Preoperative Chest Computed Tomography Scan Research Articles

Low skeletal muscle mass is associated with inferior preoperative and postoperative shoulder function in elderly rotator cuff tear patients

BackgroundThe age-related loss of skeletal muscle mass is an important characteristic of sarcopenia, an increasingly recognized condition with systemic implications. However, its association with shoulder function in elderly patients with rotator cuff tears (RCT) remains unknown. This study aimed to investigate the relationship between low skeletal muscle mass and shoulder function in elderly RCT patients.MethodsA retrospective analysis was conducted on RCT patients who underwent chest computed tomography (CT) scans for clinical evaluation. Preoperative CT scan images of the chest were used to calculate the cross-sectional area (CSA) of thoracic muscle at the T4 level. The medical records were reviewed. Shoulder function was assessed using the ASES score and CMS score both preoperatively and at the final follow-up. Data on the preoperative range of motion (ROM) for the affected shoulder, were collected for analysis. Subgroup analyses by sex were also performed.ResultsA total of 283 RCT patients, consisting of 95 males and 188 females, with a mean age of 66.22 ± 4.89(range, 60–95 years) years were included in this retrospective study. The low muscle mass group showed significantly higher level of c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) compared to the normal group(3.75 ± 6.64 mg/L vs. 2.17 ± 2.30 mg/L, p = 0.021; 19.08 ± 12.86 mm/H vs.15.95 ± 10.76 mm/H, p = 0.038; respectively). In the normal group, pre-operative passive ROM, including forward elevation, abduction, lateral rotation, and abductive external rotation, was significantly better than that in the low muscle mass group (127.18 ± 34.87° vs. 89.76 ± 50.61°; 119.83 ± 45.76° vs. 87.16 ± 53.32°; 37.96 ± 28.33° vs. 25.82 ± 27.82°; 47.71 ± 23.56° vs. 30.87 ± 27.76°, all p < 0.01, respectively). Similar results were found in the active ROM of the shoulder. The female low muscle mass group exhibited significantly poorer passive and active ROM (p < 0.05). The post-operative ASES scores and CMS scores of the female low muscle mass group were also statistically worse than those of the female normal group (p < 0.05).ConclusionsThe results of present study revealed that the low skeletal muscle mass is associated with inferior ROM of the shoulder and per- and post-operative shoulder function, especially for elderly female patients.

Computed tomography-based 3D convolutional neural network deep learning model for predicting micropapillary or solid growth pattern of invasive lung adenocarcinoma

PurposeTo investigate the value of a computed tomography (CT)-based deep learning (DL) model to predict the presence of micropapillary or solid (M/S) growth pattern in invasive lung adenocarcinoma (ILADC).Materials and MethodsFrom June 2019 to October 2022, 617 patients with ILADC who underwent preoperative chest CT scans in our institution were randomly placed into training and internal validation sets in a 4:1 ratio, and 353 patients with ILADC from another institution were included as an external validation set. Then, a self-paced learning (SPL) 3D Net was used to establish two DL models: model 1 was used to predict the M/S growth pattern in ILADC, and model 2 was used to predict that pattern in ≤ 2-cm-diameter ILADC.ResultsFor model 1, the training cohort’s area under the curve (AUC), accuracy, recall, precision, and F1-score were 0.924, 0.845, 0.851, 0.842, and 0.843; the internal validation cohort’s were 0.807, 0.744, 0.756, 0.750, and 0.743; and the external validation cohort’s were 0.857, 0.805, 0.804, 0.806, and 0.804, respectively. For model 2, the training cohort’s AUC, accuracy, recall, precision, and F1-score were 0.946, 0.858, 0.881,0.844, and 0.851; the internal validation cohort’s were 0.869, 0.809, 0.786, 0.794, and 0.790; and the external validation cohort’s were 0.831, 0.792, 0.789, 0.790, and 0.790, respectively. The SPL 3D Net model performed better than the ResNet34, ResNet50, ResNeXt50, and DenseNet121 models.ConclusionThe CT-based DL model performed well as a noninvasive screening tool capable of reliably detecting and distinguishing the subtypes of ILADC, even in small-sized tumors.

Clinicopathological and computed tomography features associated with recurrence-free survival of patients with small-sized peripheral invasive lung adenocarcinoma after sublobectomy.

Sublobar resection is gradually becoming a standard treatment for small-sized (≤2 cm) peripheral non-small cell lung cancer (NSCLC), with lung adenocarcinoma (LADC) being the most frequent histologic subtype. However, the prognostic predictors for preoperatively determining whether sublobectomy is feasible for patients with early LADC have not yet been well identified. Therefore, this study aimed to investigate the clinicopathological and computed tomography (CT) features associated with the recurrence-free survival (RFS) of patients with small-sized invasive LADC (SILADC) after sublobar resection. This retrospective cohort study analyzed 107 patients with SILADC who underwent preoperative chest CT scan and sublobar resection from December 2012 to March 2019. The Kaplan-Meier survival was used to analyze the relationship between clinicopathological characteristics, preoperative chest CT findings, and RFS. The Cox proportional hazards regression was used to identify independent prognostic factors of poor RFS. For clinicopathological characteristics, RFS was shorter in patients aged ≥70 years, smokers, and those with micropapillary/solid-predominant adenocarcinomas (all P values <0.05). For preoperative CT features, RFS was shorter in patients with tumor size ≥1.4 cm, solid component size ≥1.1 cm, proportion of solid component ≥72%, solid density, spiculation, vascular convergence sign, peripheral fibrosis, and type II pleural tag (all P values <0.05). Multivariate analysis showed proportion of solid component ≥72% [hazard ratio (HR): 5.920; P=0.006; 95% confidence interval (CI): 1.686-20.794], spiculation (HR: 5.026; P=0.001; 95% CI: 2.008-12.581), and type II pleural tag (HR: 4.638; P=0.002; 95% CI: 1.773-12.136) were independent risk factors for poor prognosis in patients with SILADC after sub-lobectomy. Clinicopathological and CT characteristics are helpful for predicting the RFS of patients with SILADC after sublobar resection and can be used as an auxiliary tool for thoracic surgeons to choose the best surgical mode.

Augmented reality navigation-guided intraoperative pulmonary nodule localization: a pilot study.

With the increasing number of small pulmonary nodules detected, effective localization of pulmonary nodules has become an issue. The goal of this study is to determine the safety and feasibility of a newly developed augmented reality navigation technology for intraoperative localization of small pulmonary nodules. We conducted a prospective single-center feasibility study of a novel augmented reality navigation system and lung localization (LungBrella) marker on ten patients between July and October 2020. For augmented reality navigation-guided localization, a preoperative chest computed tomography scan was performed to generate 3-dimensional (3D) virtual images and individualized localization plan, which were uploaded into Hololens (a head-mounted augmented reality device). Under the guidance of established procedure plan displayed by HoloLens, localization marker was placed in operating room. Segmentectomy or wedge resection was subsequently performed. The primary endpoint was the localization procedure success rate, and the secondary endpoints were localization time, operation time, and complications. Localization was successful in seven of the ten procedures. Due to different reasons, failures were noted in three cases, after which immediate adjustments were made. In the successful cases, the LungBrella marker was positioned at a median of 5.8 mm (range, 0-10 mm) from the edge of the nodule. Median localization time was 9.4 min (range, 5-19 min), and median operation time was 172.9 min (range, 105-200 min). There were no complications during the entire process. This exploratory study suggests that augmented reality navigation-guided pulmonary nodule localization is a safe and feasible technique (ClinicalTrials.gov identifier, NCT04211051).

CT-derived body composition associated with lung cancer recurrence after surgery

ObjectivesTo evaluate the impact of body composition derived from computed tomography (CT) scans on postoperative lung cancer recurrence. MethodsWe created a retrospective cohort of 363 lung cancer patients who underwent lung resections and had verified recurrence, death, or at least 5-year follow-up without either event. Five key body tissues and ten tumor features were automatically segmented and quantified based on preoperative whole-body CT scans (acquired as part of a PET-CT scan) and chest CT scans, respectively. Time-to-event analysis accounting for the competing event of death was performed to analyze the impact of body composition, tumor features, clinical information, and pathological features on lung cancer recurrence after surgery. The hazard ratio (HR) of normalized factors was used to assess individual significance univariately and in the combined models. The 5-fold cross-validated time-dependent receiver operating characteristics analysis, with an emphasis on the area under the 3-year ROC curve (AUC), was used to characterize the ability to predict lung cancer recurrence. ResultsBody tissues that showed a standalone potential to predict lung cancer recurrence include visceral adipose tissue (VAT) volume (HR = 0.88, p = 0.047), subcutaneous adipose tissue (SAT) density (HR = 1.14, p = 0.034), inter-muscle adipose tissue (IMAT) volume (HR = 0.83, p = 0.002), muscle density (HR = 1.27, p < 0.001), and total fat volume (HR = 0.89, p = 0.050). The CT-derived muscular and tumor features significantly contributed to a model including clinicopathological factors, resulting in an AUC of 0.78 (95% CI: 0.75–0.83) to predict recurrence at 3 years. ConclusionsBody composition features (e.g., muscle density, or muscle and inter-muscle adipose tissue volumes) can improve the prediction of recurrence when combined with clinicopathological factors.

HPB P39 Do indeterminate pulmonary nodules in patients undergoing resection for pancreas cancer influence pulmonary metastasis and survival outcomes?

Abstract Background The significance of indeterminate pulmonary nodules (IPNs) on preoperative imaging in the surgical resection of pancreatic cancers remains a clinical dilemma. IPNs are defined as ≥ 1 well-defined, non-calcified lung nodules that are ≤ 1cm in diameter. We report the prevalence and impact of IPNs in surgically managed pancreatic cancer patients from our centre. Methods We studied patients who had attempted/successful surgical resection of pancreatic cancers between 2014 and 2020. The summary statistics are presented as frequencies and percentages, while Fisher's exact test was used to calculate p value for the compared variables including the presence of IPNs, pulmonary metastasis and death. P value of &amp;lt;0.05 was considered statistically significant. Results Our study included 262 patients – 204 (77.9%) had surgical resections including pancreaticoduodenectomy (with or without portal venous resection) or total or distal pancreatectomy, while 58 (22.1%) had trial dissection, bypass and/or laparoscopy. All patients had a preoperative chest computed tomography (CT) scan. 25/262 (9.5%) had IPN on preoperative CT scans. 15/25 (60%) had solitary IPN, 2/25 (8%) had two IPNs, 3/25 (12%) had three IPNs, 1/25 (4%) had 6 IPNs and 4/25 (16%) reported multiple/plural IPNs. In patients with more than 1 IPN, only one patient had unilateral pulmonary nodules. 23/262 (8.8%) developed pulmonary metastasis. Of these, none had IPN preoperatively. There was no statistically significant association between IPN and pulmonary metastasis (p = 0.1428). Neoadjuvant chemotherapy was given to 13/262 patients. None of these patients had IPN pre-operatively, but 4 of them had recurrent/metastatic disease (3 Liver &amp; 2 Pulmonary). IPN was found in 3 patients on post-operative imaging, all three developed metastatic disease after pancreaticoduodenectomies. As at 31st of October 2021, 177/262 patients had died. There was a statistically significant association between pulmonary metastasis and mortality (p = 0.0379). On the other hand, an association between IPN and mortality showed no statistical significance (p = 1.0). Conclusions Our study suggests that IPN is not linked to pulmonary metastasis in pancreatic cancer patients that were offered surgical resection. The presence of IPN did not impact mortality. Therefore, we conclude that IPN should not be used as a determining factor for surgical management of pancreatic cancers.

Contemporary Role of Computed Tomography in Managing Pediatric Primary Spontaneous Pneumothorax.

The value of chest computed tomography (CT) in pediatric primary spontaneous pneumothorax (PSP) remains controversial. This study sought to evaluate the utility of CT scans in a contemporary cohort of children with PSP. An institutional review board approval was obtained for a retrospective review of all children (aged ≤18y) who underwent video-assisted thoracoscopic surgery (VATS) for PSP between 2009 and 2019 at a university-affiliated pediatric hospital. Preoperative CT scans were evaluated for diagnostic accuracy of the CT of bleb disease. Thirty nine patients underwent VATS procedures for PSP, 34 (87%) of the patients were noted to have blebs. Twenty eight (72%) patients received preoperative CT scans with a 5.5:1 male to female ratio. On CT, 17 (61%) were diagnosed with blebs and all had blebs intraoperatively. CT did not identify disease in 11 patients, but seven had blebs intraoperatively. The positive and negative predictive values of preoperative CT for detecting ipsilateral bleb disease were 100% and 36%, respectively, with a sensitivity of 71%. Eleven patients had a contralateral disease on CT (39%). Five received elective contralateral VATS and three developed spontaneous PSP, with intraoperative blebs in all eight patients. Three never developed contralateral PSP. Six (21%) patients with no contralateral disease on CT developed spontaneous PSP with intraoperative blebs. The decision to operate for PSP should be made based on clinical findings rather than on the presence or absence of blebs identified by CT.

Augmented reality navigation-guided pulmonary nodule localization in a canine model.

BackgroundThe current intraoperative pulmonary nodule localization techniques require specific medical equipment or skillful operators, which limits their widespread application. Here, we present an innovative nodule localization technique in a canine lung model using augmented reality (AR) navigation.MethodsPeripheral pulmonary lesions were artificially created in canine model. A preoperative chest computed tomography scan was performed for each animal. The acquired computed tomography images were analyzed, and an established intraoperative localization plan was uploaded into HoloLens (a head-mounted AR device). Under general anesthesia, lung localization markers were implanted in each canine, guided by the established procedure plan displayed by HoloLens. All artificial lesions and markers were removed by video-assisted wedge resection or lobectomy in a single operation.ResultsSince June 2019, 12 peripheral pulmonary lesions were artificially created in 4 canine models. All lung localization markers were precisely implanted with a median registration and implantation time of 6 minutes (range, 2–15 minutes). The average distance between pulmonary lesions and markers was 1.9±1.7 mm, based on computed tomography examination after localization. No severe pneumothorax was observed after marker implantation. After an average implantation period of 16.5 days, no marker displacement was observed.ConclusionsThe AR navigation-guided pulmonary nodule localization technique was safe and effective in a canine model. The validity and feasibility of using this technology in patients will be examined further (NCT04211051).

Predictive value of chest computed tomography for axillary lymph node metastasis in patients with breast cancer: A retrospective cohort study

Purpose: This study aimed to evaluate the predictive value of preoperative chest computed tomography (CT) for axillary lymph node (ALN) metastasis in patients with breast cancer.Methods: CT features of ALNs were retrospectively reviewed in 212 patients with breast cancer who underwent preoperative chest CT examination and ALN dissection. Primary tumor size and CT characteristics of ALNs (cortical thickness, cortical shape, the presence or absence of contrast enhancement of ALNs, and the presence or absence of perinodal infiltration) were recorded and analyzed. A nomogram was developed to visualize the associations between the predictors and each ALN status endpoint.Results: Of 212 patients, 95 (44.8%) had ALN metastasis. Primary tumor size and CT characteristics of ALNs were identified as predictors of ALN metastasis. The nomogram comprising primary tumor size and cortical shape was a good validation model for predicting ALN metastasis. The sensitivity, specificity, and accuracy of the nomogram for predicting ALN metastasis were 88.4%, 79.5%, and 83.5%, respectively.Conclusion: Using preoperative chest CT scans, a nomogram combining the cortical shape of ALNs with the primary tumor size showed good performance in predicting ALN metastasis.

Deep Learning for the Detection of Breast Cancers on Chest Computed Tomography

BackgroundIncidental breast cancers can be detected on chest computed tomography (CT) scans. With the use of deep learning, the sensitivity of incidental breast cancer detection on chest CT would improve. This study aimed to evaluate the performance of a deep learning algorithm to detect breast cancers on chest CT and to validate the results in the internal and external datasets. Patients and MethodsThis retrospective study collected 1170 preoperative chest CT scans after the diagnosis of breast cancer for algorithm development (n = 1070), internal test (n = 100), and external test (n = 100). A deep learning algorithm based on RetinaNet was developed and tested to detect breast cancer on chest CT. ResultsIn the internal test set, the algorithm detected 96.5% of breast cancers with 13.5 false positives per case (FPs/case). In the external test set, the algorithm detected 96.1% of breast cancers with 15.6 FPs/case. When the candidate probability of 0.3 was used as the cutoff value, the sensitivities were 92.0% with 7.36 FPs/case for the internal test set and 93.0% with 8.85 FPs/case for the external test set. When the candidate probability of 0.4 was used as the cutoff value, the sensitivities were 88.5% with 5.24 FPs/case in the internal test set and 90.7% with 6.3 FPs/case in the external test set. ConclusionThe deep learning algorithm could sensitively detect breast cancer on chest CT in both the internal and external test sets.

Outcome of asymptomatic patients with positive SARS-CoV-2 viral RNA reverse transcriptase-PCR undergoing surgery: A matched cohort study.

Outcome of asymptomatic patients with positive SARS-CoV-2 viral RNA reverse transcriptase-PCR undergoing surgery: A matched cohort study.

Living Donor Hepatectomy After Proven SARS-CoV-2 Infection: First Report of 9 Cases From 3 Centers

We read the report by Kute et al1 published in Transplantation regarding the safety of live kidney donation in 31 individuals with previous severe acute respiratory syndrome coronovirus-2 (SARS-CoV-2) infection. Liver transplantation (LT) has been severely restricted during the coronavirus disease 2019 (COVID-19) pandemic due to concerns of perioperative SARS-CoV-2 infection in donors and recipients.2,3 Unlike kidney transplantation that can be postponed for an extended duration, there is an element of urgency for patients awaiting LT. While there is general consensus that individuals with symptomatic SARS-CoV-2 infections should not proceed with living donor hepatectomy (LDH), there are no clear recommendations regarding the safety of LDH in individuals with recent asymptomatic infection. We had several instances of asymptomatic donors testing positive on preoperative screening. We set up a protocol of reassessing these donors for LDH if they satisfied the following 4 criteria: asymptomatic infection without abnormal inflammatory markers or liver function tests, have completed 2-wk isolation period, 2 negative real-time polymerase chain reaction (RT-PCR) tests 48 h apart—the second within 48 h of LDLT, and normal preoperative chest computed tomography scan. SARS-nCoV2 antibody levels were not routinely measured. Donors and recipients were managed in a COVID-19 free unit. All donors received perioperative deep venous thrombosis prophylaxis. Postdischarge follow-up visits were minimized and donors were followed by e-consultation with home blood sample collection.4 This is a retrospective report of living donors who tested positive for SARS-nCoV2 infection on routine RT-PCR screening. All clinical procedures were performed in accordance with the principles of the Istanbul Declaration. The study was exempt from ethics board approval as it was a retrospective review of deidentified data. Between July and December 2020, 9 potential living donors tested positive for SARS-nCoV2 infection on routine RT-PCR screening at 3 LT centers in India. There were 3 male and 6 female donors donating to 5 adult and 4 pediatric recipients (Table 1). Six tested positive during donor evaluation, while 3 tested positive during preoperative testing. None had computed tomography chest findings suggestive of SAR-nCoV2 infection. Two potential recipients also had positive testing with no symptoms. LT was postponed in all cases and donors and recipients were managed with strict home isolation for 2 wk. Repeat testing was performed after 2 wk, and donors proceeded with LDH once previously mentioned criteria were satisfied. TABLE 1. - Details of 9 donors who underwent LDH after asymptomatic SARS-CoV-2 infection Center number Donor age/sex Recipient age/sex Cause/MELD (PELD) Donor-patient relationship Graft type Time interval between first positive test and LDH (d) Total RT-PCR tests performed Peak postop serum bilirubin (mg%) Perioperative morbidity Hospital stay (d) Current status of donor Follow-up duration (mo) 1.1 24/M 41/M ALD/12 Uncle LL 92 4 2.1 Nil 7 Good 2.5 1.2 34/F 9/F Wilson’s/11 Mother LL 72 3 1.9 Ileus, NG 5 Good 1 1.3 35/F 47/M ALD/31 Spouse RL 64 3 3.4 Nil 6 Good 2 1.4 29/F 2/F EHBA/18 Mother LLS 53 3 1.6 Nil 6 Good 1 2.1 43/F 48/M ALD/24 Spouse RL 27 5 1.8 Pleural effusion 7 Good 4 2.2 33/F 8/F Wilson’s ACLF/28 Mother LL 15 3 1.3 Nil 7 Good 1 3.1 32/M 12/F BCS with HCC/20 Cousin RL 49 3 3.3 Nil 7 Good 1.5 3.2 30/F 35/M Cryptogenic CLD/22 Spouse RL 22 6 1.7 Nil 8 Good 1 3.3 46/M 3/M Abernathy syndrome Father LLS 87 4 1.0 Nil 7 Good 1 ACLF, acute on chronic liver failure; ALD, alcoholic liver disease; BCS, Budd-Chiari syndrome; CLD, chronic liver disease; EHBA, extrahepatic biliary atresia; F, female, HCC, hepatocellular carcinoma; LDH, living donor hepatectomy; LL, left lobe; LLS, left lateral segment graft; M, male; MELD, Model for End-stage Liver Disease; NG, nasogastric tube; PELD, pediatric end-stage liver disease; RL, right lobe; RT-PCR, real-time polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronovirus-2. Median interval between the first positive RT-PCR and LDH was 53 d. Three donors had positive RT-PCR tests even 3 wk after the initial positive test necessitating further delays in surgery until 2 consecutive negative tests were obtained. There were no major complications in any of the donors. One recipient needed reoperation for sepsis and developed early allograft dysfunction leading to prolonged hospital stay. All donors and recipients were discharged in stable condition. There were no COVID-19-related complications among the donors or recipients during the perioperative and follow-up period. Our report provides initial evidence for the safety of LDH after previous asymptomatic SARS-nCOV2 infection. Clarity is needed regarding the significance of repeat positive tests beyond 3 wk, role of antibody testing, and the benefit of preoperative vaccination for potential donors with previous asymptomatic SARS-nCOV2 infection.

Biomarker Potential of Preoperative Tumor Size in Determination of the Lymphovascular Invasion in Squamous Cell Lung Cancer and Lung Adenocarcinoma.

Introduction:The invasion of blood and lymph vessels with tumor tissue represents a negative prognostic factor of the disease course in patients with non-small cell lung cancer.Aim:The aim of the study was to determine the marker value of a preoperatively determined size of pulmonary squamous cell carcinoma and adenocarcinoma and its impact on lymphovascular invasion (LVI) in resected lung tissue.Materials and Methods:The conducted observational cross-sectional study included 322 patients with a complete resection of confirmed squamous cell lung carcinoma and lung adenocarcinoma. Preoperative size and type of tumor were determined by a preoperative chest computed tomography scan and cytological/histological analysis of obtained samples, while LVI status was determined by pathohistological analysis of resected tumor lung tissue. Receiver operating characteristic (ROC) curve analysis was performed to assess whether tumor size could serve as a reliable marker for LVI. P < 0.05 was considered statically significant.Results:A statistically significant difference in the frequency of tumor size (P = 0.580) along with LVI (P = 0.656) was not established between the patients with squamous cell lung cancer and lung adenocarcinoma. A ratio between the size of lung adenocarcinoma and LVI status (P < 0.001) was determined as statistically significant, while such a difference was not established in squamous cell lung cancer (P = 0.052). The ROC analysis revealed that tumor size >39 mm in patients with lung adenocarcinoma has obtained a sensitivity of 70.8% and a specificity of 60.9% to differentiate patients with a LVI (areas under the curve [AUC] = 0.70; 95% CI 0.60‒0.79; P < 0.001). A tumor size >4.6 cm in patients with squamous cell lung cancer obtained a sensitivity of 56.5% and a specificity of 60.3% to differentiate patients with a LVI (AUC = 0.59; 95% CI 0.50‒0.67; P = 0.043).Conclusion:The preoperative size of lung adenocarcinoma could be an acceptable marker of LVI presence in resected lung tissue, while in the squamous cell lung cancer, a potential biomarker role of the preoperative size of the tumor was inadequate.

Uniportal Thoracoscopic Decortication for Stage III Tuberculous Empyema With Severe Rib Crowding

This study explored the safety and feasibility of uniportal video-assisted thoracoscopic (VATS) decortication in patients presenting with stage III tuberculous empyema with severe rib crowding. From August 2017 to January /2019, 33 patients with stage III tuberculous empyema and severe rib crowding underwent uniportal VATS decortication with partial rib resection and the use of a customized periosteal stripper. Preoperative and postoperative chest computed tomography (CT) imaging and pulmonary function testing were analyzed to evaluate the clinical significance of certain imaging findings and surgical efficacy. There was 1 conversion to open thoracotomy. Median operative time was 3.5 hours (range, 2.1-4.5 hours) and the median blood loss was 500 mL (range, 250-1000 mL). There were no perioperative mortalities. The incidence of prolonged air leaks (>5 days) was 81.8%. Median postoperative hospital stay was 4 days (range, 4-5 days). All patients were discharged with 2 chest tubes, and median duration drainage was 39 days (range, 30-60 days). The presence of a low-density line between the parietal fibrous pleural rind and chest wall was demonstrated on chest CT in 13 patients. Intraoperative blood loss was considerably lower in these patients compared with those without this imaging finding. Follow-up was complete in all patients over a median of 8 months (range, 6-11.5 months). All patients recovered well and achieved notable improvement in pulmonary function. Uniportal VATS decortication is safe and effective. Patients presenting with a low-density line around the thickened fibrous pleural rind on preoperative chest CT scan may be good candidates.

Centrilobular nodules in a smoker: Respiratory bronchiolitis or something else?

A 63-year-old male was referred for right upper lobectomy for squamous cell lung cancer. Pre-operative chest computed tomography scan described the biopsy proven subpleural squamous cell carcinoma as well as bilateral diffuse centrilobular micronodules favored to represent respiratory bronchiolitis in the context of significant past smoking history. On histological examination of the resection specimen, these multifocal nodules corresponded to macules of macrophages filled with iron rich pigment and silicate particles, consistent with a histologic diagnosis of siderosilicosis. Upon further questioning, the patient’s occupation of welding was confirmed by his primary care physician. We herein point out key features of this entity.

Sarcopenia as a prognostic factor for outcomes after isolated tricuspid valve surgery

BackgroundSarcopenia, characterized by decreased skeletal muscle mass, is a comprehensive and objective marker of frailty and is associated with poor postoperative outcomes in adult surgery patients. We aimed to evaluate the prognostic implications of preoperative sarcopenia assessed by chest computed tomography in patients undergoing isolated tricuspid valve surgery. MethodsThis observational study retrospectively reviewed records of 144 consecutive adult patients who underwent isolated tricuspid valve surgery between January 2010 and December 2016. Preoperative chest computed tomography scans were used to measure the area of the erector spinae muscle and pectoralis muscle which was then indexed to height in meters squared. The total skeletal muscle index was defined as the sum of the right and left cross-sectional areas of the erector spinae muscle index and the pectoralis muscle index. Sarcopenia was defined as any total skeletal muscle index below the 50th sex-specific percentile. Multivariable Cox proportional hazard models were used to identify the independent association between preoperative sarcopenia and major 30-day postoperative complications. ResultsA total of 53 (36.8%) patients suffered from complications. Major 30-day postoperative complications occurred more frequently in patients with sarcopenia than in those without sarcopenia [46.6% (34/73) vs. 26.8% (19/71), p = 0.022]. With multivariable analyses, sarcopenia was independently associated with incidence of major 30-day postoperative complications (hazard ratio 2.24, 95% confidence interval 1.27–3.94, p = 0.005). ConclusionsOur study demonstrates a significant association between preoperative total skeletal muscle index and major 30-day postoperative complications in patients undergoing isolated tricuspid valve surgery.

Applications of rib sparing technique in internal mammary vessels exposure of abdominal free flap breast reconstructions: a 12-year single-center experience of 215 cases.

Internal mammary vessels (IMVs) are widely used recipient vessels in abdominal free flap breast reconstructions. Rib sparing technique is an alternative method with less damage in IMVs exposure. This study aims to investigate the factors influencing the selection of IMVs, as well as analyze the applicability and related factors of rib sparing technique in abdominal breast reconstruction. Medical records of 215 patients who underwent abdominal free flap reconstruction from November 2006 to December 2017 in Fudan University Shanghai Cancer Center (FUSCC) were analyzed. Intercostal space (ICS) was measured from preoperative chest computed tomography scan. Factors influencing the choice of recipient vessels and rib sparing were analyzed. Surgery time, hospitalization and complications were assessed. Among all 218 flaps, 172 flaps used IMVs as the recipient vessels while 46 used other vessels. patients with immediate reconstruction (P=0.005) and axillary lymph nodes dissection (ALND) (P<0.001) were less likely to use IMVs. Patients' body mass index (BMI) and radiotherapy history showed no statistically significant differences between the two groups (P=0.338 and 0.811). In IMVs group, 62% cases used rib sparing technique. Compared with rib resection group, patients with rib sparing were taller (P=0.047) and with a wider ICS (2.65±0.54 vs. 2.25±0.38 cm, P<0.001). Rib sparing group had a shorter surgery and postoperative hospitalization time, as well as a lower complication rate, but the differences were not statistically significant (P=0.120, 0.450 and 0.612). IMVs were used more frequently as the recipient vessels in abdominal free flap breast reconstructions, especially when axillary operation was not performed at the same time. Rib sparing technique had the potential to decrease surgery time, hospitalization days and complications rate. It could be applied in most of the patients with IMVs exposure, particularly in taller patients and patients with a wider ICS. Preoperative chest computed tomography scan can be used to assess the ICS width to provide operational suggestions.

Simple calculation of the optimal insertion depth of esophageal temperature probes in children.

Placing an esophageal temperature probe (ETP) in the optimal esophageal site is important in various anesthetic and critical care settings to accurately monitor the core temperature of a pediatric patient. However, no reported study has provided a formula to calculate the optimal insertion depth of ETP placement in children based on direct measurement of the optimal depth. The aim of this study was to develop a simple and reliable method to determine the optimal depth of ETP placement in children via their mouth. Using preoperative chest computed tomography scans, intraoperative chest X-rays, and the actual depth of ETP insertion, we measured the optimal depth of ETP placement retrospectively in 181 children aged 3-13years who underwent minimally invasive repairs of the pectus excavatum and removal of a pectus bar. A linear regression analysis was performed to assess the correlation of the optimal depth of ETP placement with the children's age, weight, and height. The optimal depth of ETP placement had a greater correlation with height than with age or weight, and the best-fit equation was '0.180 × height + 6.749 (cm) (R2 = 0.920).' We obtained three simplified formulae, which showed no statistically significant difference in predicting the optimal depth of ETP placement: height/6 + 8 (cm), height/5 + 4 (cm), and height/5 + 5 (cm). The optimal depth of ETP via children's mouths has a close correlation with height and can be calculated with a simple formula 'height/5 + 5 (cm)'.

Centrally located lung cancer and risk ofoccult nodal disease: an objective evaluation of multiple definitions of tumour centrality with dedicated imaging software.

Current guidelines recommend invasive mediastinal staging in patients with centrally located radiographic stage T1N0M0 nonsmall cell lung cancer (NSCLC). The lack of a specific definition of a central tumour has resulted in discrepancies among guidelines and heterogeneity in practice patterns. Our objective was to study specific definitions of tumour centrality and their association with occult nodal disease. Pre-operative chest computed tomography scans from patients with clinical (c) T1N0M0 NSCLC were processed with a dedicated software system that divides the lungs in thirds following vertical and concentric lines. This software accurately assigns tumours to a specific third based both on the location of the centre of the tumour and its most medial aspect, creating eight possible definitions of central tumours. 607 patients were included in our study. Surgery was performed for 596 tumours (98%). The overall pathological (p) N disease was: 504 (83%) N0, 56 (9%) N1, 47 (8%) N2 and no N3. The prevalence of N2 disease remained relatively low regardless of tumour location. Central tumours were associated with upstaging from cN0 to any N (pN1/pN2). Two definitions were associated with upstaging to any N: concentric lines, inner one-third, centre of the tumour (OR 3.91, 95% CI 1.85-8.26; p<0.001) and concentric lines, inner two-thirds, most medial aspect of the tumour (OR 1.91, 95% CI 1.23-2.97; p=0.004). We objectively identified two specific definitions of central tumours. While the rate of occult mediastinal disease was relatively low regardless of tumour location, central tumours were associated with upstaging from cN0 to any N.

Abstract P5-16-08: Applications of rib sparing technique in internal mammary vessels exposure of abdominal free flap breast reconstructions

Abstract Background: Internal mammary vessels (IMVs) are widely used recipient vessels in abdominal free flaps breast reconstructions. Exposure of IMVs usually needs to resect a segment of costal cartilage or rib during the operations. The rib sparing technique is an alternative method with less damage. This study aims to analysis the applicability and advantages of rib sparing technique of IMVs exposure in breast reconstruction. Methods: medical records of 215 patients who underwent abdominal free flap reconstruction from November 2006 to December 2017 were analyzed. The factors influencing the choice of vessels and rib sparing were analyzed. The outcomes of rib sparing were assessed. Intercostal space (ICS) width and other related data were measured by the preoperative thin slice chest computed tomography (CT) scan images. Results: Among all 215 patients with 218 flaps, 172 flaps used IMVs as the recipient vessels while 13 used thoracodorsalvessels and 33 used subscapular vessels. The proportion of IMVs as recipient vessels showed a rising trend in general and remained over 90% for the last three years in our center. Patients with immediate reconstruction (p=0.005) and axillary lymph nodes dissection(ALND) (p&amp;lt;0.001) were less likely to use IMVs, both in univariate and multivariate logistic regression analysis. Patients' BMI and radiotherapy history showed no statistically significant differences between the IMVs group and the other vessels group (p=0.338 and 0.811). The rib sparing rate in IMVs exposure increased yearly and exceeded 40% in 2013, now it maintained more than 60% during the recent 3 years. Additionally, among the patients who received rib sparing IMVs exposure in 2017, the mean ICS width was relatively smaller than that in 2013 (2.54cm V.S 2.93cm, p=0.124). Compared with rib resection group, patients with rib sparing were higher (163.57 ± 4.44 cm vs. 161.83 ± 4.30 cm, p=0.047) and with a wider ICS (2.65 ± 0.54 cm vs. 2.25± 0.38 cm, p&amp;lt;0.01), while the depth from the surface of the pectoralis major muscle to the IMVs and distance between the parasternal line and IMVs had no difference between the two groups. Rib sparing group has a shorter surgery and hospitalization time, as well as a lower severe complication rate, but the differences were not statistically significant (p= 0.120, 0.450 and 0.296). Conclusion: IMVs were used more frequently as the recipient vessels in abdominal free flap breast reconstructions, especially when axillary operation was not carried out at the same time. Rib sparing technique had the potential to decrease surgery time and hospitalization days, as well as the severe complications rate. It could be used in most of patients received free flap reconstruction when IMVs were used, particularly in higher patients and patients with a wider ICS. Preoperative slice chest CT scan can be used to measure the ICS width to provide suggestions for dealing with the ribs. Citation Format: Zhang Q, Xiao Q, Guo R, Wu J, Gu Y, Xiu B. Applications of rib sparing technique in internal mammary vessels exposure of abdominal free flap breast reconstructions [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-16-08.