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Surgery of aspergilloma has been renowned to be technically challenging and has a high complication rate. We have already demonstrated an improved outcome as a result of a reduction in complex cases related to history of tuberculosis. In this paper we will evaluate whether this time trend has continued during recent years. Initial presentation and postoperative outcome of 33 patients who underwent surgical treatment between 1998 and 2009 were reviewed and compared with two previous reports (group 1: 55 patients from 1974 to 1991; group 2: 12 patients from 1992 to 1997). Underlying disease was tuberculosis in 15% of patients (57% in group 1, 17% in group 2), and 12% of patients had complex aspergillomas (80% in group 1, 41% in group 2). Postoperatively, there was no mortality (5% in group 1, 0% in group 2). Morbidity decreased progressively in terms of bleeding (44% in group 1, 9% in group 2, and 6% in recently, accrued patients), of pleural space problems (47%, 18% and 12%, respectively), and of prolonged hospital stay (32%, 8% and 6%, respectively). With a decreased postoperative complications rate after resection, contemporary surgery of aspergilloma is safe and offers satisfactory early and long-term results.

In thoracic surgery, extracorporeal life support (ECLS) techniques are performed to (I) provide a short to mid term extracorporeal mechanical support; (II) realize the gas exchanges; and (III)-depending the configuration of the circuit-substitute the failed heart function. The objective of this review is to describe the rational of the different ECLS techniques used in thoracic surgery and lung transplantation (LTx) with a specific attention to the vascular access. Venovenous extracorporeal membrane oxygenation (VV ECMO)is the most common ECLS technique used in thoracic surgery and represents the best strategy to support the lung function. VV ECMO needs peripheral vascular access. The selection between his double-site or single-site configuration should be decided according the level of O 2 requirements, the nosological context, and the interest to perform an ECLS ambulatory strategy. Venoarterial (VA) ECMO uses peripheral and/or central cannulation sites. Central VA ECMO is mainly used in LTx instead a conventional cardiopulmonary bypass (CPB) to decrease the risk of hemorrhagic issues and the rate of primary graft dysfunction (PGD).Peripheral VA ECMO is traditionally realized in a femoro-femoral configuration. Femoro-femoral VA ECMO allows a cardiocirculatory support but does not provide an appropriate oxygenation of the brain and the heart. The isolated hypercapnic failure is currently supported by extracorporeal CO 2 removal (ECCO 2 R) devices inserted in jugular or subclavian veins. The interest of the Novalung (Novalung GmbH, Hechingen, Germany) persists due to his central configuration indicated to bridge to LTx patients suffering from pulmonary hypertension. The increasing panel of ECLS technologies available in thoracic surgery is the results of a century of clinical practices, engineering progress, and improvements of physiological knowledges. The selection of the ECLS technique-and therefore the vascular access to implant the device-for a given nosological context trends to be defined according an evidence-based medicine.

Trichosporon mycotoxinivorans is a novel pathogen recently found in cystic fibrosis patients. We report the first case of a disseminated fatal infection with T. mycotoxinivorans associated with invasive Aspergillus fumigatus and Scedosporium apiospermum infection after lung and liver transplantation in a cystic fibrosis patient. CASE REPORTA 35-year-old man with cystic fibrosis (CF) was admitted for rapid respiratory deterioration and high-level oxygen requirements with respiratory acidosis. He was a nonsmoker and was still working actively as a farmer until a few days before his admission. His past medical history included sinonasal polyposis and diabetes mellitus. He was in good general condition despite a severe obstructive pulmonary disease that had been stable over the previous 5 years, with a forced expiratory volume in the first second at 20% of that predicted. He also had a 5-year bronchial colonization with Pseudomonas aeruginosa and Aspergillus fumigatus.Because of respiratory deterioration despite noninvasive ventilation and antibiotics, an extracorporeal membrane oxygenation, inotropic support, and hemodialysis were started and an emergency double lung transplantation (LT) was performed. The immunosuppression included basiliximab and high-dose methylprednisolone for induction, a standard dose of tacrolimus, mycofenolate mofetil, and methylprednisolone for maintenance. Due to immediate postoperative acute liver failure, an emergency liver transplantation was performed on day 2 post-LT. Another dose of basiliximab and high dose of methylprednisolone were given. Antifungal prophylaxis with caspofungin (70 mg) started on the day of LT was discontinued the next day due to liver dysfunction. Amyloidosis AA (deposition of amyloid protein A) was diagnosed on explanted liver. The patient's condition remained stable, although invasive ventilation and hemodialysis were maintained. Routine bronchoalveolar lavage specimens at days 1 and 6 post-LT were positive for P. aeruginosa (treated with ceftazidime, ciprofloxacin, and meropenem) and A. fumigatus. Caspofungin was resumed (50 mg daily) at day 6 post-LT because an Aspergillus galactomannan detection test (Platelia Aspergillus antigen; Bio-Rad) became positive in serum.On day 9 post-LT, nonfebrile sleepiness was noted. Within 4 days, the neurologic condition worsened, with tetraparesis and coma. Cerebral magnetic resonance imaging (MRI) showed multiple foci of cortical, subcortical, and periventricular hyperinten-

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Background:Identifying patients who will experience lung cancer recurrence after surgery remains a challenge. We aimed to evaluate whether mutant forms of epidermal growth factor receptor (EGFR) and Kirsten rat sarcoma viral oncogene homolog (KRAS) (mEGFR and mKRAS) are useful biomarkers in resected non-small cell lung cancer (NSCLC).Methods:We retrospectively reviewed data from 841 patients who underwent surgery and molecular testing for NSCLC between 2007 and 2012.Results:mEGFR was observed in 103 patients (12.2%), and mKRAS in 265 (31.5%). The median overall survival (OS) and time to recurrence (TTR) were significantly lower for mKRAS (OS: 43 months; TTR: 19 months) compared with mEGFR (OS: 67 months; TTR: 24 months) and wild-type patients (OS: 55 months; disease-free survival (DFS): 24 months). Patients with KRAS G12V exhibited worse OS and TTR compared with the entire cohort (OS: KRAS G12V: 26 months vs Cohort: 60 months; DFS: KRAS G12V: 15 months vs Cohort: 24 months). These results were confirmed using multivariate analyses (non-G12V status, hazard ratio (HR): 0.43 (confidence interval: 0.28–0.65), P<0.0001 for OS; HR: 0.67 (0.48–0.92), P=0.01 for TTR). Risk of recurrence was significantly lower for non-KRAS G12V (HR: 0.01, (0.001–0.08), P<0.0001).Conclusions:mKRAS and mEGFR may predict survival and recurrence in early stages of NSCLC. Patients with KRAS G12V exhibited worse OS and higher recurrence incidences.

BackgroundHomeostatic turnover of the extracellular matrix conditions the structure and function of the healthy lung. In lung transplantation, long-term management remains limited by chronic lung allograft dysfunction, an umbrella term used for a heterogeneous entity ultimately associated with pathological airway and/or parenchyma remodeling.ObjectiveThis study assessed whether the local cross-talk between the pulmonary microbiota and host cells is a key determinant in the control of lower airway remodeling posttransplantation.MethodsMicrobiota DNA and host total RNA were isolated from 189 bronchoalveolar lavages obtained from 116 patients post lung transplantation. Expression of a set of 11 genes encoding either matrix components or factors involved in matrix synthesis or degradation (anabolic and catabolic remodeling, respectively) was quantified by real-time quantitative PCR. Microbiota composition was characterized using 16S ribosomal RNA gene sequencing and culture.ResultsWe identified 4 host gene expression profiles, among which catabolic remodeling, associated with high expression of metallopeptidase-7, -9, and -12, diverged from anabolic remodeling linked to maximal thrombospondin and platelet-derived growth factor D expression. While catabolic remodeling aligned with a microbiota dominated by proinflammatory bacteria (eg, Staphylococcus, Pseudomonas, and Corynebacterium), anabolic remodeling was linked to typical members of the healthy steady state (eg, Prevotella, Streptococcus, and Veillonella). Mechanistic assays provided direct evidence that these bacteria can impact host macrophage-fibroblast activation and matrix deposition.ConclusionsHost-microbes interplay potentially determines remodeling activities in the transplanted lung, highlighting new therapeutic opportunities to ultimately improve long-term lung transplant outcome.

Prophylactic postoperative NIV did not reduce the rate of ARE in COPD patients undergoing lung resection surgery and did not influence other postoperative complications rates, mortality rates, and duration of ICU and hospital stay.