OBJECTIVES: The International Association for the Study of Lung Cancer (IASLC) proposed further subdivisions of pathological N1 (pN1) and pN2 by including the location and the number of involved lymph node (LN) stations. We adopted the subdivided N descriptors and reclassified them according to the involved LN zones or LN stations, and compared the discrimination abilities of the 2 classifications.METHODS: A retrospective analysis was carried out on patients who underwent complete resection with systematic LN dissection for non-small cell lung cancer diagnosed as pathological stages I–III between 2006 and 2015. N classification was grouped into 6 categories: no LN involvement, single-station N1, multiple-station N1, single-station N2 without N1, single-station N2 with N1 and multiple-station N2. LN zones were defined by grouping the LN stations: peripheral or hilar for N1 nodes, and upper mediastinal, lower mediastinal, aortopulmonary and subcarinal for N2 nodes.RESULTS: A total of 3971 patients (2451 men, median age: 63 years) were analysed. Median follow-up was 59 months. A multivariable analysis showed that the subdivided N descriptors based on LN station and zone were both independent prognostic factors in terms of both overall survival and freedom from recurrence. Whether multiple LN involvements were confined within a single LN zone was a significant prognostic factor in the multiple-station N2 group. A zone-based classification showed similar discrimination ability to the station-based classification.CONCLUSIONS: Both LN station- and zone-based classifications showed favourable prognostic discrimination abilities. The new N classifications could be considered for future revisions of tumour, node and metastasis (TNM) staging system for lung cancer.

OBJECTIVES: Although the standard treatment for pathological N2 (pN2) non-small-cell lung cancer (NSCLC) patients is definitive chemoradiation, surgery can be beneficial for resectable pN2 disease. Herein, we report the long-term clinical outcomes of upfront surgery followed by adjuvant treatment for selected patients with resectable pN2 disease. METHODS: We performed a retrospective analysis of clinical outcomes for patients with pN2 disease who underwent surgery as the first-line therapy. Multivariable Cox regression analysis was used to identify the significant factors for overall survival (OS) and recurrence-free survival. RESULTS: From 2004 to 2015, a total of 706 patients with pN2 NSCLC underwent complete anatomical resection at our institution. The patients’ clinical N stages were cN0, 308 (43.6%); cN1, 123 (17.4%) and cN2, 275 (39.0%). Adjuvant chemotherapy, radiotherapy and chemoradiotherapy were administered to 169 (23.9%), 115 (17.4%) and 299 patients (42.4%), respectively. With a median follow-up of 40 months, the respective median time and 5-year rate of OS were 52 months and 44.7%. According to subdivided pN2 descriptors, the median OS time was 80, 53 and 37 months for patients with pN2a1, pN2a2 and pN2b, respectively. Adjuvant chemotherapy was a significant prognostic factor for both OS [hazard ratio (HR) 0.39, 95% confidence interval (CI) 0.28–0.52; P < 0.001] and recurrence-free survival (HR 0.42, 95% CI 0.30–0.58; P < 0.001). CONCLUSIONS: Upfront surgery followed by adjuvant therapy for resectable N2 disease showed favourable outcomes compared to those reported in previous studies. Adjuvant chemotherapy is essential to improve the prognosis for patients undergoing upfront surgery for N2 disease.

Right heart decompensation is a fatal complication in patients with respiratory failure, particularly in those transitioned to lung transplantation using veno-venous extracorporeal membrane oxygenation (V-V ECMO). In these patients, veno-arterial (V-A ECMO) or veno-arterialvenous extracorporeal membrane oxygenation (V-AV ECMO) is used to support both cardiac and respiratory function. However, these processes may increase the risk of device-related complications such as bleeding, thromboembolism, and limb ischemia. In the present case, a 64-year-old male patient with idiopathic pulmonary fibrosis developed respiratory failure and commenced treatment with V-V ECMO as a bridge to lung transplantation. Unfortunately, the patient developed right heart decompensation and required both cardiac and respiratory support during treatment with V-V ECMO. Instead of adding arterial cannulation, he was switched to a novel configuration, a right ventricular assist device with an oxygenator (Oxy- RVAD) using ECMO, with drainage cannulation from the femoral vein and return cannulation to the main pulmonary artery. The patient was successfully bridged to lung transplantation without serious complications after 10 days of Oxy-RVAD support. To the best of our knowledge, this is an extreme rare and challenging case of Oxy-RVAD using ECMO in a patient successfully bridged to lung transplantation.

Background: Although bridge to lung transplantation (BTT) with extracorporeal membrane oxygenation (ECMO) is increasingly performed, the impact of BTT and its duration on post-transplant outcomes are unclear.Methods: We retrospectively reviewed medical records of adult patients who underwent lung or heart-lung transplantation in our institution between January 2008 and December 2018. Data were compared in patients who did (n = 41; BTT) and did not (n = 36; non-BTT) require pre-transplant ECMO support. Data were also compared in patients who underwent short-term (<14 days; n = 21; ST-BTT) and long-term (≥14 days; n = 20; LT-BTT) BTTs.Results: Among 77 patients included, 51 (66.2%) were male and median age was 53 years. The median bridging time in the BTT group was 13 days (interquartile range [IQR], 7–19 days). Although simplified acute physiologic score II was significantly higher in the BTT group (median, 35; IQR, 31–49 in BTT group vs. median, 12; IQR, 7–19 in non-BTT group;p<0.001), 1-year (73.2% vs. 80.6%; p = 0.361) and 5-year (61.5% vs. 61.5%; p = 0.765) post-transplant survival rates were comparable in both groups. Comparison of ST- and LT-BTT subgroups showed that 1-year (90.5% vs. 55.0%; p = 0.009) and 5-year (73.0% vs. 48.1%; p = 0.030) post-transplant survival rates were significantly higher in ST-BTT group. In age and sex adjusted model, the LT-BTT was an independent risk factor for 1-year post-transplant mortality (hazard ratio, 3.019; 95% confidence interval, 1.119–8.146; p = 0.029), whereas the ST-BTT was not.Conclusions: Despite the severe illness, the BTT group showed favorable post-transplantation outcomes, particularly those bridged for less than 14 days.

OBJECTIVES: Thymectomy is the treatment of choice for thymomatous myasthenia gravis (MG) for both oncological and neurological aspects. However, only a few studies comprising small numbers of patients have investigated post-thymectomy neurological outcomes. We examined post-thymectomy long-term neurological outcomes and predictors of thymomatous MG using a multi-institutional database. METHODS: In total, 193 patients (47.3 ± 12.0 years; male:female = 90:103) with surgically resected thymomatous MG between 2000 and 2013 were included. Complete stable remission (CSR) and composite neurological remission (CNR), defined as the achievement of CSR and pharmacological remission after thymectomy, were evaluated. Predictors for CSR and CNR were examined by Cox regression analysis. RESULTS: The median duration between MG and thymectomy was 3.1 months. In addition, 161 patients (83.4%) had symptoms less than Myasthenia Gravis Foundation of America clinical classification III. All patients underwent an extended thymectomy; there were no perioperative deaths. The 10-year cumulative probability of CSR and CNR was 36.9% and 69.1%, respectively. Mild preoperative symptoms were a significant predictor for CSR (P = 0.040), and a large tumour was a predictor for CNR (P < 0.001). Patients with a large tumour were associated with early MG onset and no steroid treatment. Surgical methods, thymoma stage and histological subtypes were not associated with long-term neurological remission. CONCLUSIONS: Large tumour size and preoperative mild symptoms were predictors for long-term neurological outcome in thymomatous MG. Considering that patients with early onset of MG and no immunosuppressive treatment tend to have large tumours, early surgical intervention for patients with thymomatous MG having mild symptoms might be beneficial for controlling neurological outcomes.