Publications by authors named "Chien-Sheng Huang"

64 Publications

Salvage surgery after definitive chemoradiotherapy through VATS for an initial unresectable locally advanced lung cancer: an alternative consolidative modality to radiotherapy?

Surg Case Rep 2021 Jun 8;7(1):138. Epub 2021 Jun 8.

Division of Thoracic Oncology, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

Background: Definitive chemoradiotherapy (dCRT) is the first choice treatment for patients with locally advanced non-small cell lung cancer (NSCLC), but up to 35% of dCRT-treated tumors may have persistent or recurrent disease. Since the last decades, multimodality therapy showing potential for cure has become the mainstream for treatment of locally advanced NSCLCs, even some that were initially inoperable. Although salvage lung resection after dCRT has been reported with acceptable survivals, experiences in this respect are still limited. Other concerns remain debatable and inconclusive, such as dosage of radiation exposure, long interval between dCRT and surgery, and surgical comorbidity.

Case Presentation: A 73-year-old male former smoker with diagnosis of right lower lobe of lung squamous cell carcinoma (SqCC) with multiple mediastinal lymphadenopathy, cT4N2M0, stage IIIB, received salvage right lower lobe + right middle lobe bilobectomy through video-assisted thoracoscopic surgery (VATS) after dCRT and adjuvant CRT to a total of 9000 cGy dosage of radiation. The interval from the 1st and 2nd ends of radiation to the salvage surgery was 980 and 164 days, respectively. The pre-operative forced expiratory volume in the first second was 2.33 L (101% predicted) and the diffusing capacity of the lungs for carbon monoxide was 56% predicted. The operating time was 6.5 h, and the total estimated blood loss was 50 ml. The patient was discharged on the 7th postoperative day without major complications or bronchopleural fistulas. The patient was still alive 42 months after the initial diagnosis of advanced N2 lung SqCC, and kept progression-free for 7 months after salvage lung resection.

Conclusions: Salvage lung resection performed long after high-dose radiation therapy of dCRT is technically feasible through VATS approach in a patient with initially inoperable cT4N2M0 stage IIIB NSCLC, and can be an alternative consolidative treatment for locally advanced NSCLC.
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http://dx.doi.org/10.1186/s40792-021-01227-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8187677PMC
June 2021

Sequence For Surgical Resection of Primary Lung Tumor For Oligometastatic Non-Small Cell Lung Cancer.

Ann Thorac Surg 2021 May 5. Epub 2021 May 5.

Division of Thoracic Oncology, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

Background: Differing surgical series for the treatment of primary lung tumor with synchronous oligometastatic stage IV non-small cell lung cancer (NSCLC) have been published; however, outcomes remain ambiguous.

Methods: Patients with synchronous oligometastatic stage IV NSCLC treated from 2005 to 2017 were enrolled to identify the impact of treatment sequence (primary lung resection versus systemic treatment) on progression-free survival (PFS) and overall survival (OS).

Results: Fifty-one patients received tumor resection (84% adenocarcinoma, 55% non-smokers, and 65% driver gene mutation). Resection occurred before or after systemic treatment in 33 (64.7%) and 18 (35.3%) patients, respectively. Patients who received resection first were older (62.1 vs. 54 year) and at a less advanced intrathoracic stage (18% vs. 44%). No significant differences were noted regarding perioperative complication (30% vs. 28%), length of hospital stay (9.0 vs. 10.5 days), percentage of disease progression (91% vs. 94%), overall death (70% vs. 78%), median PFS (14.0 vs. 22.8 months) and OS (44.6 vs. 53.2 months). Patients with single-organ metastasis had significantly longer PFS and OS than those with oligometastases (17.5 vs. 12.8 months, p=0.040 and 55.6 vs. 39.8 months, p=0.035), respectively. Multivariable Cox analysis identified non-solitary metastasis as the only independent predictor of PFS (hazard ratio 2.27; 95% CI, 1.07-4.81, p=0.033).

Conclusions: Primary lung resection before or after induction systemic therapy may benefit patients with oligometastatic NSCLC. Future randomized clinical trials examining the effect of treatment sequence is recommended.
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http://dx.doi.org/10.1016/j.athoracsur.2021.04.057DOI Listing
May 2021

Prognostic histologic subtyping of dominant tumor in resected synchronous multiple adenocarcinomas of lung.

Sci Rep 2021 May 5;11(1):9539. Epub 2021 May 5.

Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.

The prognostic role of histological patterns of dominant tumor (DT) and second dominant tumor (sDT) in synchronous multiple adenocarcinoma (SMADC) of lung remains unclear. SMADC patients diagnosed between 2003 and 2015 were retrospectively reviewed. DT and sDT were defined as two maximum diameters of consolidation among multiple tumors. Histological pattern was determined using IASLC/ATS/ERS classification system. DTs were divided into low- (lepidic), intermediate- (acinar, papillary) and high-grade (micropapillary, solid) subtypes, and sDTs into non-invasive predominant (lepidic) and invasive predominant (acinar, papillary, micropapillary, solid) subtypes. During mean 74-month follow-up among 149 nodal-negative patients having SMADC resected, recurrence was noted in 44 (29.5%), with significantly higher percentage in high-grade DT (p < 0.001). Five-year overall (OS) and disease-free (DFS) survivals in low-, intermediate- and high-grade DT were 96.9%, 94.3%, 63.3% (p < 0.001) and 100%, 87.2%, 30.0%, respectively (p < 0.001). Cox-regression multivariate analysis demonstrated high-grade DT as a significant predictor for DFS (Hazard ratio [HR] 5.324; 95% CI 2.570-11.462, p < 0.001) and OS (HR 3.287; 95% CI 1.323-8.168, p = 0.010). Analyzing DT and sDT together, we found no significant differences in DFS, either in intermediate- or high-grade DT plus invasive or non-invasive sDT. DT was histologically an independent risk factor of DFS and OS in completely resected nodal-negative SMADCs.
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http://dx.doi.org/10.1038/s41598-021-88193-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8100294PMC
May 2021

Effects of Rehabilitation Program on Quality of Life, Sleep, Rest-Activity Rhythms, Anxiety, and Depression of Patients With Esophageal Cancer: A Pilot Randomized Controlled Trial.

Cancer Nurs 2021 Apr 1. Epub 2021 Apr 1.

Author Affiliations: School of Nursing, College of Nursing, National Taipei University of Nursing and Health Sciences (Dr Chen and Mss Lin and Huang); School of Nursing, Shu Zen College of Medicine and Management (Dr Lin), Kaohsiung; Division of Thoracic Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, and Division of Thoracic Surgery, Department of Surgery, Taipei Medical University Hospital (Dr Wu); Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, and School of Medicine, National Yang-Ming University (Drs Huang and Hsu), Taipei; and Department of Nursing, Taipei Veterans General Hospital (Ms Chien), Taiwan.

Background: Esophageal cancer patients experience severe symptoms and poor quality of life.

Objective: We examined the effects of a rehabilitation program on quality of life, sleep, rest-activity rhythms, anxiety, and depression of esophageal cancer patients.

Methods: Forty-four patients with esophageal cancer were randomly assigned to an experimental group, which underwent a 12-week brisk walking and diet education program, or a control group, which received standard care. Health-related quality of life, subjective and objective sleep quality, rest-activity rhythms, anxiety, and depression were assessed at baseline and post intervention.

Results: A generalized estimating equation analysis revealed that, after intervention, compared with the control group, the experimental group exhibited significantly improved reflux (P = .022; effect size, 0.32) and marginally improved emotional (P = .069; effect size, 0.27) and social (P = .069; effect size, 0.27) functions; constipation (P = .050; effect size, 0.29), eating difficulty (P = .058; effect size, 0.27), anxiety (P = .050; effect size, 0.29), and total sleep time (P = .068; effect size, 0.39).

Conclusions: The rehabilitation program may improve health-related quality of life and sleep and alleviate anxiety in patients with esophageal cancer.

Implications For Practice: A rehabilitation program comprising exercise and diet education is a feasible and low-cost intervention for improving quality of life of patients with esophageal cancer. Healthcare team members may consider it as a nonpharmacological treatment option for patients.
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http://dx.doi.org/10.1097/NCC.0000000000000953DOI Listing
April 2021

Preoperative consolidation-to-tumor ratio is effective in the prediction of lymph node metastasis in patients with pulmonary ground-glass component nodules.

Thorac Cancer 2021 04 25;12(8):1203-1209. Epub 2021 Feb 25.

Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.

Background: Preoperative positron emission tomography/computed tomography (PET/CT) is recommended as a guideline for staging of lung cancer. However, for patients with pulmonary ground-glass opacity (GGO) nodules who are supposed to have a relatively low risk of incidence of lymphatic metastasis, it remains uncertain whether PET/CT is more effective than consolidation-to-tumor ratio (CTR) in the prediction of regional lymphatic metastasis.

Methods: The data on patients who underwent surgery for lung cancer from 2011 to 2016 were collected retrospectively, which included CTR, results of PET/CT, and pathological characteristics. The patients who had undergone preoperative PET/CT were identified to find the risk factors for lymphatic metastasis. A receiver operating characteristic (ROC) curve and multiple logistic regression was utilized to clarify the predictive value of CTR and main tumor maximal standardized uptake value (SUVmax).

Results: Among 217 patients who had PET/CT before lobectomy, chest computed tomography revealed that 75 patients had CTR greater than 62%. The patients with lymphatic metastasis were shown to have higher CTR and higher main tumor SUVmax. Multiple logistic regression showed that younger age (<60 years), higher main tumor SUVmax on PET/CT, and greater CTR were independent predictive factors for lymphatic metastasis. The area under the ROC curve was comparable, 0.817 for CTR, and 0.816 for main tumor SUVmax.

Conclusions: The present study revealed that CTR was not inferior to main tumor SUVmax considering the predictive power for lymphatic metastasis preoperatively in lung cancer patients with a GGO component. PET/CT might not be necessary preoperatively in selected patients.
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http://dx.doi.org/10.1111/1759-7714.13899DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046132PMC
April 2021

Significance of preoperative biopsy in radiological solid-dominant clinical stage I non-small-cell lung cancer.

Interact Cardiovasc Thorac Surg 2021 Apr;32(4):537-545

Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.

Objectives: The present study aimed to clarify the association between preoperative biopsy and surgical outcomes in clinical stage I non-small-cell lung cancer (NSCLC) with different proportions of ground-glass opacity (GGO).

Methods: Data on patients who underwent pulmonary resection for NSCLC from 2006 to 2016 were drawn from a prospective registered database and analysed retrospectively. Patient characteristics collected included tumour size, location and staging, surgical approach, consolidation-tumour ratio, histopathology and the presence or absence of preoperative biopsy to identify the independent prognostic factors of disease-free survival (DFS) and cancer-specific survival. A 1:1 propensity score matching was conducted between the preoperative biopsy and reference groups based on their baseline characteristics measured before the decision for preoperative biopsy.

Results: A total of 1427 patients were collected to achieve an overall 5-year DFS as 84.5% (median follow-up: 67.3 months), stratified to be 99.5% in the GGO-dominant group (n = 430) and 78.2% in the solid-dominant group (n = 997). Only 2 patients (0.5%) in the GGO-dominant group experienced tumour recurrence. For solid-dominant tumours matched with propensity scores (279 in preoperative biopsy vs 279 in reference group), the independent predictors of DFS included preoperative biopsy, sublobar resection, pathological staging and angiolymphatic invasion. Preoperative biopsy was a predictor of cancer-specific survival in univariable analysis but was not in multivariable analysis. Significant differences were also found between matched groups in those with late-delay surgery, but not in patients receiving preoperative biopsy with early-delay surgery (≤21 days).

Conclusion: Preoperative biopsy may worsen surgical outcomes in patients with clinical stage I, solid-dominant NSCLC.
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http://dx.doi.org/10.1093/icvts/ivaa297DOI Listing
April 2021

Clinicopathological Significance of Pathologic Complete Lymph Node Regression After Neoadjuvant Chemoradiotherapy in Esophageal Squamous Cell Carcinoma.

Ann Surg Oncol 2021 Apr 20;28(4):2048-2058. Epub 2020 Nov 20.

Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, School of Medicine, National Yang-Ming University, Taipei, Taiwan.

Background: Pathologic complete lymph node regression (LNR), where the lymph nodes show evidence of neoadjuvant treatment effect but have no viable residual tumor cells, is sometimes observed following neoadjuvant treatments and has been shown to be prognostic; conflicting results exist in the current literature.

Methods: Patients who received neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy for squamous carcinoma (ESCC) were retrospectively reviewed and classified according to their LNR score; 0: N(-) with no evidence of tumor involvement or regression; 1: N(-) with evidence of complete regression; 2: N(+) with < 50% viable tumor; and 3: N(+) with > 50% viable tumor.

Results: In total, 136 patients, comprising 73, 25, 16, and 22 patients with LNR scores of 0, 1, 2, or 3, respectively, were included. Pathologic complete LNR (LNR 1) was significantly associated with lower risks of lymphovascular invasion (0%, p < 0.001) and perineural invasion (4%, p = 0.038), and a higher rate of pathologic complete response in the primary tumor (76%, p < 0.001). The 5-year overall survival rates were 42.1%, 52.8%, and 8.0% in patients with an LNR score of 0, 1, and 2/3, respectively (p < 0.001). There was no significant difference between patients with LNR scores of 0 and 1 in overall survival (p = 0.454), disease-free survival (p = 0.501), and cumulative incidence of recurrences (hazard ratio 0.84, 95% confidence interval 0.432-1.623, p = 0.601).

Conclusions: Pathologic complete LNR could be an indicator of nCRT sensitivity and can be regarded as a good prognostic factor in patients with ESCC. In the survival curve analysis that included patients with lymph node regression (LNR) scores of 0 (blue), 1 (red), and 2/3 (green), we found that patients with pathologic complete LNR (LNR 1), which suggests prior positive nodal involvement, had similar outcomes as those without evidence of prior tumor involvement in lymph node (LNR0).
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http://dx.doi.org/10.1245/s10434-020-09363-zDOI Listing
April 2021

Active surveillance or early resection for ground-glass nodules that need preoperative localization.

J Surg Oncol 2021 Jan 28;123(1):322-331. Epub 2020 Sep 28.

Department of Surgery, Division of Thoracic Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.

Introduction: Few studies have investigated the impact of active surveillance on pathological outcome ground-glass nodules (GGNs). We focused on GGNs that needed preoperative localization before resection and compared the pathological results between GGNs that underwent early resection or active surveillance.

Methods: We retrospectively reviewed data of resected GGNs between January 2017 and December 2018. GGNs were classified by early resection (Group A) and active surveillance (Group B). Group B was subclassified as no (Group B1) and with (Group B2) growth, and intergroup comparison of pathological results was undertaken.

Results: In total, 509 GGNs (124, 275, and 110 in Groups A, B1, and B2, respectively) were included. Malignancy (primary lung cancer) ratios were 68% and 72% in Groups A and B (p = .312) and 65% and 92% in Groups B1 and B2, respectively (p < .001). The ratios of invasive carcinoma were 21.4%, 9.6%, and 35.6% in Groups A, B1, and B2, respectively. Predictors for invasive carcinoma included history of lung cancer, GGN size ≥ 10 mm, solid size ≥ 6 mm, and GGN growth.

Conclusions: The pathological findings were similar for GGNs in the early resection and active surveillance groups. However, rates of malignancy and invasive carcinoma increased in the group that manifested growth during active surveillance.
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http://dx.doi.org/10.1002/jso.26241DOI Listing
January 2021

De novo thymic carcinoma or malignant transformation: a myasthenic patient presented with multiple mediastinal tumours.

Respirol Case Rep 2020 Oct 23;8(7):e00629. Epub 2020 Jul 23.

Division of Thoracic Surgery, Department of Surgery Taipei Veterans General Hospital Taipei Taiwan.

A 63-year-old man presented with bilateral ptosis, and detailed evaluation confirmed ocular myasthenia gravis with three anterior mediastinal masses on computed tomography (CT) of the chest. Extended thymectomy was performed, and pathology revealed two thymic carcinoma and one thymoma. After surgery, the patient is free from recurrence. Synchronous triple thymic carcinomas and thymoma have not been reported. The finding of this case report supports the hypothesis of malignant transformation of thymoma to thymic carcinoma. Thymic carcinoma should be considered in the differential diagnosis of multiple thymic tumours, and extended thymectomy should be the treatment of choice.
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http://dx.doi.org/10.1002/rcr2.629DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376331PMC
October 2020

Delayed surgery after histologic or radiologic-diagnosed clinical stage I lung adenocarcinoma.

J Thorac Dis 2020 Mar;12(3):615-625

Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei.

Background: The impact of delayed surgery on clinical outcomes after histologic or radiologic diagnosis of clinical stage I adenocarcinoma remains controversial. We evaluated the effects of delayed surgery on outcomes of patients with early-stage lung cancer.

Methods: Associations between time intervals of "histologic diagnosis-to-surgery" (HDS), "radiologic diagnosis-to-surgery" (RDS), and overall survival in clinical stage I adenocarcinoma were assessed using multivariable Cox proportional hazard analysis.

Results: A total of 561 consecutive patients with preoperative histologic confirmation of stage I lung cancer between 2006 and 2016 were included. Median time to HDS and RDS were 20 (2-267) and 58 (38-2,983) days. Higher Charlson comorbidity score, receiving brain magnetic resonance imaging screening, and video-assisted thoracoscopic surgery approach were significantly associated with increased risk of late HDS (>21 days). Smaller tumor size and non-radiologic solid-dominant pattern were significantly associated with increased risk of late RDS (>60 days). In the overall cohort, worse 5-year overall survival was associated with late HDS compared to early HDS (75.9% . 85.5%, P=0.003). No significant differences were found in later late . early RDS (83.7% . 83.3%, P=0.570). In 286 propensity-score matched patients, late HDS [adjusted hazard ratio (aHR) =2.031, P=0.038], higher Charlson comorbidity score (aHR=1.610, P=0.023), larger tumor size (aHR=2.164, P=0.031), without brain magnetic resonance imaging screening (aHR=2.051, P=0.045), and tumor with angiolymphatic invasion (aHR=4.638, P=0.001) were significantly associated with lower overall survival.

Conclusions: In patients with stage I lung adenocarcinoma, delayed surgery after a histologic diagnosis is an independent predictor of overall survival after adjusting for clinical risk factors, suggesting meaningful differences in clinical outcomes between timely . delayed surgeries.
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http://dx.doi.org/10.21037/jtd.2019.12.123DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7139031PMC
March 2020

Electromagnetic navigation-guided versus computed tomography-guided percutaneous localization of small lung nodules before uniportal video-assisted thoracoscopic surgery: a propensity score-matched analysis.

Eur J Cardiothorac Surg 2020 08;58(Suppl_1):i85-i91

Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.

Objectives: An optimal method for preoperative localization of small lung nodules is yet to be established, and there are few comparative studies in the literature. In the present study, we aimed to compare electromagnetic navigation-guided and computed tomography (CT)-guided methods of percutaneous transthoracic localization.

Methods: The clinical, radiographic, surgical and pathological data of patients who underwent electromagnetic navigation-guided localization (EMNGL) and CT-guided localization (CTGL) before uniportal video-assisted thoracic surgery (VATS) were reviewed. Propensity score matching analysis was performed to compare the localization and surgical results.

Results: After matching, 25 EMNGL and 50 CTGL patients were included in the analysis. In the CTGL group, pulmonary haemorrhage and pneumothorax were noted in 56% and 34% of patients, respectively, on postprocedural CT scans. Successful localization was achieved in 96% and 100% of patients in the EMNGL and CTGL groups, respectively (P = 0.333). The median time in the operation room was significantly shorter in the CTGL group {142.5 [interquartile range (IQR) 123.8-175.0] vs 205.0 [IQR 177.5-290.0] min, P < 0.001}. In contrast, EMNGL significantly decreased the total time [205.0 (IQR 177.5-290.0) vs 324.0 (IQR 228.3-374.0) min, P = 0.002]. The median duration of chest drainage was 1 day shorter in the EMNGL group [2.0 (IQR 1.5-2.5) vs 3.0 (IQR 2.0-3.0), P = 0.002]; the surgical complication rates were comparable between the 2 groups.

Conclusions: The localization and surgical results were similar between the EMNGL and CTGL groups. EMNGL is comparable to conventional CTGL with respect to preoperative localization of small lung nodules before uniportal VATS.
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http://dx.doi.org/10.1093/ejcts/ezz338DOI Listing
August 2020

The Prognostic Impact of Extracapsular Lymph Node Involvement in Esophageal Squamous Cell Carcinoma.

Ann Surg Oncol 2020 Aug 20;27(8):3071-3082. Epub 2020 Feb 20.

Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.

Background: The role of extracapsular lymph node involvement (ELNI) in esophageal cancer has not been fully investigated. We aim to assess its incidence and prognostic significance in patients with esophageal squamous cell carcinoma (ESCC) treated with and without neoadjuvant treatments.

Methods: Data of patients who underwent esophagectomy for ESCC in a single medical center was retrospectively reviewed. Patients with positive lymph node involvement were classified as either with ELNI or without ELNI (intracapsular lymph node involvement, ILNI). The impact of ELNI on overall survival (OS), disease-free survival (DFS), and disease recurrence was analyzed.

Results: A total of 336 patients, including 179 without (NCRT -) and 157 with (NCRT +) neoadjuvant chemoradiotherapy, were included. Seventy-two of 179 (40.2%) patients in NCRT - group were with positive lymph node, of whom 19 (26.4%) had ELNI, whereas 49 (31.2%) patients in NCRT + group had positive lymph node, of whom 25 (51.0%) had ELNI. In NCRT + group, patients with ELNI had worse outcome compared to those with ILNI in 5-year OS (10.4 vs. 13.8%, p = 0.008), and DFS (5.3 vs. 17.5%, p = 0.008). The presence of ELNI was also associated with more distant recurrence (p = 0.03). In contrast, there was no survival difference between patients with ELNI and ILNI in NCRT - group.

Conclusions: Compared with ILNI, ELNI is a significant poor prognostic factor in patients with ESCC treated with neoadjuvant treatments, but not in those with primary surgery.
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http://dx.doi.org/10.1245/s10434-020-08260-9DOI Listing
August 2020

Surgeons' preference sublobar resection for stage I NSCLC less than 3 cm.

Thorac Cancer 2020 04 9;11(4):907-917. Epub 2020 Feb 9.

Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.

Background: This study aimed to compare survival between standard lobectomy and surgeons' preference sublobar resection among patients with stage I non-small cell lung cancer (NSCLC).

Methods: Medical records of patients undergoing pulmonary resection between 2006 and 2016 were reviewed retrospectively. Differences in disease-free survival (DFS) and DFS-associated factors between patients receiving lobectomy and surgeons' preference sublobar resection were analyzed after 1-1 propensity score-matching (n = 119 per group).

Results: In total, 1064 pathological stage I NSCLC patients were identified, including 816 (76.7%) who underwent lobectomy, 111 (10.4%) who underwent sublobar resection as a compromised procedure (medically unfit), and 137 (12.9%) who underwent surgeons' preference sublobar resection. Rates of five-year DFS for patients undergoing lobectomy, medically unfit, and surgeons' preference sublobar resection were 88.7%, 71.0%, and 93.4%, respectively (P < 0.001). Multivariable Cox regression analysis demonstrated that radiological solid-appearance (adjusted hazard [aHR] = 2.908, P = 0.003), PL2 invasion (aHR = 1.970, P = 0.024), and angiolymphatic invasion (aHR = 2.202, P = 0.005) were significantly associated with lower DFS after adjusting for surgeons' preference sublobar resection (aH = 1.031, P = 0.939). Subgroup analysis of all 403 solid-dominant patients demonstrated equivalent five-year DFS between surgeons' preference sublobar resection and lobectomy (87.7% and 84.1%, respectively, P = 0.721). Propensity-matched analysis showed no differences in five-year DFS in stage I NSCLC patients undergoing lobectomy or surgeons' preference sublobar resection (90.5% vs. 93.4% P = 0.510), and DFS for surgeons' preference sublobar resection remained an insignificant factor (aHR = 0.894, P = 0.834).

Conclusions: Carefully selected patients who have undergone surgeons' preference sublobar resection have comparable outcomes to those receiving lobectomy for stage I NSCLC <3 cm.

Key Points: Significant findings of the study Intended sublobar resection has a good outcome. What this study adds Sublobar resection is applicable for stage I NSCLC <3 cm.
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http://dx.doi.org/10.1111/1759-7714.13336DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7113050PMC
April 2020

Preoperative biopsy and tumor recurrence of stage I adenocarcinoma of the lung.

Surg Today 2020 Jul 23;50(7):673-684. Epub 2019 Dec 23.

Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei, Taiwan.

Purpose: To evaluate whether preoperative biopsy affects the outcomes of patients undergoing at least lobectomy for stage I lung adenocarcinoma.

Methods: We reviewed the medical records of patients who underwent surgery for stage I lung adenocarcinoma between 2006 and 2013. Tumor recurrence and survival were compared between patients who underwent preoperative biopsy, including computed tomographic-guided needle biopsy and transbronchial biopsy, and those who underwent intraoperative frozen section.

Results: Among 509 patients, 229 patients (44.9%) underwent preoperative biopsy and 280 patients had lung adenocarcinoma diagnosed by intraoperative frozen section (reference group). Recurrence developed in 65 (12.8%) patients within a median follow-up period of 54.4 months. Multivariate analysis demonstrated that preoperative biopsy (OR 1.97, p = 0.045), radiological solid appearance (OR 5.43, p < 0.001), and angiolymphatic invasion (OR 2.48, p = 0.010) were independent predictors of recurrence. In the overall cohort, preoperative biopsy appeared to worsen 5-year disease-free and overall survival significantly (76.6% vs. 93.0%, p < 0.001; and 83.8% vs. 94.5%, p = 0.002, respectively) compared with the reference group. After propensity matching, multivariable logistic regression still identified preoperative biopsy as an independent predictor of overall recurrence (OR 2.21, p = 0.048) after adjusting for tumor characteristics.

Conclusion: Preoperative biopsy might be considered a prognosticator of recurrence of stage I adenocarcinoma of the lungs in patients who undergo at least anatomic lobectomy without postoperative adjuvant chemotherapy.
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http://dx.doi.org/10.1007/s00595-019-01941-3DOI Listing
July 2020

Complications after Chest Tube Removal and Reinterventions in Patients with Digital Drainage Systems.

J Clin Med 2019 Dec 1;8(12). Epub 2019 Dec 1.

Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, and School of Medicine, National Yang-Ming University, Taipei 100116, Taiwan.

Introduction: Digital thoracic drainage systems are a new technology in minimally invasive thoracic surgery. However, the criteria for chest tube removal in digital thoracic drainage systems have never been evaluated. We aim to investigate the incidence and predictive factors of complications and reinterventions after drainage tube removal in patients with a digital drainage system.

Method: Patients who received lung resection surgery and had their chest drainage tubes connected with a digital drainage system were retrospectively reviewed.

Results: A total of 497 patients were monitored with digital drainage systems after lung resection surgery. A total of 175 (35.2%) patients had air leak-related complications after drainage tube removals, whereas 25 patients (5.0%) required reintervention. We identified that chest drainage duration of five days was an optimal cut-off value in predicting air leak-related complications and reinterventions. In multiple logistic regression analysis, previous chest surgery history; small size (16 Fr.) drainage tubes; the presence of initial air leaks, defined as air leaks recorded by the digital drainage system immediately after operation; and duration of chest drainage ≥5 days were independent factors of air leak-related complications, whereas the presence of initial air leaks and duration of chest drainage ≥5 days were independent predictive factors of reintervention after drainage tube removal.

Conclusion: Air leak-related complications and reinterventions after drainage tube removals happened in 35.2% and 5.0% of patients with digital thoracic drainage systems. The management of chest drainage tubes in patients with predictive factors, i.e., the presence of initial air leaks and duration of chest drainage of more than five days, should be treated with caution.
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http://dx.doi.org/10.3390/jcm8122092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947439PMC
December 2019

Pathological complete response after afatinib treatment of stage IV oligometastatic adenocarcinoma of the lung: the role of pulmonary surgery.

Surg Case Rep 2019 Nov 12;5(1):178. Epub 2019 Nov 12.

Division of Thoracic Oncology, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

Background: Some oligometastatic lung cancer patients, after induction systemic chemotherapy or tyrosine kinases inhibitor treatment, followed by aggressive radical consolidative treatment, have improved overall survival. Unfortunately, clinical criteria cannot assess such patients.

Case Presentation: We hereby reported the case of a 55-year-old female with lower back pain and bilateral lower leg numbness for months and who had an osteolytic bone lesion over the third lumbar vertebra. In February 2017, a third lumbar vertebra biopsy showed metastatic adenocarcinoma, compatible with lung origin (thyroid transcription factor-1 positive [TTF-1], L858R mutation positive). Complete imaging of the right lower lobe (RLL) showed a spiculated mass of about 3.4 × 2.2 cm, and a trans-bronchoscopic lung biopsy revealed non-small cell carcinoma of lung origin (positive for TTF-1 and negative for p40). Tentative diagnosis was RLL adenocarcinoma, cT2aN0M1b, with bone metastasis at L3. The epidermal growth factor receptor-tyrosine kinase inhibitor afatinib was prescribed beginning April 2017. A November 2018 follow-up CT scan showed regression in the RLL lung mass. A whole-body positron emission tomography-computed tomography showed RLL lung nodule with faint uptake and mildly increased uptake in the L3 vertebra. After providing informed consent, the patient received uniportal video-assisted thoracoscopic RLL lobectomy and radical mediastinal lymph node dissection on December 25, 2018. The final pathology report was fibrotic scar with no residual tumor cells, compatible with post-treatment status, ypT0N0. Curative intent radiotherapy was also applied to the L3 vertebra after the operation. The patient is still alive for more than 32 months after initially diagnosed with metastatic lung adenocarcinoma.

Conclusions: Our case provides additional data to support that tissue assessment through primary lung tumor resection after systemic treatment of oligometastic lung cancer by minimally invasive surgery can reveal the treatment effect and potentially provide a surrogate endpoint in further clinical trials.
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http://dx.doi.org/10.1186/s40792-019-0741-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6851272PMC
November 2019

A symptomatic anterior mediastinal mass with a simultaneous infection.

Respirol Case Rep 2019 Feb 4;7(2):e00394. Epub 2018 Dec 4.

Division of Thoracic Surgery, Department of Surgery Taipei Veterans General Hospital Taipei Taiwan.

Surgical resection remains the treatment of choice for mature mediastinal teratoma, and the operation itself is sometimes complicated or life-threatening, especially when it ruptures into adjacent vital structures. We describe a rare case of unanticipatedly delayed complete resection of a symptomatic teratoma with simultaneous infection, followed by extended rupture into the pleural space, lung, and bronchus. The clinical presentation and the microbiological and radiologic features may lead to the impression of a lung abscess until it can be proven otherwise pathologically after an initial thoracic aspiration. Accordingly, surgical intervention through a minimal approach, such as video-assisted thoracoscopic surgery, might be considered a strategy after the initial extended rupture.
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http://dx.doi.org/10.1002/rcr2.394DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6277967PMC
February 2019

Separate or intrapulmonary metastasis?

J Thorac Dis 2018 Sep;10(Suppl 26):S3128-S3130

Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei.

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http://dx.doi.org/10.21037/jtd.2018.08.74DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6186628PMC
September 2018

Critical airway compression caused by a large mediastinal tumour with spontaneous haemorrhage.

Respirol Case Rep 2018 04 15;6(3):e00300. Epub 2018 Feb 15.

Division of Thoracic Surgery, Department of Surgery Taipei Veterans General Hospital Taipei Taiwan.

We report the case of a 77-year-old woman presenting with out-of-hospital cardiac arrest, which was then interpreted as an acute, life-threatening critical airway compression by a huge mediastinal tumour without appropriate diagnosis. Emergency extracorporeal membrane oxygenation was cannulated for sufficient respiratory support after spontaneous circulation was regained. After the multidisciplinary team, involving thoracic surgeons, discussed the resectability of the mediastinal tumour, the patient underwent successful resection of the mediastinal tumour through a median sternotomy. The pathological report demonstrated an intrathoracic goitre with spontaneous haemorrhage and haematoma formation, and the patient was discharged with favourable respiratory and neurological outcomes.
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http://dx.doi.org/10.1002/rcr2.300DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5813256PMC
April 2018

Pre- versus postoperative chemoradiotherapy for locally advanced esophageal squamous cell carcinoma.

J Thorac Cardiovasc Surg 2017 08 21;154(2):732-740.e2. Epub 2017 Mar 21.

Institute of Health and Welfare Policy, National Yang-Ming University, Taipei, Taiwan.

Objectives: Although preoperative chemoradiation followed by surgery has been recognized as an efficient strategy for esophageal cancer treatments, several studies demonstrate survival benefits of postoperative chemoradiation for those undergoing upfront resection. The optimal sequence of surgery and chemoradiation remains unclear.

Methods: Data of 1647 patients with clinical stage II/III esophageal squamous cell carcinoma (ESCC), including 1245 receiving preoperative chemoradiation followed by esophagectomy (pre-OP CRT group) and 402 receiving primary esophagectomy followed postoperative chemoradiation (post-OP CRT group), were obtained from a nationwide database. Propensity score matching identified 286 well-balanced pairs for outcome comparison.

Results: In matched patients, the 3-year overall survival (OS) rates/median survival were not significantly different between the 2 groups (44.0% 3-year OS/26.0 months; 95% confidence interval [CI], 18.9-89 38.0 months) in the pre-OP CRT group, versus 37.9% 3-year OS/23.5 months (95% CI, 18.5-29.9 months) in the post-OP CRT group, P = .3152). The 3-year disease-free survival rates (DFS)/median survival after surgery were 38.7% 3-year DFS/16.7 months (95% CI, 11.9-29.6 months) in the pre-OP CRT group, compared with 30.2% 3-year DFS/10.4 months (95% CI, 7.6-14.0 months) in the post-OP CRT group (P = .0674). In patients who had complete resection, the freedom from recurrence rate at 1 year after surgery was 74.8% and 67.6% in pre-OP CRT and post-OP CRT groups, respectively (P = .2696). In the multivariable analysis, treatment modality (pre- or post-OP CRT) was not a significant factor for OS (P = .258) or disease-free survival (P = .521).

Conclusions: Similar outcome can be achieved with postoperative chemoradiotherapy compared with preoperative chemoradiotherapy in patients with locally advanced ESCC. There is little difference between these 2 strategies.
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http://dx.doi.org/10.1016/j.jtcvs.2017.03.038DOI Listing
August 2017

Prognostic histological factors in patients with esophageal squamous cell carcinoma after preoperative chemoradiation followed by surgery.

BMC Cancer 2017 01 19;17(1):62. Epub 2017 Jan 19.

Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.

Background: Pathological response is an important marker for tumor aggressiveness in patients with esophageal squamous cell carcinoma (ESCC) who receive preoperative chemoradiation followed by esophagectomy. We aim to evaluate the prognostic value of histological factors after trimodality treatments.

Methods: 91 patients who received preoperative chemoradiation followed by transthoracic esophagectomy between 2009 and 2014 were included. The pathological examination was reviewed. Overall survival and disease free survival were recorded. Survival analysis was performed using the Cox regression model, and the survival curves were compared by the log-rank test.

Results: Survival analysis showed lymphovascular invasion (LVI, hazard ratio [HR]: 2.009, p = 0.029), perineural invasion (PNI, HR: 2.226, p = 0.019), ypN stage (HR: 2.041, p = 0.019), extracapsular invasion (ECI, HR: 2.804, p = 0.003), and incomplete resection (HR: 1.897, p = 0.039) as unfavorable prognostic factors affecting overall survival (OS). Moreover, tumor regression grade (TRG, HR: 1.834, p = 0.038), LVI (HR: 1.975, p = 0.038), ECI (HR: 2.836, p = 0.003), and incomplete resection (HR: 2.254, p = 0.007) adversely affected disease-free survival (DFS). Prognostic classification based on poor primary tumor (TRG2/3, LVI(+), and PNI (+)), lymph node (ypN(+) and ECI(+)), and surgical (incomplete resection) factors significantly predicts OS (p = 0.013) and DFS (p = 0.017). However, the use of postoperative adjuvant therapy was not a significant prognostic factor even in medium- and high-risk ESCC patients who underwent trimodality treatments.

Conclusions: Histological factors, including primary tumor, lymph node, and surgical factors has high prognostic value for predicting outcomes in ESCC patients receiving preoperative chemoradiation followed by surgery.
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http://dx.doi.org/10.1186/s12885-017-3063-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5244588PMC
January 2017

A Propensity-matched Analysis Comparing Survival After Esophagectomy Followed by Adjuvant Chemoradiation to Surgery Alone for Esophageal Squamous Cell Carcinoma.

Ann Surg 2016 07;264(1):100-6

*Department of Surgery, Division of Chest Surgery, Taipei Veterans General Hospital , Taipei, Taiwan†School of Medicine National Yang-Ming University, Taipei, Taiwan‡Institute of Health and Welfare Policy, National Yang-Ming University, Taipei , Taiwan§Division of Thoracic Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan¶Department of Surgery, Division of Thoracic Surgery, Changhua Christian Hospital, Taichung, Taiwan||Department of Surgery, Division of Thoracic Surgery, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.

Background: The role of adjuvant chemoradiation in esophageal cancer has been underestimated in the literature. This study was undertaken to determine whether adjuvant chemoradiation improves survival compared with surgery alone.

Methods: Data of 1095 esophageal squamous cell carcinoma (ESCC) patients, including 679 in surgery alone group (group 1) and 416 in surgery followed adjuvant chemoradaition group (group 2), were obtained from the Taiwan Cancer Registry database. Propensity score matching (PSM) analysis was used to identify 147 well-balanced patients in each group for overall survival comparison.

Results: After PSM, the 3-year survival rates and median survival were 44.9% and 27.2 (95% confidence interval [CI]: 17.6-40.3) months in group 2, which is significantly higher than that in group 1 (28.1% and 18.2 [95% CI: 14.3-24.5] months, P = 0.0043). In the multivariate survival analysis, pT3/4 stage (Hazard Ratio [HR]: 2.03, 95% CI: 1.38-2.97, P < 0.001), pN+ stage (HR: 1.83, 95% CI: 1.31-2.57, P = 0.0004), tumor length more than 32 mm (HR: 1.93, 95% CI: 1.33-2.79, P < 0.001), R1/2 resection (HR: 1.75, 95% CI: 1.15-2.66, P = 0.009), and adjuvant chemoradiation (HR: 0.57, 95% CI: 0.42-0.78, P < 0.0001) were independent prognostic factors. Subgroup analysis suggested patients with pT3/4 stage, pN+ stage tumors, larger tumor size, poorly differentiated tumors, and R1/2 resections were more likely to demonstrate survival benefit from adjuvant chemoradiation.

Conclusions: Compared with surgery alone, adjuvant chemoradiation provides a survival benefit to ESCC patients, especially those with pT3/4 stage, N+ tumors, larger tumor size, poorly differentiated tumors, and R1/2 resections.
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http://dx.doi.org/10.1097/SLA.0000000000001410DOI Listing
July 2016

The Prognostic Impact of Preoperative and Postoperative Chemoradiation in Clinical Stage II and III Esophageal Squamous Cell Carcinomas: A Population Based Study in Taiwan.

Medicine (Baltimore) 2015 Jun;94(25):e1002

From the Institute of Health and Welfare Policy, National Yang-Ming University (H-SC, S-CW); Division of Chest Surgery, Department of Surgery, Taipei Veterans General Hospital (P-KH, C-SH, Y-CW); School of Medicine, National Yang-Ming University (P-KH, C-SH, Y-CW); and Division of Thoracic Surgery, Department of Surgery, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan (C-CL).

While preoperative chemoradiation followed by surgery (pre-OP CRT) has been widely applied in the treatment of patients with esophageal cancer, some studies have shown a survival benefit of postoperative chemoradiation (post-OP CRT). The optimal combination of multimodality therapy and the sequence of surgery and chemoradiation for esophageal cancer remain to be investigated. A total of 1385 patients with clinical stage II and III esophageal squamous cell carcinoma (ESCC) were included. On the basis of the sequence of surgery and chemoradiation, the patients were grouped as follows: preoperative chemoradiation followed by surgery (pre-OP CRT+S), surgery alone (S), and surgery followed by postoperative chemoradiation (S+post-OP CRT). Propensity score matching analysis was used to identify 78 well-balanced patients in each group for outcome comparison.In all, 753, 339, and 293 patients were in the pre-OP CRT+S, S, and S+post-OP CRT groups, respectively. Before matching, no differences were observed in the overall survival among the patients in these 3 groups (P = 0.422). After matching, both the pre-OP CRT+S and S+post-OP CRT groups were significantly associated with a better survival compared with the S group (pre-OP CRT+S vs. S: P < 0.001; S+post-OP CRT vs. S: P = 0.005). In contrast, the survival was similar between the pre-OP CRT+S and S+post-OP CRT groups (P = 0.544). In the subgroup analysis, patients with clinical T3/4 stage tumors or those with a tumor size greater than 5 cm were more likely to demonstrate an overall survival benefit from pre-OP CRT compared with post-OP CRT. Both pre-OP CRT and post-OP CRT demonstrated a survival benefit compared with surgery alone, which indicates the importance of trimodality therapy in patients with clinical stage II/III ESCC. However, no survival difference was observed among patients in the pre-OP CRT+S and S+post-OP CRT groups, which suggests that the sequence of surgery and chemoradiation may be irrelevant to the outcome.
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http://dx.doi.org/10.1097/MD.0000000000001002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4504557PMC
June 2015

Successful percutaneous tracheostomy via puncture through the thyroid isthmus.

Respirol Case Rep 2014 Jun 25;2(2):57-60. Epub 2014 Feb 25.

Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital Taipei, Taiwan ; Institute of Clinical Medicine, School of Medicine, National Yang-Ming University Taipei, Taiwan.

Tracheostomy is one of the most frequently performed procedures in intensive care units. Bedside percutaneous tracheostomy has become an increasingly popular option to standard open tracheostomy. Several contraindications for percutaneous tracheostomy, including an enlarged thyroid isthmus, have been described. However, as experience with this technique has increased, most of the described contraindications appear to be relative rather than absolute, provided the procedure is performed by an experienced practitioner. Herein we present a case of an unavoidable direct puncture of the thyroid isthmus during a percutaneous tracheostomy. The procedure was performed smoothly, and no complications occurred.
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http://dx.doi.org/10.1002/rcr2.48DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4184506PMC
June 2014

Chylothorax complicating video-assisted thoracoscopic surgery for non-small cell lung cancer.

World J Surg 2014 Nov;38(11):2875-81

Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, 112, Taiwan,

Background: Chylothorax is an infrequent but well-known complication in lung cancer surgery. Previous published studies on this topic are limited, and thoracotomy has been the main surgical approach for treatment. However, chylothorax after lung cancer surgery performed solely by video-assisted thoracoscopic surgery (VATS) has rarely been investigated. The purpose of this study is to evaluate chylothorax after VATS for lung cancer.

Methods: The records of 776 patients with primary non-small-cell lung cancer (NSCLC) who underwent VATS for pulmonary resection and mediastinal lymph node dissection (MLND) at our hospital from January 2010 to August 2013 were retrospectively reviewed. Twenty patients with chylothorax (2.58 %) were included in the analysis.

Results: The 20 patients with chylothorax were all treated conservatively, but five patients (25 %) subsequently required reoperation for chylothorax. In patients with pleural drainage of less than 400 ml the first postoperative day, the chylothorax resolved with conservative treatment. Chylothorax also resolved in patients with pleural drainage of more than 400 ml the first or second postoperative day if drainage was less than 400 ml on postoperative day 4 and thereafter. Reoperations were required in cases with an increasing amount of pleural drainage on postoperative day 4 and thereafter.

Conclusions: Most of the chylothorax following VATS for lung cancer can be treated conservatively. However, the timing of surgical intervention for chylothorax following VATS for lung cancer can be earlier if pleural drainage does not show a trend toward decreasing with conservative treatment.
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http://dx.doi.org/10.1007/s00268-014-2699-4DOI Listing
November 2014

Concomitant inhibition of oxidative stress and angiogenesis by chronic hydrogen-rich saline and N-acetylcysteine treatments improves systemic, splanchnic and hepatic hemodynamics of cirrhotic rats.

Hepatol Res 2015 May 6;45(5):578-88. Epub 2014 Aug 6.

Division of Gastroenterology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.

Aim: In cirrhosis, increased oxidative stress leads to systemic and splanchnic hyperdynamic circulation, splanchnic angiogenesis, portosystemic collateral formation, hepatic endothelial dysfunction, increased intrahepatic resistance and the subsequent portal hypertension. Like N-acetylcysteine, hydrogen-rich saline is a new documented antioxidant with the potential to treat the complications of liver diseases.

Methods: In this study, hemodynamics, splanchnic angiogenesis and hepatic endothelial dysfunction were measured in common bile duct ligation (BDL)-cirrhotic rats receiving 1-month treatment of vehicle, N-acetylcysteine and hydrogen-rich saline immediately after BDL. Additionally, acute effects of N-acetylcysteine and hydrogen-rich saline on vascular endothelial growth factor (VEGF)-induced tubule formation and migration of human umbilical vein endothelial cells (HUVEC) were also evaluated.

Results: The data indicate that 1-month treatment of N-acetylcysteine or hydrogen-rich saline significantly ameliorated systemic and splanchnic hyperdynamic circulation, corrected hepatic endothelial dysfunction, and decreased intrahepatic resistance and mesenteric angiogenesis by inhibiting inflammatory cytokines, nitric oxide, VEGF and reducing mesenteric oxidative stress in cirrhotic rats. In vivo studies revealed that acute co-incubation of N-acetylcysteine or hydrogen-rich saline with VEGF effectively suppressed VEGF-induced angiogenesis and migration of HUVEC accompanied by decreasing of oxidative stress and inflammatory cytokines.

Conclusion: Both hydrogen-rich saline and N-acetylcysteine alleviate portal hypertension, the severity of portosystemic collaterals, mesenteric angiogenesis, hepatic endothelial dysfunction and intrahepatic resistance in cirrhotic rats. N-Acetylcysteine and the new antioxidant, hydrogen-rich saline are potential treatments for the complications of cirrhosis.
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http://dx.doi.org/10.1111/hepr.12379DOI Listing
May 2015

Role of right upper mediastinal lymph node metastasis in patients with esophageal squamous cell carcinoma after tri-incisional esophagectomies.

Surgery 2014 Nov 19;156(5):1269-77. Epub 2014 Jun 19.

Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan.

Background: Whereas standard (infracarinal) mediastinal lymphadenectomy refers to the clearance of lymph nodes in the middle and lower posterior mediastinum, extension along right side of trachea and upper mediastinum is termed extended lymphadenectomy. The benefit of an extended versus standard lymphadenectomy in esophageal cancer is unclear.

Methods: The clinicopathologic data of 391 patients undergoing tri-incisional esophagectomy (McKeown type) for squamous cell carcinoma between 1995 and 2007 were analyzed retrospectively. There were 136 and 255 patients in the infracarinal and extended mediastinal lymphadenectomy groups, respectively. The outcome of these two groups and the clinical importance of right upper mediastinum lymph node metastases (LNM) were investigated.

Results: Both groups were comparable in clinicopathologic characteristics except tumor length (infracarinal vs extended group, 4.6 vs 5.2 cm, P = .023) and lymph node status. The 5-year overall survival rates were 29.7% and 27.3%, in the infracarinal and extended groups, respectively (P = .065). In the extended group, the factors correlated to right upper mediastinal LNM included neck LNM (hazard ratio [HR] 2.621, P = .029), abdominal LNM (HR 2.218, P = .016), and tumor locating in the upper/middle third of esophagus (HR 2.781, P = .014). The independent prognostic factors for overall survival included right upper mediastinal LNM (HR 1.964, P < .001), lower mediastinal LNM (HR 1.391, P = .039), and abdominal LNM (HR 1.538, P = .006).

Conclusion: The procedure of right upper mediastinum lymphadenectomy is not associated with better survival in patients with esophageal squamous cell carcinoma patients; the presence of upper mediastinum LNM predicted poor prognosis.
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http://dx.doi.org/10.1016/j.surg.2014.05.007DOI Listing
November 2014

Negative differential resistance behavior and memory effect in laterally bridged ZnO nanorods grown by hydrothermal method.

ACS Appl Mater Interfaces 2014 Apr 8;6(8):5432-8. Epub 2014 Apr 8.

Institute of Microelectronics and Advanced Optoelectronic Technology Center, National Cheng Kung University , Tainan 701, Taiwan.

A novel memory device based on laterally bridged ZnO nanorods (NRs) in the opposite direction was fabricated by the hydrothermal growth method and characterized. The electrodes were defined by a simple photolithography method. This method has lower cost, simpler process, and higher reliability than the traditional focused ion beam lithography method. For the first time, the negative differential resistance and bistable unipolar resistive switching (RS) behavior in the current-voltage curve was observed at room temperature. The memory device is stable and rewritable; it has an ultra-low current level of about 1 × 10(-13) A in the high resistance state; and it is nonvolatile with an on-off current ratio of up to 1.56 × 10(6). Moreover, its peak-to-valley current ratio of negative differential resistance behavior is greater than 1.76 × 10(2). The negative differential resistance and RS behavior of this device may be related to the boundaries between the opposite bridged ZnO NRs. Specifically, the RS behavior found in ZnO NR devices with a remarkable isolated boundary at the NR/NR interface was discussed for the first time. The memory mechanism of laterally bridged ZnO NR-based devices has not been discussed in the literature yet. In this work, results show that laterally bridged ZnO NR-based devices may have next-generation resistive memories and nanoelectronic applications.
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http://dx.doi.org/10.1021/am404875sDOI Listing
April 2014

Survival benefits of postoperative chemoradiation for lymph node-positive esophageal squamous cell carcinoma.

Ann Thorac Surg 2014 May 6;97(5):1734-41. Epub 2014 Mar 6.

Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.

Background: Little is known about the efficacy of chemoradiation therapy after surgery for patients with esophageal squamous cell carcinoma. This retrospective study aimed to determine whether postoperative chemoradiation improves survival compared with surgery alone.

Methods: Of 290 patients with esophageal squamous cell carcinoma, 104 received postoperative chemoradiation therapy (CRT group) and 186 underwent surgery alone (S group). Propensity score matching analysis was used to identify 56 well-balanced pairs of patients to compare outcomes.

Results: For N0 patients, overall survival (OS) and disease-free survival (DFS) were similar in both groups. For N+ patients, the median OS (31.0 versus 16.0 months) and the 3-year OS rate (45.8% versus 14.1%) were significantly higher in the CRT group than in the S group (p<0.001). Similarly, the median DFS (16.0 versus 9.0 months) and the 3-year DFS rate (24.1% versus 11.5%) were significantly higher in the CRT group than in the S group (p=0.002). In propensity-matched patients, a survival benefit was observed for N+ patients receiving postoperative chemoradiation (CRT versus S group: median OS 29.0 versus 16.0 months, 3-year OS rate 48.6% versus 16.8%; p=0.003). Disease-free survival (median DFS 11.0 versus 8.0 months, 3-year DFS rate 21.3% versus 12.5%) tended to be better in the CRT group than in the S group (p=0.057).

Conclusions: Postoperative chemoradiation therapy provided a survival benefit for patients with lymph node-positive esophageal squamous cell carcinoma.
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http://dx.doi.org/10.1016/j.athoracsur.2013.12.041DOI Listing
May 2014

Benzodiazepine-associated hepatic encephalopathy significantly increased healthcare utilization and medical costs of Chinese cirrhotic patients: 7-year experience.

Dig Dis Sci 2014 Jul 31;59(7):1603-16. Epub 2014 Jan 31.

Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

Background And Objectives: In cirrhosis, hypersensitivity to benzodiazepines (BZD) and precipitating hepatic encephalopathy (HE) have been reported. The aim of this study was to evaluate the safety, economic impact and modifiable factors that are associated with the excess risk of BZD-associated HE in cirrhotic patients.

Methods: Between July 2005 and March 2012, 1,612 Chinese cirrhotic patients with and without using long-t 1/2-BZD or short-t 1/2-BZD were enrolled and followed up for 6 months.

Results: Among BZD users, the per-person HE-related healthcare utilization and medical costs were found to have progressively increased from 2005 to 2012. Cirrhotic BZD users had a higher percentage of smoking, alcohol drinking, simultaneous consumption of non-BZD drugs, and had a higher incidence of non-cirrhotic chronic illness than non-BZD users. Multivariate analysis indicated that hypoalbuminemia (<3 g/dL), long-acting (t 1/2 > 12-h), high-dosage (>1.5 defined daily dose equivalents) and long-duration (>2-months) BZD use, carrier of variant genotypes (AG + GG) of GABRA 1 (rs2290732) and having the wild genotype (TT) of GABRG 2 (rs211037) were significant predictors of the development of BZD-associated HE in cirrhotic patients. Additionally, synergistic effects of the above significant predictors on BZD-associated HE risk could be identified.

Conclusions: Our study confirms the clinical and economic impact of BZD-associated HE in cirrhotic BZD-users. Accordingly, extra caution is needed when treating cirrhotic BZD users with the above risk factors in order to avoid the BZD-associated HE in cirrhotic patients.
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http://dx.doi.org/10.1007/s10620-013-3021-2DOI Listing
July 2014