Objectives: Empyema is a common disease associated with high morbidity and mortality. Conventional culture methods show negative results in up to 70%. Broad-range bacterial PCR with amplification of part of 16S ribosomal RNA gene is able to detect all bacterial species in single assay. Therefore we investigated the value of this method for pathogen detection and introduction of targeted antibiotic therapy. Methods: From 01/2013-12/2014 N=50 patients, mean age of 60 (SD: ±15) years; who underwent surgery for thoracic empyema, were included in this prospective study. Cultures of pleural fluid and biopsies were compared with broad-range 16S-PCR, S. pneumoniae PCR and S. pneumoniae antigen test. Results: N=37 video-assisted thoracoscopic surgeries and N=13 open lung decortications were performed. From 37 VATS, N=19 were converted to thoracotomy. Identical PCR results were found in pleural fluid and corresponding biopsies in 95%. PCR detected twice as many pathogens compared to culture. The antibiotic therapy was changed in 65% of patients with positive PCR results. Organisms identified by PCR were predominantly F. nucleatum (N=9), S. pneumoniae (N=8). Conclusions: Broad-range PCR increases significantly the pathogen detection and facilitate implementation of targeted antibiotic therapy. We believe that early diagnosis of pleural empyema using this technique will reduce the number of patients requires open surgery.
In the absence of standardized treatment algorithms for patients with malignant pleural mesothelioma, one of the main difficulties remains patient allocation to therapies with potential benefit. This article discusses clinical, radiologic, pathologic, and molecular prognostic factors as well as genetic background leading to preoperative identification of benefit from surgery, which have been investigated over the past years to simplify and at the same time specify patient selection for surgical treatment.
Abstract OBJECTIVES Recent trials have begun to explore immune checkpoint inhibitors for non-small cell lung cancer in the neoadjuvant setting, but data on tumour response and surgical outcome remain limited. METHODS Retrospective evaluation of clinical data from patients with non-small cell lung cancer treated with immune checkpoint inhibitors followed by lung resection was performed at 2 large volume institutions (1 North American, 1 European). Data were analysed using Chi-squared, Fisher’s and Wilcoxon rank-sum tests where appropriate. RESULTS Thirty-seven patients were identified from 2017 to 2019. Forty-nine per cent were Stage IIIB and IV. Forty-six per cent received immunotherapy alone and 54% in combination with chemo- and/or radiotherapy. Sixteen per cent of cases were successfully performed minimally invasively. Twenty patients were operated with lobectomy (6 of these with wedges or segments of a neighbouring lobe, 2 with sleeve resections and 1 with a chest wall resection), 4 with bilobectomies, 11 with pneumonectomy (including 5 extrapleural pneumonectomies and 1 atrial resection) and 1 with a wedge resection. Overall, 10 patients (27%) developed postoperative complications and the 90-day mortality was zero. One-year recurrence-free survival was 73% for stage II/IIIA and 55% for stage IIIB/stage IV. The major pathologic response rate was 34%. CONCLUSION In this retrospective study, lung resection after immunotherapy (alone or in combination) is safe, although often requires complex surgery. Due to increasing number of clinical trials adopting immunotherapy in the neoadjuvant setting, it is likely that this therapy will become part of standard of care. Immunotherapy may also allow surgery to have a role for selected patients with advanced disease.
To test the safety and efficacy of combination treatment for pleural mesothelioma (PM) with intracavitary cisplatin-fibrin (cis-fib) plus hemithoracic irradiation (IR) applied after lung-sparing surgery in an orthotopic immunocompetent rat model. We randomized male F344 rats into 5 groups: cis-fib (n = 9), 10 Gy IR (n = 6), 20 Gy IR (n = 9), cis-fib+10 Gy IR (n = 6), and cis-fib+20 Gy IR (n = 9). Subpleural tumor implantation was performed on day 0 with 1 million syngeneic rat mesothelioma cells (IL45-luciferase). Tumors were resected on day 9, followed by treatment with intracavitary cis-fib or vehicle control (NaCl-fib). On day 12, computed tomography-guided local irradiation in a single high dose of the former tumor region was applied. We observed only short-term side effects related to 20 Gy radiotherapy. Compared to 20 Gy, 10 Gy IR did not show an impact on tumor growth. At 3 days after treatment with 20 Gy IR (day 15 of the experiment), we detected significantly smaller tumors in the cis-fib+IR group compared to IR alone (mean tumor growth, 252% vs 539%; Localized treatment after tumor resection in PM aims to improve local tumor control. Irradiation applied in combination with intracavitary cis-fib in rats is safe up to a dosage of 20 Gy and shows an additive effect on tumor growth delay compared to the single treatments.
The coronavirus disease 2019 (COVID-19) pandemic has had a severe impact on oncological and thoracic surgical practice worldwide. In many hospitals, the care of COVID-19 patients required a reduction of elective surgery, to avoid viral transmission within the hospital, and to save and preserve personnel and material resources. Cancer patients are more susceptible to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection and are at an increased risk of a severe course of disease. In many patients with lung cancer, this risk is further increased owing to comorbidities, older age and a pre-existing lung disease. Surgical resection is an important part of the treatment in patients with early stage or locally advanced non-small cell lung cancer, but the treatment of these patients during the COVID-19 pandemic becomes a challenging balance between the risk of patient exposure to SARS-CoV-2 and the need to provide timely and adequate cancer treatment despite limited hospital capacities. This manuscript aims to provide an overview of the surgical treatment of lung cancer patients during the COVID-19 pandemic including the triage and prioritisation as well as the surgical approach, and our own experience with cancer surgery during the first pandemic wave. We furthermore aim to highlight the risk and potential consequences of delayed lung cancer treatment due to the deferral of surgery, screening appointments and follow-up visits. With much attention being diverted to COVID-19, it is important to retain awareness of cancer patients, maintain oncological surgery and avoid treatment delay during the pandemic.
Purpose: In patients with chronic thromboembolic pulmonary hypertension (CTEPH), partial pressure of carbon dioxide(PCO2) at rest and exercise correlated with severity of CTEPH and reflect the abnormality of ventilatory efficiency by increase in physiologic alveolar dead space (AVDSf). Aim was to determine the value of delta in PCO2 and AVDSf as prognostic marker after pulmonary endarterectomy (PEA). Methods: Between 2013 and 2020, 51 patients undergoing PEA with 2-year follow-up time were retrospectively analyzed including cardiopulmonary exercise testing and hemodynamic measurements before and 1 year after PEA. Results: PCO2 before PEA measured during induction are lower vs at the end of PEA (4.47 vs 5.66, p=0.000) and at postoperative day 1 (POD1) (4.47 vs 4.82;p=0.000). Delta PCO2 (1.183) and delta pCO2 between the end of surgery and POD 1 (0.354) correlates with postoperative NYHA and mPAP-decrease at 1-year (p=0.19;p=0.00;p=0.000;p=0,000, respectively). PEA resulted in increase of Vo2max (17.68 vs 13.47;p=0.000), oxygen uptake at aerobic threshold (12.92 vs 10.03;p=0.001), mPAP-decrease at 1-year (26.37vs 40.22;p=0.000), PVR (3.193 vs 6.13;p=0.000) and improvement of NYHA (p=0.000). AVDSf before PEA at induction (0.055) vs end of surgery (0.336) and at POD1 (mean 0.152, SD 0.15) correlated NYHA improvement and mPAP-decrease at 1-year (p=0.000;p=0.000;p=0.000 and p=0.000;p=0,000,p=0.000 respectively). Conclusion: In patients with CTEPH undergoing PEA, markers for AVDSf and ventilation/prefusion mismatch may predict outcome after surgery. If confirmed in a prospective way, these markers can support indicating start of additional treatment such as balloon angioplasty or medication.
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