Ayten Kayi Cangir

Background: Adenocarcinoma (AC) is the leading histopathological type of lung cancer (LC), curative surgery being the cornerstone for the best survival results. However, even in the patients who had curative surgery, the survival outcomes differ. Spread through air spaces (STAS), recognized as a histopathological feature in the 2015 World Health Organization (WHO) Classification, causes poor survival outcomes in lung AC. This study aimed to evaluate the prognostic impact of STAS on recurrence-free survival (RFS) and overall survival (OS) in surgically resected T1-2N0 lung AC, with particular attention to its interaction with tumor size. Methods: This single center retrospective study evaluates the effect of STAS on RFS and OS in 296 surgically resected T1-2N0 lung AC patients. For further analysis, patients were divided into four subgroups combining their STAS status and tumor size. Results: STAS presence rate was 37.5%, which was associated with aggressive tumor characteristics, such as non-lepidic predominant subtypes, higher pathological T stage (pT), visceral pleura invasion (VPI), and lymphovascular invasion (LVI). OS and RFS were significantly worse in the STAS-Present (STAS-P) group ( p = 0.030). Subgroup analysis revealed that STAS-P tumors > 2 cm had the worst outcomes, as expected. Notably, on univariate analysis STAS presence appeared most prognostically decisive in tumors ≤ 2 cm, in which there was no significant difference in survival between STAS-P tumors ≤ 2 cm and STAS-Absent (STAS-A) tumors > 2 cm. Conclusions: STAS was a significant prognostic factor on univariate analysis but did not retain independent significance after multivariable adjustment. In an exploratory subgroup analysis, STAS-P tumors ≤ 2 cm carried survival outcomes comparable to STAS-A tumors > 2 cm, suggesting STAS may attenuate the prognostic advantage of smaller tumor size. This hypothesis-generating finding warrants prospective validation before informing surgical management.

Background: Some pulmonary carcinomas display a solid pattern, and immunohistochemistry is commonly used for tumor differentiation. Micro–computed tomography (micro-CT), with its ability to produce detailed three-dimensional images using small voxel sizes, may offer additional insights. This study investigates whether three solid tumor types, solid adenocarcinoma (sAC), non-keratinizing squamous cell carcinoma, and carcinoid tumor (CaT), can be differentiated using micro-CT. Methods: Fifteen paraffin blocks, five for each type, were scanned with micro-CT (Skyscan 1275, Bruker). These images were compared to whole slide images (WSIs) of the same tumors. Consequently, tumoral (n = 74) and non-tumoral (n = 49) regions of interest (tumor ROIs [tROIs] and non-tumor ROIs [ntROIs]) were selected on the micro-CT images and evaluated in terms of certain structural variables (percent object volume, structure model index, structure thickness, structure linear density, connectivity, connectivity density, open porosity, closed porosity) to investigate whether tumors can be differentiated from normal parenchyma and from each other. Results: Although detailed images comparable to WSIs could not be obtained, it was considered an important advantage to be able to examine the entire depth of the paraffin blocks. tROIs and ntROIs could be distinguished based on all variables (p < .001). Additionally, sAC showed a notable difference from CaT in “percent object volume” (p = .011). Conclusions: With ongoing technological advancements, improving image quality without compromising tissue integrity will likely accelerate the adoption of micro-CT in pathology labs. Moreover, structural variables derived from micro-CT images may support differentiation among tumor types.

Background: Pain is the most common symptom in Thoracic Outlet Syndrome (TOS). Objective: This study was conducted to determine the characteristics of pain in patients with TOS. Methods: 66 patients (59 female, 7 male) participated in this cross-sectional study. Pressure pain thresholds (PPT) and pain intensity were evaluated. Central Sensitization Inventory (CSI), Tampa Kinesiophobia Scale (TSK), Toronto Alexithymia Scale (TAS) and Pain Catastrophizing Scale (PCS) were used. Mann-Whitney U and Spearman tests were used for statistical analyzes. Results: A significant positive correlation was observed between symptom duration (6.42 ± 5.33 years) and both CSI (r = 0.261,p = 0.034) and TSK (r = 0.271,p = 0.028). Centrally sensitized patients were found to have significantly worse kinesiophobia (p = 0.005), catastrophizing (p = 0.031) and alexithymia (p = 0.049). Patients with pain catastrophizing had higher kinesiophobia (p = 0.003). There was no difference in PPT in trapezius (p = 0.507) and infraspinatus (p = 0.690) muscles but there was a difference in the extensor carpi radialis (p = 0.009) and extensor indicis proprius (p = 0.002). Pain values were similar between patients who had undergone surgery and those who had not. Conclusions: The findings of this investigation indicate that symptoms related to central sensitization in TOS are linked to chronic pain indicators, while catastrophizing is associated with kinesiophobia. Additionally, it was observed that a prolonged duration of symptoms in TOS intensifies the severity of central sensitization and kinesiophobia. The similarity in pain parameters between the surgical and non-surgical groups may reflect the effects of chronic pain due to prolonged symptom duration. These results suggest that TOS should not be perceived solely as a musculoskeletal issue.

Introduction: Patients with hand and wrist trauma are frequently diagnosed in the emergency department. Deep learning algorithms could potentially become powerful tools to diagnose fractures from X-ray wrist images. This study aims to assess the diagnostic performance of a deep learning algorithm in detecting wrist fractures that are difficult to detect through radiographs. Methods: This retrospective study included adult patients with hand/wrist trauma who undergo CT imaging. CT imaging of injured areas, interpreted by an expert radiologist were considered as “ground truth” (GT). There were 313 cases, a total of 121 fractures (82 radius, 39 carpal bones) were identified as GT from CT images. Using the algorithm, fracture detection procedure was performed on dataset of hand and wrist X-ray images. The same datasets were evaluated by four emergency medicine doctors. Diagnostic performances such as accuracy, area under curve, sensitivity, precision and F1 score were calculated. Agreement (Kappa coefficient (κ)) between GT, observers and deep learning algorithm was determined. Results: The algorithm showed 69.6% accuracy, 57% sensitivity and 61.6% precision. Emergency medicine doctors showed better diagnostic performance with higher accuracy, sensitivity and precision and AUC values. The interobserver agreement among four EM doctors was moderate whereas the agreement with the algorithm was only fair. Conclusions: The Deep learning algorithm demonstrated an accurate detection of fractures in wrist X-rays and it had capabilities that were comparable to those of emergency medicine physicians, but the algorithm mentioned needs to be further improved to produce better outcome.

Background: This study aims to evaluate the prognostic factors for overall survival and progression-free survival in non-small cell lung cancer patients receiving platinum-based neoadjuvant therapy. Methods: Between January 2008 and December 2022, a total of 163 patients with clinical Stages 2B, 3A, and 3B non-small cell lung cancer (148 males, 15 females; mean age: 59.5±7.8 years; range, 33 to 76 years) who underwent operation after neoadjuvant chemotherapy or chemoradiotherapy were retrospectively analyzed. The prognostic factors for overall survival and progression-free survival were evaluated. Results: Higher major pathological response rate (p=0.021) and lower recurrence rate (p=0.009) were observed in patients with squamous cell carcinoma. The five-year progression-free survival rates were 56.9% and 34.1% for patients with squamous and non-squamous cell cancers (p=0.007) and the five-year overall survival rates were 68.2% and 52.2%, respectively (p=0.046). Squamous cell carcinoma histology was a favorable prognostic factor for both progression-free survival (p=0.008) and overall survival OS (p=0.031). Conclusion: Tumor histology may serve as a prognostic factor, helping to predict patient outcomes and guide the selection of neoadjuvant therapies before surgery. Currently, platinum-based chemotherapies are still used as a standard. Clinicians should consider tumor histology while deciding on neoadjuvant treatment.

Background: Detecting molecular drivers is crucial in the management of non-small-cell lung cancer (NSCLC). This study aimed to evaluate the use of pretreatment chest computed tomography (CT) radiomics features for predicting epidermal growth factor receptor (EGFR) mutation status in NSCLC. Materials and Methods: CT images were used to develop a radiomics-based model for predicting EGFR mutation status. Two different groups were formed from the dataset, namely groups for training (n = 380) and testing (n = 86). Feature selection was performed using the Least Absolute Shrinkage and Selection Operator (LASSO) algorithm on a radiomics platform. Machine learning methods were then applied to construct the radiomics models. Receiver operating characteristic curve analysis was conducted to assess the performance of the radiomics signature across different datasets and methods. Results: The frequency of EGFR mutation was 13.5% (58/430). A total of 1409 quantitative imaging features were extracted from CT images using the Radcloud platform. Among the six radiomics-based classifiers (k-Nearest Neighbor, Support Vector Machine (SVM), eXtreme Gradient Boosting, Random Forest, Logistic Regression, and Decision Tree), SVM demonstrated the highest area under the curve values in both the testing and training groups, reaching 0.87 and 0.98, respectively. Our model, which incorporated both clinical and radiomics data, successfully predicted EGFR mutation status with an accuracy rate of 86.9%. Conclusion: Our findings highlight the potential of radiomics features as a non-invasive predictive imaging biomarker for EGFR mutation status, which could enhance personalized treatment in NSCLC. Radiomics emerges as a valuable tool for identifying driver mutations, although further studies are necessary to validate its clinical utility in NSCLC.

The recommended treatment for early stage thymoma without myasthenia gravis is complete thymectomy (CT). Limited thymectomy (LT) (simply resecting the thymoma with safe surgical margins) is gaining popularity. In this study, we compared the surgical and oncological results of complete and limited thymectomy in non-myasthenic patients with early stage thymoma. Non-myasthenic, Masaoka stage I–II, 86 patients who underwent surgical resection for thymoma were included in the study. Complete thymectomy (n:44) included patients who had resection of the thymoma together with the entire thymus and limited thymectomy (n:42) included patients who had resection of the thymoma without remaining thymus. The surgical approach, tumor size, histological type, pathological stage, adjuvant therapy, complications, postop myasthenia gravis, recurrence and death were recorded and compared between groups. Complete thymectomy group had more WHO type B1-3 tumors, more complications and more deaths than patients in the limited thymectomy group (p = 0.03, 0.018 and 0.023 respectively). Although statistically not significant CT group had more recurrences than LT group (11.4%/4.8%, p = 0.43). The 10-year freedom from recurrence (FFR) rate in the CT group was 84.8% and in the LT group ıt was 97.6%, the difference was not statistically significant (p = 0.15). None of the factors including surgical extent analysed with univariate and multivariate analysis had a significant effect on FFR. Limited thymectomy may be a good treatment option for non-myasthenic early stage thymoma patients but randomized controlled trials with long follow-up periods, ideally comparing patients operated with minimally invasive surgery are necessary.

Background: This study aims to evaluate the oncological results of primary and secondary chest wall tumors treated with curative resections and to investigate possible prognostic factors. Methods: Between January 2010 and December 2021, a total of 77 patients (53 males, 24 females; median age: 59 years; range, 3 to 87 years) who underwent curative resection for malignant chest wall tumors were retrospectively analyzed. Each tumor was staged according to its histological type. Age, sex, tumor diameter, tumor type (primary/secondary), histological tumor type, grade, stage, complete resection, rib resection, reconstruction, neoadjuvant and adjuvant therapy, recurrence, and survival data were recorded. Results: Of the chest wall tumors, 33 (42.9%) were primary and 44 (57.1%) were secondary (local invasion, metastasis). Nine (11.7%) patients had positive surgical margins. Chest wall resection was most commonly performed due to lung cancer invasion (46.8%), followed by Ewing sarcoma (13%). Recurrence was observed in 34 (44.2%) patients. The five-year recurrence-free survival rate was 42.7% and the five-year overall survival rate was 58.6%. There was no significant difference between the primary and secondary tumors in terms of recurrence-free and overall survival (p=0.663 and p=0.313, respectively). In the multivariate analysis, tumor grade and rib resection were found to be independent prognostic factors for both recurrence-free survival (p=0.005 and pConclusion: Successful oncological results can be achieved in wellselected patients with primary and secondary chest wall tumors. The grade of the tumor should be taken into account while determining the neoadjuvant or adjuvant treatment approach and surgical margin width. Rib resection should not be avoided when necessary.

Mycosis fungoides is the most commonly seen type of cutaneous T-cell lymphoproliferative disease. While mycosis fungoides is linked to an increased risk of developing secondary malignancies, the occurrence of B- cell-originated disease in association with it is exceedingly rare. A 66-year-old male with persistent papillomatous skin eruption was admitted due to dyspnea. Chest X-ray, positron emission tomography, and chest computed tomography revealed axillary and mediastinal lymph node enlargement and right lower pulmonary lobe infiltration along with right-sided massive pleural effusion. Histological and immunohistochemical findings of pleural biopsy and axillary lymph nodes suggested a diagnosis of pulmonary extranodal marginal zone lymphoma. Skin biopsies from the abdomen, chest, and legs revealed CD4/CD8 double-positive patch stage of mycosis fungoides. After completing six cycles of chemotherapy, complete remission of lymphoma was achieved, with the skin eruptions remaining unchanged. Herein, the authors present a unique case of concomitant diagnoses of mycosis fungoides and marginal zone B-cell lymphoma of the respiratory system to emphasize the importance of careful evaluation of each finding.

We thank to Dr. Perrella and and his fellow authors for your kind letter and thoughtful comments