Even after transplantation of favourable donor lungs, some recipients require prolonged weaning from mechanical ventilation, indicating a poor prognosis. We investigated the effects of prolonged mechanical ventilation (PMV) for >14 days on the recovery and survival of patients who underwent cadaveric lung transplantation in relation to their physical traits.We retrospectively reviewed patients who underwent cadaveric lung transplantation (age ≥15 years) at a single centre between April 2015 and December 2020 and classified them into PMV and non-PMV groups (>14 and ≤14 days of mechanical ventilation postoperatively, respectively). The factors predicting PMV comprised clinical factors (e.g. marginal donor) and physical features, namely flat chest, narrow fourth intercostal space (length, <5 mm), mediastinal shift, thoracic mediastinal-occupying ratio (TMOR) >40% and sarcopenia, according to the logistic regression analysis. The log-rank test was used to examine the association between TMOR >40% and 3-year prognosis.The PMV group comprised 17 (33%) of 51 recipients. Multivariable logistic analysis showed that the TMOR >40% (odds ratio, 7.3; 95% confidence interval, 1.3-40.1; P = 0.023) was an independent preoperative predictive factor for PMV postoperatively. Stepwise analysis revealed intraoperative extracorporeal membrane oxygenation and reoperation as postoperative predictive factors in addition to TMOR >40%. Recipients with TMOR >40% had significantly worse 3-year survival than other recipients (71.2% vs 100.0%, respectively; P = 0.008).Recipients with a TMOR >40% may be long-term ventilator dependent and have a poor prognosis.
Abstract Background Persistent subsolid nodules requiring follow-up are often detected during lung cancer screening; however, changes in their invasiveness can be overlooked owing to slow growth. The purpose of this exploratory study was to develop a method to automatically identify invasive tumors during multiple health check-ups. Methods We retrospectively reviewed patients who underwent screening using low-dose computed tomography (CT) between 2014 and 2019. Patients with lung adenocarcinomas manifesting as subsolid nodules resected after 5 years of follow-up were enrolled. The resected tumors were categorized into invasive or less-invasive groups. The annual growth or change rate (Δ) of the nodule voxel histogram on three-dimensional CT (e.g., tumor volume [cm 3 ], solid volume percentage [%], mean CT value [HU], variance, kurtosis, skewness, and entropy) was assessed using radiomics. Multivariate regression modeling was employed to design a discriminant model. Results Forty-seven tumors (282 detectable lesions over 5 years) were included (23 and 24 in the invasive and less-invasive groups, respectively). The median tumor volumes at the initial screening were 130 and 106 mm 3 in the less-invasive and invasive groups, respectively; the difference was not significant ( P = 0.489). In the multivariate regression analysis to identify the invasive group, Δskewness was an independent predictor (adjusted odds ratio, 0.021; P = 0.043). When combined with Δvariance (odds ratio, 1.630; P = 0.037), the assessment method had high accuracy for detecting invasive lesions (true-positive rate, 88%; false-positive rate, 80%). Conclusions During check-ups, close investigation by surgery for subsolid nodules can be suggested with the application of radiomics, particularly focusing on skewness. Trial registration: Not applicable.
When performing living-donor lobar lung transplantation on small children of height 100 cm or under, accommodation of an oversized adult lobar graft is problematic, sometimes necessitating single lobar transplantation in combination with contralateral pneumonectomy. We here report a unique case of living-donor lobar lung transplantation in a 9-year-old boy with congenital pulmonary hypoplasia. Although he was 104 cm tall, and the available adult lower lobe graft appeared to be oversized, his right lung was hypoplastic, resulting in his mediastinum being shifted to the right and thus already showing "postpneumonectomy-like" anatomy. His father's left lower lobe was successfully transplanted into the left thorax without performing a contralateral pneumonectomy. Three-dimensional reconstruction of computed tomography images and computed tomography volumetry were extremely helpful in matching the size of the graft and planning this unique surgery.
To investigate the accuracy of a segment-counting method in predicting lung function and volume after stapler-based thoracoscopic segmentectomy in comparison with lobectomy.Between 2014 and 2018, patients who underwent these procedures were retrospectively reviewed. Thoracic computed tomography and spirometry data before and 1 year after the surgery were assessed. We evaluated the differences between the predicted values using a segment-counting method and the actual postoperative values for lung function and volume in each group. Sub-analyses were also performed to assess the impact of the number of staples and resected segments in predicting patient outcomes.We included 116 patients (segmentectomy, 69; lobectomy, 47). Actual postoperative lung function and volume values matched the predicted values in the stapler-based segmentectomy group, and significantly exceeded the predictions in the lobectomy group (P <0.01). Sub-analyses revealed lower postoperative lung function values than predicted existed after single segmentectomy, with an odds ratio of 3.29 (95% confidence interval: 1.02-10.70, P = 0.04) in a multivariable analysis. The degree of predicted error regarding lung function was negligible.The segment-counting method was useful in predicting lung function after stapler-based thoracoscopic segmentectomy. Segmentectomy rarely yielded lower-than-predicted lung function and volume values.
Among anterior mediastinal tumors, a teratoma is known to rupture with growth, but there have been few previous reports about thymoma rupture. We here report a rare case of an invasive thymoma with intrapulmonary and intrathoracic rupture requiring emergency life-saving surgery. To our knowledge, this is the first such case in the literature.A 56-year-old woman suddenly experienced right precordial pain and hemoptysis. Enhanced computed tomography revealed a large mediastinal tumor pressing against the pulmonary hilar vascularity, with extravasation of blood into the right lung. Tumor rupture into the lungs was suspected. Given the deterioration of her respiratory status and hemodynamics, thymomectomy with removal of the involved tissues was urgently performed using the hemi-clamshell approach and intrapericardial dissection, with veno-arterial extracorporeal membrane oxygenation on standby. She survived, and no recurrence has been noted for 2 years postoperatively.A large thymoma can suddenly rupture into the thorax, similar to the rupture of a teratoma. Additionally, in cases with hemoptysis, an appropriate procedure should be selected to reach both the pulmonary hilum and thorax for complete resection, as hemoptysis might suggest tumor invasion into the lungs.
Chronic lung allograft dysfunction (CLAD) following lung transplantation limits long-term survival considerably. The main reason for this is a lack of knowledge regarding the pathological condition and the establishment of treatment. The consensus statement from the International Society for Heart and Lung Transplantation on CLAD in 2019 classified CLAD into two main phenotypes: Bronchiolitis obliterans syndrome and restrictive allograft syndrome. Along with this clear classification, further exploration of the mechanisms and the development of appropriate prevention and treatment strategies for each phenotype are desired. In this review, we summarize the new definition of CLAD and update and summarize the existing knowledge on the underlying mechanisms of bronchiolitis obliterans syndrome and restrictive allograft syndrome, which have been elucidated from clinicopathological observations and animal experiments worldwide.
