Background: Juvenile myasthenia gravis is a rare autoimmune condition affecting children. Similar to myasthenia in adults, juvenile myasthenia gravis is associated with thymomas and many of these patients undergo thymectomy. However, there is no clear consensus on which patients could benefit from surgical intervention and how to manage refractory disease.

technological advances on haptic devices, together with further studies focused on haptic feedback, be useful to develop efficient and effective training curricula and for establishing the value of simulators with haptic feedback in training and assessing thoracic surgical skills.

Background and Objective: An estimated 1.5 million people develop pleural effusion each year in the United States. Although substantial progress has been made in understanding pleural effusion, establishment of a definite diagnosis usually necessitates thoracentesis with pleural fluid analysis. Lymphocyte predominant pleural effusion is defined as an exudative effusion with lymphocytes over 50% of the total white cell count. The purpose of this review article is to elaborate on the different causes of lymphocyte predominant pleural effusion and the unique biochemical and cellular characteristics of pleural fluid in these conditions. Methods: This review is based on a PubMed search of English-language articles published between 1955 and 2020, using search terms including pleural effusion and lymphocyte predominant to generate a comprehensive literature list that highlights characteristics of pleural fluid in the different conditions associated with lymphocyte predominant pleural effusion. Key Content and Findings: Tuberculosis and malignancy account for the majority of lymphocyte predominant pleural effusions. While less common, a number of conditions such as rheumatoid arthritis, post cardiac injury syndrome, chylothorax, sarcoidosis, yellow-nail syndrome, and uremia have also been described as potential causes of lymphocyte predominant pleural effusions. Conclusion: Once an exudative effusion is identified, cell count and differential can further help narrow the differential diagnosis. Other diagnostic modalities including imaging and thoracoscopy with biopsy can also assist in achieving an accurate diagnosis. Management options include treatment for the underlying cause and/or symptoms, particularly in recurrent malignant pleural effusion.

Shanghai Chest serves as an important platform for surgeons and physicians around the world to share the advanced researches, spectacular surgical techniques and precious experience in the field of chest disease.

Lung cancer is a heterogeneous disease with distinct histologic differentiation patterns and molecular subtypes. This heterogeneity results in different prognoses and therapeutic implications. In case a lung nodule, defined as a lesion 3 cm or less in diameter, or a lung tumor, defined as a lesion larger than 3 cm, has been detected by imaging and a core needle biopsy (CNB) performed, the question arises whether the biopsy is representative for the nodule or tumor and leads to the correct histopathologic and molecular diagnosis, which is essential for matching therapy and tumor biology. The aim of this narrative review is to give an overview on the diagnostic efficacy of CNB to reflect the histomorphology of a lung carcinoma and to yield tissue suitable for molecular diagnostics also taking into account tumor heterogeneity. We conducted a literature search using PubMed to gather findings on the diagnostic utility of CNB of lung nodules and tumors. The prevailing assessment reports a high accuracy for detecting a malignancy. However, CNB cannot predict reliably prognostically relevant morphologic subtypes of lung adenocarcinomas.

Abstract: Atrio-esophageal fistula (AEF) is a rare but fatal complication of cardiac ablation procedures. Approaches to management have focused on prompt diagnosis and surgical correction, as there is a high risk of patient decompensation and death from cerebrovascular morbidity and mortality. Esophageal stenting is not a standard approach and has been used exclusively for palliation in select cases with limited outcomes data. We report a case of a 61-year-old male presenting in critical condition due to AEF 4 weeks after cardiac ablation for persistent atrial fibrillation. The patient presented in septic shock, multisystem organ failure and was not a candidate for definitive surgical repair. Therefore, he underwent treatment with covered esophageal stent placement. The post-operative course was complicated by septic shock and cranial emboli. Despite the complex presentation and clinical progression, the patient made a meaningful neurologic and physiologic recovery. At 8 weeks he was discharged and at 10 weeks the stent was removed with demonstration of complete healing of the AEF. While surgical repair remains the standard of care for treatment of AEF as a result of cardiac ablation, in high-risk patients, esophageal stenting may provide a means for effective palliation. Stenting may allow for spontaneous healing of AEF in these select high-risk populations.

Abstract: Transbronchial cryobiopsy (TBC) is a bronchoscopic procedure for obtaining larger and higher quality peripheral lung biopsies with less crush artifact as compared to conventional transbronchial lung biopsy. It has demonstrated a higher diagnostic yield than the traditional forceps biopsy and thus has generated significant interest as a minimally invasive diagnostic tool for the diagnosis of diffuse parenchymal lung disease (DPLD) in recent years. However, the possibility of intra-operative bleeding, pneumothorax, and other postoperative complications have raised significant concerns. More recently, studies on postoperative complications, morbidity, and mortality as well as the use of techniques to prevent complications of this procedure have been published. Expert guidelines with graded recommendations based on the GRADE approach have been released. Ours is an updated review of practices to perform TBC safely; classified as pre-procedural, intraoperative and postoperative practices that can be adopted and applied in clinical practice based on current evidence to decrease the incidence of adverse outcomes.

: Bronchopleural fistula (BPF) describes an abnormal connection between a bronchus (main, lobar or segmental) and the pleural cavity. BPF is a recognized complication after pneumonectomy and is associated with significant morbidity and mortality. The risk of post-pneumonectomy BPF (PP-BPF) is greater in right sided operations, male patients, residual tumor, barotrauma, previous TB and active infection. If suspected, diagnosis of BPF should be made expeditiously with computed tomography scanning and bronchoscopy. The management depends on the timing of presentation, the size of the fistula and the clinical status of the patient. All patients require drainage of the infected pleural space and intravenous antibiotics. In early presentations, re-do thoracotomy followed by stump closure and reinforcement with a pedicled muscle flap is recommended. If the fistula is small (<5 mm) or the patient is not fit enough for major surgery, bronchoscopic repair using fibrin glue application, stents or closure devices can be attempted. Minimally invasive techniques can also be used as a temporizing measure while optimizing a patient for a major intervention. There are multiple case reports describing novel bronchoscopic techniques for management of BPF. The risk of BPF should be reduced in high-risk patient groups by implementing bronchial stump coverage (BSC) at the time of pneumonectomy. Overall, the literature is limited by the relative rarity of the problem. Much of the literature is based on retrospective studies and case series which leads to inherent biases preventing true comparative studies in operative techniques and outcomes. Meta-analysis of case reports and new randomized controlled trials may give more evidence to support the current findings. While some simple principles should be followed, management of BPF needs to be individualized to each patient’s clinical picture.

Lung cancer remains the leading cause of cancer morbidity and mortality worldwide among both men and women. While surgical resection remains the standard of care for early stage NSCLC, chemoradiation has been a mainstay of treatment for locally advanced non-small-cell lung cancer (LA-NSCLC) patients for decades. Consolidation immunotherapy has improved survival in this subset of patients after conventional chemoradiation, and has emerged as the new standard. The synergy between immunotherapy and radiation, as well as ongoing research on the effects of radiation on the immune system, allows for the exploration of new avenues in the treatment of LA-NSCLC. In addition to the use of durvalumab as consolidative systemic therapy after concurrent chemoradiotherapy for Stage III NSCLC, other combination regimens have been shown to be effective in various disease stages in preclinical and clinical studies. These regimens include CTLA-4 and PD/PDL-1 checkpoint inhibitors combined with radiation treatment. While these combined regimens have demonstrated efficacy, they are not without toxicity, and require additional evaluation when combined with radiation. In this review, we have summarized the immunostimulatory and immunosuppressive effects of radiation therapy. We also evaluate the current evidence and ongoing research supporting the combination of radiotherapy and immunotherapy across early to LA-NSCLC.

: Cancer is one of the primary concerns of mortality throughout the world in the present day. Among different types of cancers, lung cancer (LC) is predominant (21.77% of overall cancer caused death). It is classified into two major categories: oat cell or small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). The mortality due to NSCLC (~85%) is almost six times higher than the SCLC (15%). The identification of risk factors can reduce cancer burden and human fatality; however, this cannot prevent the severity of LC. In this case, the early diagnosis of LC can be an effective pathway in providing better treatment to the patients, which eventually may result in less fatality. This article offers an overview of several existing screening methods for the early diagnosis of LC. Nevertheless, these methodologies have limitations of reliability towards the diagnosis of cancer malignancy. Therefore, the prospects of different alternative approaches and their challenges to overcome this barrier for the early diagnosis of malignant tumor cells have been articulated in this article.