Background: Additional data regarding the ability of navigational bronchoscopy (NB) to provide sufficient material for programmed death-ligand 1 (PD-L1) expression is needed. We performed a retrospective study of NB cases at our institution to determine performance of NB in providing adequate samples for PD-L1. Methods: We conducted a retrospective review of all consecutive NB procedures performed at our institution from January 1, 2018 to August 4, 2020 that involved biopsies of a lung nodule/mass with a diagnosis of non-small cell lung cancer (NSCLC). The primary outcome was adequacy of material for PD-L1 testing. All procedural, demographic, and diagnostic data were collected. The association of factors with PD-L1 adequacy was evaluated with rate ratios (RR) using modified Poisson regression models with robust standard errors. Results: A total of 102 NB procedures with a diagnosis of NSCLC were performed over a 2-year period. The mean [standard deviation (SD)] nodule size was 25.0 [interquartile range (IQR), 18.0–32.0] mm and 57.8% (59/102) had a bronchus sign; 73% (68/93, 9 missing data) of samples were adequate for PD-L1 testing. Radial endobronchial ultrasound (REBUS) was utilized in 99% (101/102) of biopsies; a concentric or eccentric view was observed in 78.2% (79/101) and 16.8% (17/101), respectively. Transbronchial biopsy (TBBX) was performed in 92.2% (94/102). Only 4% (4/102) of cases required additional biopsies with either computed tomography (CT) guided transthoracic or surgical biopsies due to insufficient bronchoscopy tissue. No factors were predictive of PD-L1 adequacy in regression models. Conclusions: NB demonstrated good performance in obtaining adequate samples for PD-L1 testing. Only 4% of patients required additional procedures for more tissue when clinically indicated. However, additional study is needed to validate these results against surgical resection specimens.

Thoracic surgery in Palestine ran across a significant shift in the past couple of years, moving from performing all surgeries by open thoracotomy incision to the current rate of more than two-thirds of surgeries being conducted using Uniportal video-assisted thoracic surgery (VATS). Thoracic surgeons most commonly deal with lung cancer, followed by chest trauma, inflammatory or infectious diseases, and congenital malformations of the chest. One of the most prominent strengths that Palestinian thoracic surgeons have is their extensive experience in managing trauma and hydatid cyst patients. While the limited number of thoracic surgeons, the complex referral process between governmental and private hospitals, and the late presentation of lung cancer patients are considered the specialty’s weaknesses. Despite the challenges that thoracic surgeons face, they aim to overcome them by establishing lung cancer screening programs and enhancing the role of the primary healthcare system in order to achieve better outcomes in early diagnosed patients. Moreover, thoracic surgeons are relentlessly determined to take part in global research and publish their most notable contributions to share their experiences and prove that they can make a real change. Finally, the authors emphasize establishing a well-constructed thoracic surgery unit, which also includes a residency training program to ensure self-sufficiency in the future by having national graduates who will be the leading providers and researchers.

Background: Non-small cell lung cancer (NSCLC) is one of the most common malignant tumors worldwide. Lung adenocarcinoma (LUAD), the main subtype of NSCLC, has a poor prognosis. In recent years, circadian rhythm (CR)-related genes (CRRGs) have demonstrated associations with tumor occurrence and development, but the relationship between CRRGs and LUAD is not clear. Because of the correlation between CRRGs and tumors, we have reason to believe that CRRGs will become an important prognostic indicator for LUAD and guide the treatment of LUAD prognosis. Methods: Based on data from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) databases, we explored the biological function and immune cell infiltration of LUAD in different CR clusters and quantified CR genes using principal component analysis (PCA). Then, we built a CR scoring system (CRscore) to explore the relationship between CRRGs and LUAD prognosis. Results: Patients were divided into three clusters (A, B, and C). Biological characteristics, such as survival, immune cell infiltration, and gene enrichment, were significantly different among the three clusters (P<0.001). We then established the usefulness of the CR score, which could probably predict the prognosis of LUAD. Specifically, patients with a high CR score had a better prognosis and were more sensitive to chemotherapy than those with a low CR score. Conclusions: It is possible to use CRRGs to assess the prognosis of patients with LUAD. Quantification of CR using the CRscore tool in patients with LUAD maybe help to guide personalized cancer immunotherapy strategies in the future. Thus, the CRscore may be a prognostic tool for LUAD.

Background: The frozen elephant trunk technique is useful in aortic arch repair; however, some adverse events are associated with the Frozenix J-graft. We designed a technique to prevent these adverse events and achieve easy anastomosis (Total Exclusion of the Non-Stent part of Frozenix using an Everting anastomosis [TENSE]), and we assessed the outcomes of this technique in the present study. Methods: From April 2017 to May 2021, 44 patients with aortic arch disease underwent TENSE, in which the proximal stump of the stent part of Frozenix was matched to the distal anastomosis end between the left common carotid and left subclavian arteries. Results: The median age of the patients (35 men, 9 women) was 76.5 years. The predicted mortality and morbidity rates were 10.0% and 40.2%, respectively, according to the JapanSCORE II. Two patients (4.5%) died of aneurysm rupture and interstitial pneumonia, respectively, during hospitalization. Four patients (9.1%) who developed postoperative cerebral infarction had a previous cerebral infarction (P=0.010). No patients developed spinal cord complications or Frozenix kinking. Follow-up computed tomography showed no endoleaks or aneurysmal dilatation, although one patient had possible distal stent graft-induced new entry. Conclusions: Our strategy provided good early outcomes without spinal cord complications or Frozenix kinking in patients with aortic arch disease. Continuous follow-up is needed to avoid missing distal changes.

Background: Hypotension is a dangerous vital sign frequently encountered during the postoperative management of cardiac surgery. However, factors influencing the systemic vascular resistance index (SVRI), which is strongly related to hypotension, are not well understood. This study evaluated the characteristics of the SVRI according to the type of cardiac surgery. Methods: During this retrospective cohort study, we used the clinical data of patients who underwent cardiac surgery at Asahi General Hospital from April 2014 to August 2020. We analyzed their vital signs during the first 12 hours after surgery and evaluated the differences in vital signs among four types of surgery: mitral valve (MV) surgery; aortic valve (AV) surgery; coronary artery bypass grafting (CABG); and thoracic aorta (TA) surgery. Data were compared among these four groups using one-way analysis of variance every 2 hours postoperatively. Those with significant differences were further compared using the post hoc Tukey-Kramer test. Results: A total of 493 patients participated in this study. Overall, the SVRI decreased within 2 hours after the cardiopulmonary bypass surgery. The SVRI after MV surgery was significantly lower than that after other surgery types. The doses of inotropes used for MV surgery and TA surgery were significantly greater than those used for the other surgery types. Conclusions: The SVRI changes significantly after cardiac surgery and may decrease, especially after MV surgery. For better results, it is necessary to consider the differences in the SVRI that are associated with different types of cardiac surgery.

The FLAURA study comparing the 3rd-generation epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (-TKI) osimertinib versus a 1st-generation EGFRTKI such as gefitinib or erlotinib clearly demonstrated the superior efficacy of osimertinib in EGFR-mutated non-small cell lung cancer (NSCLC) patients (1,2). As a result, osimertinib has since then become the preferred first-line therapeutic option in this setting, at least for the patients who harbor a common EGFR exon 19 deletion or exon 21 L858R mutation. On the other hand, the optimal treatment approach to be offered at the time of acquired resistance to osimertinib remains unsettled. While continuing osimertinib beyond progression with or without the addition of local ablative therapy is an option for some patients with oligoprogressive disease (3,4), platinumdoublet chemotherapy should be offered in fit patients with rapid systemic progression (3,5).