Po-Kuei Hsu

Iatrogenic chylothorax is generally attributed to injury to the main thoracic duct and its tributaries. However, the current anatomic classification of the thoracic duct primarily focuses on the morphology and outlet of the main duct. Using thoracic ductography, this study aimed to identify the presence of a large-caliber transverse branch of the thoracic duct and to evaluate its role as a cause of chylothorax. This retrospective study included 25 patients who underwent thoracic ductography for chylous leakage between May 2020 and May 2025. Thoracic duct branching patterns and leakage sites were correlated with surgical history, and clinical outcomes following lymphatic embolization were analyzed. A single thoracic duct was identified in 52% of patients, whereas 48% had at least one large-caliber transverse branch crossing the mediastinum at the carinal or upper tracheal level. All patients ( n = 12) who developed chylothorax after surgery at the mediastinum had a transverse branch, which was confirmed as the source of lymphatic leakage in 100% of these cases. In contrast, leaks following surgery at the left mediastinal border originated from the main thoracic duct. There was statistically significant lower pretreatment daily drainage volume in patients with transverse branch injury than in those with main duct injury ( p = 0.048). Large-caliber transverse branches of the thoracic duct may be more prevalent than previously recognized and represent a frequent cause of iatrogenic chylothorax when injured. Improved awareness of this anatomic variant may generate hypotheses for future preventive strategies during mediastinal procedures.

Ying-Che Ting, M.D., Ling-I Chien, B.S., Chia Liu, M.D., Yi-Ying Lee, M.D., Chien-Sheng Huang, M.D., Yu-Chung Wu, M.D., Po-Kuei Hsu, M.D., Ph.D.. J Chest Surg -0001;0:. https://doi.org/10.5090/jcs.25.108

Summary: Thoracic duct obliteration (TDO), either ligation or resection, is performed during esophagectomy to enhance oncological radicality or manage chylothorax. However, its nutritional and oncological effects are unclear. We retrospectively analyzed patients undergoing esophagectomy for esophageal cancer at our institution between January 2016 and May 2024. We assessed laboratory parameters and computed tomography-derived body composition indices from diagnosis to 9–12 months postoperatively (15–25 months for laboratory data). We also analyzed nutritional indices, overall survival (OS), and recurrence-free survival (RFS). A total of 82 patients underwent TDO, and 313 did not (non-TDO). After propensity score matching, we included 75 TDO and 150 non-TDO patients. The TDO group achieved a higher lymph node yield, without affecting chylothorax incidence, nutritional or body composition indices, OS, RFS, or recurrence patterns between the TDO and non-TDO groups. However, analysis of neoadjuvant therapy (NAT) subgroup found more subcutaneous fat loss 3–6 months postoperatively in TDO patients (−55.35% vs. −32.93%, P = 0.002). This difference was no longer evident at 9–12 months (−42.97% vs. −42.89%, P = 0.859). Among the NAT patients, thoracic duct resection was associated with better OS and RFS than non-resection (3-year OS: 77.15% vs. 57.25%, P = 0.038; 3-year RFS: 72.41% vs. 48.08%, P = 0.049). In conclusion, TDO during esophagectomy does not compromise long-term nutritional or oncological outcomes in patients with esophageal cancer. In the NAT subgroup, transient subcutaneous fat loss was evident during the early postoperative period but was no longer apparent after a year. Survival outcomes were better among NAT patients who received thoracic duct resection.

Ping-Chung Tsai, M.D., Chia Liu, M.D., Ling-I Chien, M.S., En-Kuei Tang, M.D., Chien-Sheng Huang, M.D., Ph.D., Chih-Cheng Hsieh, M.D., Ph.D., Han-Shui Hsu, M.D., Ph.D., Po-Kuei Hsu, M.D., Ph.D.. J Chest Surg -0001;0:. https://doi.org/10.5090/jcs.25.111

Chia Liu, M.D., Ling-I Chien, B.S., Yi-Ping Hung, M.D., Ph.D., Tzu-Yu Lai, M.D., Ph.D., Chien-Sheng Huang, M.D., Ph.D., Han-Shui Hsu, M.D., Ph.D., Ming-Huang Chen, M.D., Ph.D., Pin-I Huang, M.D., Ph.D., Po-Kuei Hsu, M.D., Ph.D.. J Chest Surg -0001;0:. https://doi.org/10.5090/jcs.25.040

Background: Metaplastic thymoma (MT) is an exceptionally rare, biphasic epithelial tumor of the thymus, officially designated by the World Health Organization in 2004. It is characterized histologically by intermixed epithelioid and spindle cell components and harbors a unique YAP1-MAML2 gene fusion, distinguishing it from other thymoma subtypes which typically carry GTF2I mutations. Fewer than 100 cases have been documented in the English literature, often presenting as incidental anterior mediastinal masses in asymptomatic middle-aged women. Case Description: We present three cases of MT to enrich the current understanding of this rare entity. The first case involved a 47-year-old woman with non-specific symptoms and a 6.5-cm anterior mediastinal mass, managed successfully with bilateral video-assisted thoracoscopic thymectomy followed by radiotherapy, with no recurrence at 11 years. The second case was an asymptomatic 37-year-old woman with a 3.1-cm lesion detected during routine health screening. She underwent curative resection without adjuvant therapy and remains disease-free at 2 years. The third case involved a 56-year-old woman with long-standing chest tightness and a 10-cm anterior mediastinal tumor, excised via median sternotomy with no evidence of recurrence at 2 years postoperatively. Pathologically, all three tumors displayed the characteristic biphasic morphology of MT. Immunohistochemistry revealed expression of epithelial markers (CK AE1/AE3, p40, p63), and fluorescence in situ hybridization confirmed MAML2 rearrangement. RNA sequencing identified in-frame YAP1-MAML2 fusions in two cases. Conclusions: MT typically presents as a well-circumscribed anterior mediastinal mass in asymptomatic middle-aged women and demonstrates excellent outcomes with complete surgical resection. The presence of YAP1-MAML2 fusion serves as a valuable diagnostic marker. Our cases contribute further to the limited pool of documented MTs, supporting its indolent behavior and favorable prognosis.

Background: Airway stenting in patients with esophageal cancer involving the airway possibly improves survival by relieving the symptoms of obstructive pneumonitis and facilitating cancer treatment. However, its advantages over conservative management remain unclear. Therefore, we compared the survival outcomes of airway stenting and conservative treatment in patients with advanced esophageal cancer. Methods: We retrospectively reviewed patients with advanced esophageal cancer involving the airway who were treated at Taipei Veterans General Hospital between July 2005 and January 2023. Airway involvement included airway obstruction with obstructive symptoms or esophago-respiratory fistulas. Patients were categorized into the stent and conservative treatment groups. We compared patients’ clinical characteristics, post-airway involvement survival (PAIS), and overall survival (OS) and assessed the prognostic factors for survival. Results: A total of 52 patients, including 31 with airway stenting and 21 with conservative treatment, were included. No differences were observed between the two treatment groups in terms of age, sex, body mass index, clinical performance (Eastern Cooperative Oncology Group [ECOG]), tumor location, clinical N stage, or site of airway involvement. However, the conservative treatment group had more patients with clinical T4 stage (p < 0.001) and M1 stage (p = 0.04) than did the stent group. PAIS (117 vs 43 days; p = 0.02) and OS (351 vs 106 days; p < 0.001) were significantly longer in the stent group than in the conservative treatment group. In addition, airway stenting significantly reduced pneumonia-related mortality (9.7% vs 52.4%; p = 0.001). Multivariable analysis revealed anticancer treatment after airway involvement (hazard ratio [HR], 0.13; confidence interval [CI], 0.06-0.27; p < 0.001) and airway stenting (HR, 0.37; CI, 0.20-0.68; p = 0.001) as significant prognostic factors for PAIS. For OS, ECOG ≥1 (HR, 2.20; CI, 1.09-4.42; p = 0.03) and airway stenting (HR, 0.37; CI, 0.17-0.78; p = 0.01) were significant prognostic factors. Conclusion: Airway stenting reduced pneumonia-related mortality in patients with advanced esophageal cancer with airway involvement. Moreover, patients who underwent airway stenting had better survival than did those who received conservative treatment alone; thus, airway stenting should be recommended after careful patient selection.

The CheckMate 577 trial demonstrated that adjuvant nivolumab improves disease-free survival in patients with resected esophageal cancer following neoadjuvant chemoradiotherapy. This study aimed to evaluate real-world outcomes associated with adjuvant immunotherapy. Patients with esophageal cancer and residual pathological disease who underwent neoadjuvant therapy followed by surgical resection between January 2019 and February 2024 were retrospectively analyzed. Participants were grouped by adjuvant treatment received: no adjuvant therapy, adjuvant immunotherapy (AI), or adjuvant chemotherapy (AC). Primary outcomes included overall survival (OS) and recurrence-free survival (RFS). Subgroup analyses were performed for patients meeting CheckMate 577 eligibility criteria and those with pathological node-positive (ypN+) status. The study included 127 patients (mean age: 60 years; male: 86%): 23 received AI, 36 AC, and 68 received no adjuvant therapy. There were no significant differences in OS between AI and AC groups (median OS [mOS]: 34 months vs. 34 months; p=0.81), nor in RFS (median RFS [mRFS]: 15 months vs. 16 months; p=0.94). In the CheckMate 577-eligible subgroup (n=68), OS and RFS were similar between AI and AC groups (mOS: 25 months vs. 47 months; p=0.16; mRFS: 19 months vs. 20 months; p=0.74). Likewise, among ypN+ patients (n=54), no significant differences in OS or RFS were noted between AI and AC (mOS: 34 months vs. 31 months; p=0.74; mRFS: 9.5 months vs. 14 months; p=0.89). AI did not demonstrate a significant survival advantage compared to AC, even in patients meeting CheckMate 577 criteria or those with ypN+ status. Identifying the optimal adjuvant treatment for esophageal cancer remains a challenging and evolving issue.

Managing esophageal squamous cell carcinoma (ESCC) in patients with a history of cervical radiotherapy for a head and neck cancer (HNC) often requires a careful evaluation of esophagectomy due to concerns regarding complications and prognosis. This study evaluates the periesophagectomy and oncological outcomes of such patients. Patients diagnosed with ESCC between January 2010 and August 2023 and who had undergone esophagectomy with cervical anastomosis were retrospectively reviewed. Patients were categorized into two groups based on the presence (group 1) or absence (group 2) of a history of radiotherapy for as HNC. After 1: 2 propensity score matching, the perioperative and oncological outcomes, including overall survival (OS) and recurrence-free survival (RFS), were evaluated. A total of 481 patients, 32 in group 1 and 449 in group 2, were included. After matching, group 1 patients and 64 patients in the group 2 were analyzed. All the patients in group 1 were males, and their mean age was 56 years. The median radiation dose was 69 Gy. The rates of anastomosis leakage, pneumonia, respiratory failure, and reoperation were comparable between the two groups. However, vocal cord palsy occurred more frequently in group 1, particularly in those with recurrent laryngeal nerve lymph node dissection (37.5%). The 3-year OS (69.6% vs. 75.2%; p = 0.26) and RFS (50.8% vs. 55.9%; p = 0.63) were similar between groups 1 and 2. In conclusion, perioperative and oncological outcomes were comparable between ESCC patients with and without prior HNC radiotherapy, supporting esophagectomy as a feasible option.

The role of surgery in oligometastatic esophageal squamous cell carcinoma (ESCC) remains controversial. This study evaluated the oncological outcomes after esophagectomy in patients with ESCC with distant lymph node (LN) metastasis. Patients with ESCC and nodal metastasis treated with chemoradiotherapy or chemotherapy followed by esophagectomy between 2010 and 2020 were included. Overall survival (OS) and recurrence-free survival (RFS) were compared between patients with distant LN metastasis (dLN+) and exclusively regional LN metastasis (dLN–). The cohort comprised 69 dLN+ and 111 dLN– patients. Survival was significantly better in the dLN– group than in the dLN+ group (5-year OS, 51.9% vs. 25.5%, P < 0.001; RFS, 47.2% vs. 18.1%, P < 0.001). Stratified by the yp stage, 49 (44.1%) dLN– and 30 (43.5%) dLN+ patients achieved a pathological complete response (pCR). In the dLN– and dLN+ groups, the OS rates were significantly higher in the pCR group than in the non-pCR group (dLN–: 76.7% vs. 32.4%, P < 0.001; dLN+: 39.6% vs. 14.2%; P = 0.002). The dLN–/pCR group had the best OS, significantly outperforming the dLN−/non-pCR and dLN+/pCR groups. OS did not differ between the dLN−/non-pCR and dLN+/pCR groups. The dLN+/non-pCR group had the worst OS. The RFS analysis paralleled the OS findings. Patients with dLN+ disease had worse outcomes than their dLN– counterparts, irrespective of the pCR status. The survival rates were poor but comparable between the dLN+/pCR and dLN−/non-pCR groups. Adjuvant therapy may be required for dLN+ patients following systemic treatment and surgery, even after achieving pCR.