignant or malignant lung lesions. Four patients experienced postoperative complications. No intraoperative and postoperative deaths occurred.ConclusionsSurgical resection remains the preferred approach for adults with CCAM and has satisfied outcomes. Clinicians should be aware of possible coexisting infections and malignancies.

Is there any change in disease presentation and surgical outcomes in patients with pulmonary aspergilloma? An evaluation of the time trend.

Background This study aims to investigate the changes in the clinical and radiological presentations of pulmonary aspergilloma in patients undergoing surgery and to evaluate changes in the surgical outcomes over time. Methods Between January 2000 and January 2020, a total of 88 patients (69 males, 19 females; mean age: 45.4±11.2 years; range, 17 to 70 years) who underwent surgery for pulmonary aspergilloma were retrospectively analyzed. Surgeries performed were divided into two groups based on their chronological order: first period (from 2000 to 2010, n=44) and second period (from 2010 to 2020, n=44). Results The most frequent underlying disorder was tuberculosis (72.7%), whereas 10 patients did not have any predisposing conditions for pulmonary aspergilloma. Regarding the aspects of radiological imaging and operative findings, 22 patients had simple aspergilloma and 66 patients had complex aspergilloma. Complications and mortality rates were 33.0% and 5.7%, respectively. A statistical downward was observed in the second period compared to that in the first period regarding the rate of patients with tuberculosis history (61.4% vs. 84.1%, p=0.01). There were more patients who did not have any predisposing conditions for pulmonary aspergilloma in the second period and in the simple aspergilloma group (p=0.04 and p<0.001, respectively). Simple aspergilloma was often observed in the second period than that in the first period (31.8% vs. 18.2%). There was no significant difference between the periods regarding the type of surgical resection (p=0.506), whereas in the simple aspergilloma group, more patients underwent wedge resection (p<0.001). There were no significant differences between the periods and radiological groups in terms of complications and mortality. Patients who underwent pneumonectomy had significantly higher rates of complications and mortality (p=0.01 and p=0.03, respectively). Conclusion Although pulmonary aspergilloma patients who underwent surgery in the last 10 years had a lower history of tuberculosis than those who were operated in the previous 10 years, there was no change in postoperative complications and mortality rates. An increase in simple aspergilloma prevalence may reduce the rate of surgical morbidity.

Wedge resection or enucleation in pulmonary hamartoma?

Background: Wedge resection and enucleation are the most commonly preferred surgical modalities for the treatment of pulmonary hamartomas. There is a concern about the safety and efficacy of enucleation for a pulmonary hamartoma. Aim of the study: To compare wedge resection and enucleation for the surgical treatment of pulmonary hamartomas. Material and Methods: We retrospectively analyzed the data from patients who were surgically diagnosed with pulmonary hamartoma between January 2014 and December 2019. We obtained data on clinical findings, radiological features, surgical modality, postoperative complications, and follow-up results from the hospital electronic database. We compared all these features in the patients who underwent wedge resection with those who received enucleation. Results: A total of 18 patients with pulmonary hamartoma were analyzed. The mean age of the patients was 60.56 ± 9.25 years and 10 (55.6%) were male. Twelve (66.7%) patients had no respiratory symptoms. Ten (55.6%) of the patients underwent wedge resection and 8 (54.4%) patients had enucleation. There were no significant differences in age, gender, symptom distribution, prolonged air leakage, hospital stay length, intensive care unit stay length, mortality, or relapse rate between the patients with wedge resection and enucleation. Nodule size, calcification, metabolic activity, central or peripheral location, and lobar distribution were also similar. Conclusions: We observed that there were no significant differences in the postoperative complications, hospital stay length, mortality or relapse between the patients with wedge resection and enucleation. Minimal parenchymal damage and resection should be the aim of surgical interventions for benign lung diseases. Therefore, we believe that enucleation should be the first choice for the surgical treatment pulmonary hamartomas.