Synchronous multiple primary lung cancer (sMPLC) exhibits distinct histopathological characteristics among pulmonary nodules. However, a comprehensive understanding of the somatic mutation landscape and transcriptome heterogeneity is lacking. Therefore, our study aims to meticulously investigate genomic distinctions among multiple pulmonary nodules within individual patients. We performed targeted DNA sequencing on tumor specimens and conducted bulk RNA transcriptome analysis on 53 multiple nodules originating from 26 lung cancer patients. The multiple nodules from the same patient was determined as major nodule and minor nodule. Additionally, the tumor tissues underwent histopathological evaluation through H E staining, complemented by a comprehensive series of immunohistochemistry (IHC) analyses to detect protein expression. The detected protein markers encompassed PD-L1, Ki67, and others. For the 53 nodule samples from 26 MPLCs patients, EGFR was the mostly mutated genes, and the TP53 mutation frequency was notably different between major and minor nodules. Furthermore, pathway enrichment analysis based on the differentially expressed genes (DEGs) between major and minor nodules revealed the significantly active cell cycle and p53 pathways in the major nodules. Additionally, both major and minor nodules demonstrated mostly similar immune microenvironment and PD-L1 protein expression, and a significantly higher expression of Ki67. A noteworthy suppression was observed in the immune microenvironment in nodules, revealed by the expression of macrophage, neutrophils, and NK cells. Furthermore, minor nodules exhibited a modestly elevated expression of macrophages compared to major nodules. Additionally, among the significantly up-regulated cell cycle-related genes in the major nodules when compared with minor nodules, CCNE1 mRNA expression demonstrated significant correlation with poor prognosis in the lung cancer. Furthermore, the MYC inhibitor demonstrated more sensitivity for the major nodules than minor nodules. This study validated molecular distinctions between samples from major and minor nodules in patients with sMPLC at both genomic and transcriptomic levels. The major nodules exhibited heightened activity in tumor cell proliferation pathways and demonstrated malignancy-related biological characteristics, which correlated with pathological assessment results.

So far, the monoclonal hypothesis of tumor occurrence and development cannot be justified. The genetic diversity selection hypothesis for the occurrence and development of lung cancer links Mendelian genetics with Darwin's theory of evolution, suggesting that the genetic diversity of tumor cell populations with polyclonal origins-monoclonal selection-subclonal expansion is the result of selection pressure. Normal cells acquire mutations in oncogenic driver genes and have a selective advantage over other cells, becoming tumor initiating cells; In the interaction with the tumor microenvironment (TME), the vast majority of initiating cells are recognized and killed by the human immune system. If immune escape occurs, the incidence of malignant tumors will greatly increase, and subclonal expansion, intratumour heterogeneity, etc. will occur. This article proposed the hypothesis of genetic diversity selection and analyzed its clinical significance.

ABSTRACT:This expert consensus reviews current literature and provides clinical practice guidelines for the diagnosis and treatment of multiple ground glass nodule-like lung cancer. The main contents of this review include the following: ① follow-up strategies, ② differential diagnosis, ③ diagnosis and staging, ④ treatment methods, and ⑤ post-treatment follow-up.

With the popularization of chest computed tomography (CT) lung cancer screening, the detection rate of peripheral pulmonary nodules is increasing day by day. Some patients could make clear diagnoses and receive early treatment by obtaining biopsy specimens. Transbronchial lung biopsy (TBLB) is one of the non-surgical biopsy methods for peripheral pulmonary nodules, which has less trauma and lower incidence of complications compared to percutaneous thoracic needle biopsy (PTNB). However, the diagnostic rate of TBLB is about 70%, which is still inferior to that of PTNB, which is about 90%. Since 2018, robot assisted bronchoscopy systems have been applied in clinical practice. This article reviews their application in further improving the diagnostic rate of peripheral pulmonary nodules by TBLB.

BACKGROUND:With the extensive application of segmental lung resection in the treatment of early-stage lung cancer, how to complete segmentectomy more accurately and minimally invasively has become a research hotspot. The aim of this study is to explore the application of three-dimensional computed tomography bronchography and angiography (3D-CTBA) combined with perfusion area recognition technique in single-hole thoracoscopic complex segmentectomy.METHODS:From January 2021 to January 2022, the clinical data of 112 consecutive patients undergoing single-port thoracoscopic complex segmentectomy in the Department of Thoracic Surgery, Xuanwu Hospital, Capital Medical University were retrospectively analyzed. The three-dimensional reconstruction combined with perfusion area identification technique was used to perform the operation and the clinical data were analyzed.RESULTS:The average operation time was (141.1±35.4) min; the initial time of intersegmental plane display was (12.5±1.7) s; the maintenance time of intersegmental plane was (114.3±10.9) s; the intersegmental plane was clearly displayed (100%); the amount of bleeding was [10 (10, 20)] mL; the total postoperative drainage volume was (380.5±139.7) mL; the postoperative extubation time was (3.9±1.2) d; and the postoperative hospitalization time was (5.2±1.6) d. Postoperative complications occurred in 8 cases.CONCLUSIONS:The advantages of 3D-CTBA combined with perfusion area recognition technique are fast, accurate and safe in identifying intersegmental boundary in single-port thoracoscopic complex segmentectomy, which could provide guidances for accuratding resection of tumors, shortening operation time and reducing surgical complications.

目的:回顾性评价CT引导下经皮射频消融(radiofrequency ablation,RFA)治疗全肺切除术后转移癌的可行性、有效性和安全性.方法:2010年01月至2022年05月,5例单肺转移癌患者(5例男性,平均年龄59.6岁),共接受了8次RFA治疗.4例患者为原发肺癌术后转移癌,1例患者为肾盂输尿管肿瘤肺转移.其中2例患者因肿瘤局部复发而分别接受了2次和3次RFA.8个RFA治疗的肿瘤大小2.0～5.0 cm(平均3.0 cm).根据RFA后立即进行的CT检查及临床随访结果评估RFA治疗全肺切除术后转移癌的可行性、有效性及安全性.结果:术后并发症包括气胸(37.5％)、胸痛(37.5％)以及以低热为主要表现的消融后综合征(25.0％).没有一例患者在手术期间或RFA后30天内死亡.死亡病例存活期分别为3个月、25个月、33个月.1例首次RFA后38个月随诊仍然生存,1例术后3个月随诊仍然生存.结论:RFA可以在全肺切除术后提供局部肿瘤控制,并且可以重复射频.RFA治疗全肺切除术后转移癌安全、可行、有效.

目的 探讨术前辅助定位联合CT三维重建技术在以肺结节为中心的单孔胸腔镜联合亚段/肺段切除术中的临床应用.方法 回顾性分析2019年12月—2021年10月于首都医科大学宣武医院行联合亚段/肺段切除术30例患者的临床资料,其中男19例、女11例,平均年龄56.4(32.0～71.0)岁.术前应用CT引导下注射定位胶辅助定位肺结节,用Mimics 21.0软件三维重建技术做手术规划,术中根据定位胶的位置和CT三维重建图像行胸腔镜联合亚段/肺段切除术.结果 全组患者均顺利完成手术,无中转开胸或肺叶切除.平均肿瘤直径(11.6±3.5)mm,平均结节距离脏层胸膜(13.6±5.6)mm,平均实际切缘宽度(25.0±6.5)mm,平均手术时间(110.2±23.8)min,平均淋巴结清扫站数(6.5±2.4)站,平均术中出血量(50.8±20.3)mL,平均胸腔引流管留置时间(3.2±1.1)d,平均术后住院时间(4.5±1.7)d.术后并发症包括皮下气肿1例、心房颤动1例、痰中带血1例.结论 术前CT引导下注射医用胶辅助定位联合CT三维重建技术,在以肺结节为中心的单孔胸腔镜联合亚段/肺段切除术中安全可行,既保证了手术切缘,又最大限度地保留了肺组织,达到解剖学切除的目的.

目的 系统评估优质护理服务在胸腺瘤合并重症肌无力患者中的临床疗效、不良反应发生率以及患者满意度.方法 使用计算机检索国内外数据库在2023 年4 月之前公开发表的随机对照临床试验(RCTs),国内数据库包括万方、中国知网、维普,国外数据库包括PubMed、SCI、the Cochrane Library,并运用Cochrane偏倚评价工具对符合纳入标准的文献进行质量评价,提取研究特征和疗效评价相关数据,使用Revman软件进行Meta分析.结果 最终共纳入15 项RCTs研究,共计1105 例.7 项研究538 例报告了住院时间结果,其效应值MD(95%CI)为-3.55(-4.96,-2.15).14项研究1005例报告了不良反应发生率,其效应值MD(95%CI)为0.17(0.11,0.26).7 项研究519 例报告了护理满意度,其效应值MD(95%CI)为7.59(3.95,14.56).13 项研究916 例报告了重症肌无力危象发生率,其效应值MD(95%CI)为 0.25(0.13,0.49).13 项研究 916 例报告了肺部感染发生率,其效应值MD(95%CI)为0.17(0.10,0.30).结论 优质护理服务在胸腺瘤合并重症肌无力患者中的临床疗效较好,不良反应发生率较低,患者满意度较高.

《重症肌无力外科治疗中国临床专家共识》于2022 年发表.该文围绕重症肌无力的临床分型、手术基础、术前准备、手术适应证、手术方式和疗效评价等方面进行了解读.

目的 分析全身型重症肌无力(MG)患者胸腺切除术后肌无力危象(POMC)的影响因素.方法 回顾性分析2018 年1 月至2022 年6 月于首都医科大学宣武医院胸外科接受胸腺切除术的116 例全身型MG患者的临床资料,根据术后是否出现POMC分为POMC组38 例和非POMC组78 例.对其临床特点进行单因素和多因素分析,确定POMC的影响因素.结果 POMC组的机械通气时间、住ICU时间显著长于非POMC组(P＜0.001).POMC组和非POMC组在改良Osserman分型、合并胸腺瘤、手术方式、用力肺活量(FVC)、第一秒用力呼气容积(FEV1)以及血清白蛋白与球蛋白比值(AGR)等方面比较差异均有统计学意义(P＜0.05).多因素logistic回归分析结果显示,Osserman分型、FVC、FEV1 以及AGR是POMC发生的影响因素(P＜0.05).结论 术前Osserman分型、FVC、FEV1 以及AGR是全身型MG患者发生POMC的影响因素,可为临床工作提供参考.

Oligometastasis can be regarded as a transition state between early metastasis and extensive metastasis (limited tumor load, unique tumor biological behavior). Due to the relatively limited number of metastatic foci and the number of affected organs, there is a potential chance of cure after active systemic and local treatment. With the rapid development of molecular targeted drug therapy and immunotherapy, local therapy for oligometastatic non-small cell lung cancer (NSCLC), including oligorecurrence and oligoprogression, has received increasing attention. In this paper, the relevant research, efficacy, influencing factors, safety and indications of local therapy such as surgery and thermal ablation were discussed.
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BACKGROUND:The localization of pulmonary nodules is related to whether the lesions can be found and removed accurately and quickly. It is an important link for the success of minimally invasive video-assisted thoracic surgery (VATS). This study investigated the feasibility of medical glue localization under VATS video-assisted thoracoscopic computed tomography (CT) guidance for single pulmonary nodule and more than two pulmonary nodules, and compared with the accuracy and safety of single nodule localization. METHODS:A retrospective analysis of the clinical data of patients who underwent unilateral CT-guided medical glue localization before VATS from November 2018 to March 2021 were performed, the patients was divided into multiple pulmonary nodules group (localized nodules ≥2) and single pulmonary nodule group according to the number of localized nodules. The localization time, success rate and complication rate of the two groups were compared. RESULTS:There were 126 nodules in the two groups, including 62 in single pulmonary nodule group and 64 in multiple pulmonary nodules group. The average single nodule localization time was (13.23±4.5) min in single pulmonary nodule group and (10.52±2.8) min in multiple pulmonary nodules group, the difference between the two groups is statistically significant (P<0.05). The localization success rate of single pulmonary nodule group and multiple pulmonary nodules group were 100% and 98.4% separately, the difference between the two groups was not statistically significant (P>0.05). All VATS were successfully completed after localization. The incidence of pneumothorax was higher in multiple pulmonary nodules group than in single pulmonary nodule group (P=0.07). CONCLUSIONS:Compared with localization of single lung nodule, unilateral CT-guided medical glue localization for multiple pulmonary nodules before VATS is also feasible and accuracy, it is worthy of clinical application. But the higher rate of pneumothorax should be paid attention to.

近年来,随着新一代CT分辨率的提升、辐射剂量的降低、肺癌筛查的普及和人们健康保健意识的增强,肺结节的检出率越来越高.由于肺结节与肺癌关系密切,因此越来越受到关注.尽管早中期肺癌患者接受了完全性切除手术,但所有术后患者都存在复发转移风险.术后辅助或术前新辅助治疗可以提高生存率、降低复发转移率.因此多学科团队作为最佳模式为肺结节、肺癌患者的诊治提供了规范化、个体化方案.但实际操作过程中,多学科团队工作效率不高、患者参与度低,而以胸外科医生为主的多学科医生模式是其合理替代方案.

随着麻醉技术的完善、手术器械的改进、手术技巧的提高和围手术期管理的进步，肺结节和肺癌的诊治已经到了微创和精准的时代。现以微创和精准两大理念为基础，对诊断、分期、定位、治疗等一站式管理平台的现状进行评述，为该领域的学科建设提供参考。

Recent studies have shown that tumor immune microenvironment is closely related to tumor progression, metastasis, recurrence and response to treatment. Some immunotherapies also offer hope for cancer patients. However, the efficacy of tumor immunotherapy is uncertain and has some side effects. In order to enhance its efficacy, tumor immunotherapy combined with tumor thermal ablation has been studied. Thermal ablation has the advantages of minimally invasive, rapid recovery, safety, fewer complications, conformation, reliable effect, repeatable, low cost, and has become the fourth tumor treatment measure after surgery, radiotherapy, and drug therapy. It can directly kill tumor cells and modulate the immune system through a variety of mechanisms, although the corresponding mechanisms are not well understood, but combined tumor immunotherapy has been proposed to treat several solid malignancies. In this review, the current status and progress of thermal ablation combined with immunotherapy for lung tumor were reviewed, and further studies on the efficacy and safety of thermal ablation combined with immunotherapy were expected.
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Visceral pleural invasion (VPI) is one of the negative prognostic factors of non-small cell lung cancer (NSCLC). With the popularization of computed tomography (CT) screening for lung cancer, more and more ground-glass nodule (GGN) have been found. However, it remains unclear whether the relationship between the pleural deformation of lung cancer manifesting as ground-glass opacity (GGO) and VPI affects the effect of sub-lobectomy, which is reviewed in this paper.
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The main contents of the Clinical Practice Guidelines on Image-Guided Thermal Ablation (IGTA) of Primary and Metastatic Lung Tumors (2022 Edition) include the following: epidemiology of primary and metastatic lung tumors; the concepts of the IGTA and common technical features; procedures, indications, contraindications, outcomes evaluation, and related complications of IGTA on primary and metastatic lung tumors; and limitations and future development.

目的 研究磨玻璃结节(GGN)预测非小细胞肺癌(NSCLC)浸润的情况.方法 回顾性选择2014年1月至2019年6月经手术切除病理证实为GGN型NSCLC患者244例,分析其CT特征和病理检查结果,评估GGN与NSCLC浸润的关联性.结果 244例GGN病理检查为腺癌,其中原位腺癌(AIS)44例,微浸润腺癌(MIA)53例,浸润性腺癌(IA)147例.9例支气管充气征GGN病理结果全部为IA.2例存在淋巴结转移.AIS组、MIA组和IA组在密度、分叶、毛刺、空泡征、支气管充气征、胸膜牵拉征、血管集束征,以及实性成分大小、实性成分比例和结节最大径方面比较差异有统计学意义(P<0.05).受试者工作特征(ROC)曲线分析结果显示,结节最大径、实性成分大小、实性成分比例具有预测NSCLC是否浸润的价值,其中以结节最大径的诊断效能最佳.结论 GGN大小可用于预测NSCLC是否浸润.

BACKGROUND:With the wide application of computed tomography (CT) in the screening of early lung cancer, more and more ground glass nodules (GGNs) have been found. Early intervention is helpful to improve the survival rate of lung cancer patients. Radiofrequency ablation (RFA) is an alternative option to manage primary or metastatic lung malignancies. The purpose of this study is to review the safety and clinical efficacy for lung GGN treated by RFA.METHODS:From June 2016 to March 2021, 24 patients with a total of 28 lung GGNs in our hospital underwent 28 sessions of RFA. There were 13 males and 11 females with an average age of (69.4±11.1) years. The size of GGN receiving RFA was (1.30±0.56) cm; The ablation range was (2.50±0.63) cm and ablation time was (15.00±8.68) min.RESULTS:The procedure of all RFAs went smoothly, no perioperative deaths occurred and no serious complications during the operation. The median follow-up was 25 months. One case died of myocardial infarction 2 months after operation. All 28 GGNs showed no evidence of local progression and the local control rate was 100.0%. Kaplan-Meier analysis showed that the 1-year and 2-year overall survival rates were 95.8% and 95.8%; the tumor specific survival rates were 100.0% and 100.0%, respectively.CONCLUSIONS:RFA is a safe, effective and minimally invasive technique for the treatment of lung GGNs.

Objectives: This retrospective study aimed to evaluate the safety and efficacy of thulium laser pulmonary wedge resection under thoracoscopy. Methods: Sixty cases of thoracoscopic pulmonary wedge resection by thulium laser and sixty cases with mechanical stapler from February 2015 to September 2018 were selected. The operation time, intraoperative hemorrhage, postoperative hospital stay, severe air leaks, drainage time, and complications (including postoperative hemorrhage, hemoptysis, atelectasis, and pulmonary infection) were compared between groups. Results: The thulium laser group showed a lower incidence of intraoperative hemorrhage (10.0 [5.0–20.0] ml vs. 15.0 [10.0–50.0] ml, P = 0.010) and a shorter postoperative hospital stay (3.9 ± 2.5 days vs. 4.9 ± 2.0 days, P = 0.031).There was no significant difference between groups in the operation time, postoperative drainage time, the occurrence of severe air leaks, or complication rate (P > 0.05). No patients were lost during follow?up (median follow?up time: 28.4 months, range: 18.0–36.0 months). No statistically significant difference in overall survival was found (P = 0.547). Conclusion: pulmonary wedge resection with thulium laser under thoracoscopy had better safety, less damage, and higher accuracy compared with the control group.