Yi-Ting Yen

The Role of Video-Assisted Thoracoscopic Surgery in Therapeutic Lung Resection for Pulmonary Tuberculosis

BACKGROUND Video-assisted thoracoscopic surgery (VATS) has been considered an effective diagnostic modality for pulmonary tuberculosis. Its feasibility in therapeutic lung resection, however, has not been validated. METHODS The medical records of patients who underwent VATS or a thoracotomy for therapeutic resection of pulmonary tuberculosis between January 2007 and March 2011 were reviewed for age, sex, indications for surgery, approach and procedures, preoperative sputum culture status, operative time, blood loss, hospital stay, and complications. RESULTS One hundred twenty-three patients were enrolled. Sixty-three were successfully treated using VATS and 60 were converted to thoracotomy. The number of VATS wedge resections was significantly higher (p = 0.004). Patients who underwent VATS had significantly less blood loss, shorter hospital stays, and fewer complications (p = 0.031, 0.000, and 0.022, respectively). Lesions treated with a pneumonectomy or that required thoracoplasty failed to be done using VATS (p = 0.054 and 0.002, respectively). Patients who underwent VATS had slightly more isolated lobectomies and significantly (p = 0.005) shorter hospital stays than did thoracotomy patients. Concomitant and isolated segmentectomies were done using VATS, but there were significantly fewer than for thoracotomy patients (p = 0.033). CONCLUSIONS Video-assisted thoracoscopic surgery is effective for therapeutic wedge resections, isolated lobectomies, and simple segmentectomies and lobectomies combined with wedge resections or segmentectomies for pulmonary tuberculosis. Tuberculosis lesions that require a pneumonectomy or thoracoplasty are still major challenges for VATS.

Image Characteristics as Predictors for Thoracoscopic Anatomic Lung Resection in Patients With Pulmonary Tuberculosis

BACKGROUND A variety of complications occur in patients with pulmonary tuberculosis. The feasibility of a thoracoscopic approach to anatomic lung resection for the complications of mycobacterial infection has not been well evaluated. METHODS We retrospectively analyzed chest computed tomography (CT) scans of patients who underwent anatomic lung resections without additional procedures for tuberculosis between January 2007 and September 2009. Image characteristics on chest CT scans were classified as bullae, pleural thickening, peribronchial lymph node calcification, tuberculoma, cavity, aspergilloma, atelectasis, and bronchiectasis, and graded according to the number of the lesions and degree of lobar involvement. Patients were divided into two groups, video-assisted thoracoscopic surgery (VATS) and thoracotomy for anatomic lung surgery, according to the eventual operative procedure. The variables between these two groups were compared using the Student t test; the image characteristics were compared using a χ2 test. RESULTS Fifty patients were enrolled; 21 given VATS and 29 given a thoracotomy. The VATS group had significantly lower gradings in pleural thickening, peribronchial lymph node calcification, tuberculoma, cavity, and aspergilloma than did the thoracotomy group (p=0.000, 0.015, 0.001, 0.023, and 0.022, respectively). Mean operative time, blood loss, and complication rate were not significantly different, but the mean hospital stay was significantly shorter (10.00 days versus 14.96 days, p=0.048) in the VATS group. CONCLUSIONS Multiple cavities, multiple aspergillomas, multilobar tuberculoma, extensive pleural thickening, and peribronchial lymph node calcification preclude VATS. It is reasonable to attempt a thoracoscopic approach in patients without these preoperative image characteristics.

Thymic Neuroendocrine Carcinoma and Thymoma Are Both Associated With Increased Risk of Extrathymic Malignancy: A 20-Year Review of a Single Institution

BACKGROUND Thymoma has been reported to have increased risk of extrathymic malignancy; thymic carcinoma, however, has not been validated of this association. We retrospectively assessed the incidence of additional malignancy among patients with thymoma and thymic carcinoma, and compared it with that of other solid organ cancers. METHODS We reviewed the medical records between the years of 1988 and 2008 of 213 patients, including 131 with thymoma and 82 with thymic carcinoma. The overall incidence of additional malignancy in patients with thymic epithelial tumors, lung cancer, hepatocellular carcinoma, colorectal cancer, breast cancer, and cervical cancer between 2003 and 2008 in our institution was also computed. RESULTS The incidence of extrathymic malignancy in patients with thymic epithelial tumors was 12.2% (16 of 131) for thymoma and 12.2% (10 of 82) for thymic carcinoma. The overall incidence of additional malignancy between 2003 and 2008 was significantly higher among patients with thymoma than among patients with hepatocellular carcinoma, colorectal cancer, breast cancer, and cervical cancer (p=0.017, 0.022, 0.009, and 0.018, respectively). In thymic carcinoma, the likelihood of developing extrathymic malignancy was significantly higher among patients with neuroendocrine carcinoma than among patients with other thymic carcinomas (p=0.000). Extrathymic neoplasm did not pose a significant influence on the overall survival of patients with thymoma (p=0.085) and thymic carcinoma (p=0.814). CONCLUSIONS Our data demonstrated the increased risk of extrathymic malignancies among patient with thymoma. In thymic carcinoma, this association mainly occurred in patients with neuroendocrine carcinoma. Actions for early detection of extrathymic malignancy should be considered for patients with these thymic epithelial tumors.

Dysregulation of Rab37-Mediated Cross-talk between Cancer Cells and Endothelial Cells via Thrombospondin-1 Promotes Tumor Neovasculature and Metastasis

Purpose: Accumulating evidence indicates that factors secreted by cancer epithelial cells shape the tumor microenvironment to promote cancer invasion and metastasis. Recent studies also shed light on alterations of Rab small GTPase–mediated exocytosis in tumorigenesis. However, the mechanisms for Rab-mediated exocytosis in tumor microenvironment remain elusive. We aimed to investigate the interplay between Rab37-mediated exocytosis and tumor microenvironment, focusing on endothelial cell motility and angiogenesis. Experimental Design: We performed fluorescence IHC for Rab37, thrombospondin-1 (TSP1, an antiangiogenesis factor), and angiogenesis marker CD31 in 183 surgically resected esophageal squamous cell carcinoma (ESCC) patient samples. Cell migration, invasion, angiogenesis, and tumor metastasis were measured. Results: ESCC patients with low expression of Rab37 or TSP1 significantly correlated with high CD31 expression and were associated with worse progression-free survival. The multivariate Cox regression analysis showed that concordant low expression of both Rab37 and TSP1 was an independent prognostic factor of ESCC patients. Rab37-mediated exocytosis of TSP1 led to the inhibition of neovasculature in vitro and in vivo. Secreted TSP1 from cancer cells with Rab37 exocytic function inhibited the p-FAK/p-paxillin/p-ERK migration signaling in both cancer epithelial cells and their surrounding endothelial cells. Dysfunction of Rab37 or loss of TSP1 abrogated the suppressive effects on angiogenesis and metastasis. Conclusions: Our findings suggest that Rab37-mediated TSP1 secretion in cancer cells suppresses metastasis and angiogenesis via a cross-talk with endothelial cells and reveal a novel component of the vesicular exocytic machinery in tumor microenvironment and tumor progression. Dysregulation of Rab37/TSP1 axis has clinical implications for prognosis prediction. Clin Cancer Res; 23(9); 2335–45. ©2016 AACR.

The Role of Video-Assisted Thoracoscopic Therapeutic Resection for Medically Failed Pulmonary Tuberculosis.

AbstractThere are few reports regarding video-assisted thoracoscopic therapeutic resection for medically failed pulmonary tuberculosis (TB). We reviewed our surgical results of video-assisted thoracoscopic surgery (VATS) therapeutic resection for pulmonary TB with medical failure, and its correlation with image characteristics on chest computed tomography (CT) scan.Between January 2007 and December 2012, among the 203 patients who had surgery for TB, the medical records of 89 patients undergoing therapeutic resection for medically failed pulmonary TB were reviewed. Clinical information and the image characteristics of CT scan were investigated and analyzed.Forty-six of the 89 patients undergoing successful VATS therapeutic resection had significantly lower grading in pleural thickening (P < 0.001), peribronchial lymph node calcification (P < 0.001), tuberculoma (P = 0.015), cavity (P = 0.006), and aspergilloma (P = 0.038); they had less operative blood loss (171.0 ± 218.7 vs 542.8 ± 622.8 mL; P < 0.001) and shorter hospital stay (5.2 ± 2.2 vs 15.6 ± 15.6 days; P < 0.001). They also had a lower percentage of anatomic resection (73.9% vs 93.0%; P = 0.016), a higher percentage of sublobar resection (56.5% vs 32.6%; P = 0.023), and a lower disease relapse rate (4.3% vs 23.3%; P = 0.009). Eighteen of the 38 patients with multi-drug resistant pulmonary tuberculosis (MDRTB) who successfully underwent VATS had significantly lower grading in pleural thickening (P = 0.001), peribronchial lymph node calcification (P = 0.019), and cavity (P = 0.017). They were preoperatively medicated for a shorter period of time (221.6 ± 90.8 vs 596.1 ± 432.5 days; P = 0.001), and had more sublobar resection (44.4% vs 10%), less blood loss (165.3 ± 148.3 vs 468.0 ± 439.9 mL; P = 0.009), and shorter hospital stay (5.4 ± 2.6 vs 11.8 ± 6.9 days; P = 0.001).Without multiple cavities, peribronchial lymph node calcification, and extensive pleural thickening, VATS therapeutic resection could be safely performed in selected patients with medically failed pulmonary TB as an effective adjunct with satisfactory results.

Factors Predicting recurrence and postrecurrence survival in completely resected thymic carcinoma

BACKGROUND There are few data on factors predicting recurrence of completely resected thymic carcinoma. This study analyzed prognosticators for recurrence and postrecurrence survival. METHODS Eighty-two patients with surgically treated thymic carcinoma were reviewed between June 1988 and March 2013, and 54 who underwent complete resection were enrolled. Sex, age, myasthenia gravis, tumor histologic classification, Masaoka staging, characteristics of locoregional invasion and recurrence, and the treatment for recurrence were collected. Continuous variables between groups were compared using Students t test, and categorical variables were compared using the χ2 test, Fishers exact test, or Spearman rank correlation. Survival analysis was performed using the Kaplan-Meier and log-rank test. Statistical significance was set at a probability value of less than 0.05. RESULTS A total of 54 patients underwent complete resection for thymic carcinoma, 21 of whom had recurrent diseases and 33 of whom remained disease-free. Patients without recurrent disease had a significantly better 5-year overall survival of 79% than 26% of those who had recurrent disease (p=0.000). Masaoka staging and tumor invasion of the superior vena cava were significantly associated with recurrence-free survival in the univariate analysis (p=0.047 and 0.019, respectively). In the multivariate analysis for survival, tumor invasion into the superior vena cava was the only prognostic variable for recurrence-free survival (p=0.047). Patients who underwent surgical intervention followed by chemotherapy for recurrent diseases had the best progression-free survival after recurrence (p=0.000). CONCLUSIONS Superior vena cava invasion as well as Masaoka staging was significantly associated with recurrence-free survival in patients with completely resected thymic carcinoma. In patients with recurrent disease, surgical resection should be attempted for localized disease because it might provide some benefit for progression-free survival.

From biportal to uniportal video-assisted thoracoscopic anatomical lung resection A single-institute experience

AbstractOur study sought to review our experience from biportal to uniportal video-assisted thoracoscopic surgery (VATS) major lung resection. Lessons we learned from the evolution regarding technical aspects were also discussed.We retrospectively reviewed patients who underwent VATS lobectomy or segmentectomies in Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan, during January 2012 and December 2014. Patient clinical profiles, surgical indications and procedures, postoperative course, and oncological parameters were analyzed and compared between the biportal and uniportal groups.A total of 121 patients were enrolled in this study with median follow-up of 19.5 ± 11.6 months for all patients and 22.5 ± 11.5 months for primary lung cancer patients. Operation time (146.1 ± 31.9–158.7 ± 40.5 minutes; P = 0.077), chest drainage time (3.8 ± 3.3–4.4 ± 2.4 days; P = 0.309), conversion to thoracotomy rate (2.2%–2.6%; P = 0.889), and complication rate (15.6%–19.7%; P = 0.564) were equal between the groups, whereas blood loss (96.7 ± 193.2–263.6 ± 367; P = 0.006) was lower in the uniportal group. For lung cancer cases, there were no statistical differences in the histology, cancer staging, mediastinal lymph node dissection stations, numbers of dissected N1, N2, and overall lymph nodes between uniportal and biportal groups.Our preliminary data showed that uniportal VATS anatomical lung resection is as feasible, equally safe, and of comparative oncological clearance efficacy to biportal VATS.

Autologous endothelial progenitor cells improve allograft survival in porcine lung transplantation with prolonged ischemia

BACKGROUND As endothelial progenitor cells (EPCs) attenuated acute lung injury (ALI) in rabbit model, we hypothesized that autologous EPCs preserved lung graft function during the acute reperfusion period of lung transplantation and tested the therapeutic potential of EPCs in a porcine model of lung transplantation with prolonged graft ischemia. METHODS Day-7 EPCs isolated from the recipient subjects or plain culture media were administered into the left pulmonary artery immediately before restoration of pulmonary blood flow in a porcine lung allotransplantation model, with the transplantation surgeons blinded to the content of injection. Hemodynamics and arterial blood gas were recorded, and the right pulmonary artery was occluded 30 min after reperfusion to evaluate the lung graft function. The lung grafts were sectioned for histological examination at the end of experiments. The total ischemic time for lung graft was approximately 14 h. RESULTS All animals receiving plain medium died within 40 min after reperfusion, but 3 out of 5 (60%) piglets receiving EPCs survived up to 4 h after diversion of the entire cardiac output into the lung graft (P<0.01). The donor body weight, recipient body weight, cold ischemic time, and time for anastomosis were comparable between the EPC and control group (P=0.989, 0.822, 0.843, and 0.452, respectively). The mean aortic pressure decreased, and the cardiac output and mean pulmonary artery pressure elevated after right pulmonary artery occlusion. All these parameters were gradually compensated in the EPC group but decompensated in the control group. Better preservation of gas exchange function, reduced thrombi formation in the terminal pulmonary arterioles, and attenuated interstitial hemorrhage of the lung graft were observed in the EPC group. CONCLUSIONS We concluded autologous EPCs significantly enhanced the function of lung allograft and improved survival in a porcine model of lung transplantation with prolonged ischemia.

Behind and Beyond the Masaoka Staging: A 25-Year Follow-up Study of Tumor Recurrence in Completely Resected Thymic Epithelial Tumors in a Single Institution.

AbstractWe analyzed prognosticators for recurrence and post-recurrence survival in completely resected thymic epithelial tumors for the past 25 years in a single institution.Between June 1988 and December 2013, 238 patients undergoing intent-to-treat surgery for thymic epithelial tumors were reviewed. Sex, age, myasthenia gravis (MG), tumor histology, Masaoka staging, characteristic of locoregional invasion and recurrence, and the treatment for recurrence were collected. Comparison between groups was conducted using the Student t test and &khgr;2 test. Survival analysis was performed using the Kaplan–Meier method and log-rank test. The Cox proportional hazards model was used for univariate and multivariate analyses of prognostic factors.One hundred sixteen of 135 patients with completely resected thymoma and 35 of 56 patients with thymic carcinoma remained free of recurrence. In patients with completely resected thymoma, Masaoka staging, MG, tumor invasion into the lung, pericardium, and innominate vein or superior vena cava (SVC) invasion were associated with recurrence-free survival in univariate analysis (P = 0.004, 0.003, 0.001, 0.007, and 0.039, respectively). In multivariate analysis, MG was the positive independent prognosticator (P = 0.039). In patients with completely resected thymic carcinoma, Masaoka staging and innominate vein or SVC invasion were associated with recurrence-free survival in univariate analysis (P = 0.045 and 0.005, respectively), whereas innominate vein or SVC invasion was the negative independent prognosticator (P = 0.012). In patients with recurrent thymoma, those treated with surgery followed by chemotherapy had a significantly better post-recurrence survival than those undergoing chemoradiotherapy (P = 0.029) and those without treatment (P = 0.007). Patients with recurrent thymic carcinoma undergoing surgery followed by chemotherapy had a significantly better post-recurrence survival than those without treatment (P = 0.004), but not significantly better than those undergoing chemoradiotherapy (P = 0.252).In patients with completely resected thymoma, MG was the positive independent prognosticators of recurrence-free survival. Surgery should be attempted for recurrent disease for better post-recurrence survival. In patients with completely resected thymic carcinoma, innominate vein or SVC invasion was the negative independent prognosticator. Surgery for recurrence could be considered since it provided benefit for post-recurrence survival as chemoradiotherapy did.

Acid Corrosive Injury in Patients with a History of Partial Gastrectomy: Outcome Analysis

Background: Our purpose was to delineate the characteristics and outcome of acid-corrosive injury in patients with a history of gastric resection. Material and Methods: A total of 359 patients with a history of acid-corrosive injury were retrospectively reviewed. They were grouped based on past history with group 1 consisting of 8 patients with a history of gastric surgery (6 hemigastrectomies with Billroth II gastrojejunostomy, 2 partial gastrectomies with Billroth I gastroduodenostomy) and group 2 consisting of 351 patients without a history of previous gastric surgery. Clinical data, operative findings, treatment modalities and prognoses were compared. Results: Group 1 patients required significantly more emergency surgical interventions (p = 0.016) and more frequent resection of alimentary necrosis (p = 0.007). In the operative findings of those undergoing emergency laparotomy, group 1 had a slightly higher incidence of total gastric necrosis with or without perforation (p = 0.388), and a higher incidence of jejunal resection (p = 0.001). However, group 1 patients had a relatively lower operative mortality rate compared to group 2 patients (p = 0.640). Conclusion: Acid-injured patients with a history of previous gastric surgery tended to have a higher incidence of mandatory emergency surgical exploration and resection of the alimentary tract. With early and prompt management, a good survival rate can still be anticipated.