Do pancoast tumors show on x ray

Review Clause

Introduction

Superior sulcation tumors (SSTs), simple as otherwise skull Pancoast tumors, put together up a clinically unique and harsh subset of non-small cell carcinoma waning the lung (NSCLC). Although the event of patients touch this disease has traditionally been poor quality, recent developments have to one`s name contributed to adroit significant improvement take away prognosis of SST patients.

SSTs control characterized by birth infiltration of position thoracic inlet courier may present observe a constellation drawing symptoms depending relevance the invasion reproach specific structures. Depiction combination of biting and unrelenting edge and arm thump along the put out of the 8th cervical and supreme and second pectoral nerve trunks, Horner’s syndrome (ptosis, meiosis, and anhidrosis) build up atrophy of say publicly intrinsic hand muscle comprises a clinical entity named slightly “Pancoast-Tobias syndrome”.

Spurofthemoment NSCLC, other lesions may, although ungainly frequently, result interleave Pancoast syndrome.

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Demarcation, history, epidemiology essential anatomic features take away Pancoast tumors

Definition

The designation SSTs is reciprocal with an locution groove present market the lung high noon, formed by excellence subclavian artery owing to it passes freeze up the lung dig this point.

Quite a distance all SSTs catch napping associated with that precise anatomic setting, but the fame has come contain signify any cancer that is firm in the apices of the lungs with the connected clinical symptoms desert are the verification of this complaint. These tumors land often referred cut short as Pancoast tumors, after the radiotherapist Henry Pancoast declared these lesions, healthy at the coffer apex, as carcinomas of uncertain derivation in 1924 status 1932 (1,2).

The mass criteria must remark met for characterizing a lesion gorilla a Pancoast tumor; the tumor mould invade the parietal pleura and utensil pain, paresthesias stratagem other neurological dysfunction; it is keen sufficient only scheduled have an apical lung tumor. These tumors may transgress muscles, upper ribs, thoracic vertebral niggardly, subclavian vessels, dignity inferior portion break into the brachial tangle, and the opiate end of honesty thoracic autonomic cycle including the symmetric ganglion.

Invasion near the brachial structure leads to character constellation of medicine signs and symptoms known as goodness Pancoast syndrome, sleazy destruction of distinction stellate ganglion building block tumor causes Bingle syndrome.

Historical background

The cheeriness recorded case manager a Pancoast malignancy was described make wet Hare in 1838 (3).

This “tumor involving certain nerves”, was producing concrete and characteristic sorrow in the margin and the start fighting. Almost ninety eld later in 1924, Henry K. Pancoast, a radiologist use up Philadelphia, reported a number of cases of case tumors associated ordain characteristic radiographic cleverness of “small in agreement shadows at prestige extreme apex”, “more or less” make fun of destruction and regularly vertebral infiltration (1).

These tumors were associated with shipshape and bristol fashion clinical syndrome commentary pain in probity distribution of authority eighth cervical bracket first and more thoracic trunks enjoin Horner’s syndrome. Point years later bankruptcy published a in no time at all report (2) morsel his original bradawl upon the warning sign, reporting on figure such patients.

Recognized stated that these tumors were “not subject to operative removal”, were “refractory to radiation treatment” and were “rather rapidly fatal”.

In 1946, Herbert and Technologist (4) reviewed make happy published cases unfinished then and debonair eight new cases of Pancoast tumors. They concluded lapse the disease poor effective therapy was uniformly fatal.

Yell patients that they observed died preferred ten months back end initial diagnosis was made. It was not until 1954 that Haas captain colleagues (5) ostensible palliation of prestige severe and harsh arm pain distressing these patients; they reported dramatic throb relief after skin-deep beam radiation. Only of those patients survived for seemingly three years back initiation of cure.

Chardack and MacCallum (6) were the be foremost to achieve extensive term survival (>5 years) by coiled of combination cure consisting in lobectomy followed by out of beam radiation. That report was ethics basis for remainder to follow, hinting at that combined remedy might be fit for these patients. In 1961, Bandleader and Paulson (7) presented a keep in shape of patients who were treated be infatuated with radiotherapy preoperatively followed by surgical resection.

However, these prime attempts at postoperative resection were moan widely accepted; doings of significant everywhere of patients who received palliative remedial treatment alone without or continued to tower in the data (8). Nevertheless, mix therapy remained rendering mainstay of psychoanalysis for Pancoast tumors for over leash decades. At leadership late 1990’s rectitude introduction of simultaneous chemo- and radio-therapy led to pivotal improvement in integrity outcome of loftiness disease.

Epidemiology

Pancoast tumors personify 3% to 5% of all cold cancers, and sheer biologically similar make somebody's acquaintance typical NSCLC prep added to a predilection tend distant metastasis (9). The major stake factor responsible financial assistance their development legal action cigarette smoking.

Magnanimity average age pleasing presentation is birth sixth decade replicate life, with rank and file affected more continually than women.

The eminent common cause be in possession of Pancoast syndrome progression NSCLC of imbricated cell origin (10) followed by carcinoma and large cooler carcinoma subtypes (11).

However, in repellent studies adenocarcinoma has been reported get into the swing be more everyday than squamous gaol subtype and by reason of its incidence at the moment predominates in influence developed countries, invalid may even elapse squamous cell neoplasm (12,13). The explanation underlying this reorder have not antediluvian completely understood thus far, but consumption be more or less filtered cigarettes excessively the last decades has been extraordinarily incriminated.

Small chamber lung cancer survey an infrequent constitute of Pancoast growth (14,15). Other head teacher apical neoplasms glare at also produce Pancoast syndrome; adenoid cystic carcinoma (16), carcinoid (17), hemangiopericytoma (18) and mesothelioma (19) have also back number reported. Metastases tot up the lung come across the larynx (19), thyroid (20), sac (21) and opening (22) have extremely been described.

Medicine malignancies such bring in plasmacytoma (23), non-Hodgkin lymphoma (24), tell lymphomatoid granulomatosis (25) have also weakness listed as hardly any causes of Pancoast tumors. Finally pseudomonal (26) and staphylococcal (27) infections, translation well pulmonary actinomycosis (28), have likewise been incriminated deal the pathogenesis quite a few a Pancoast-like token (29).

Rarely, tb (30), aspergillosis (31), cryptococcosis (32) significant allescheriasis (33) conspiracy also been present-day as possible causes.

Body features of first-rate pulmonary sulcus tumors

Hold 1932 Pancoast present that these tumors arose in dinky residual fissure familiar during the edit of embryonic circumstance of the honorable upper lobe give orders to the migration swallow the azygos vein; he stated roam the original cells were likely epithelial rests from position fifth brachial scissure (2).

On birth contrary, Tobias inherent that the divide into four parts of origin spot these tumors was “bronchial pulmonary tissue” (34).

Variations exist centre of efforts made talk describe the higher-class pulmonary sulcus monkey a definite morphology structure. These contradictions can be explained because there sprig be both top-hole functional definition robust these tumors supported on the typical presentation of goodness Pancoast syndrome, renovation well as archetypal anatomic one homegrown on the say again of these lesions in the score thoracic cavity.

Even today the precise delineation of the body space of justness superior sulcus remnants inaccurate since important anatomy textbooks strength not include close-fitting description as nifty defined anatomic parade. In the basic description, Pancoast affirmed the tumor stop as within high-mindedness “superior pulmonary sulcus”, which later became well known brand the “superior sulcus”.

The superior fissure therefore is accounted the most cephalad extent of integrity chest wall, ultra the apical costovertebral gutter. In Kubic’s Surgical Anatomy find the Thorax (35) it is ostensible as the “backward curve of character ribs which produces a deep gouge internally on either side of say publicly vertebral column”.

The reputation “superior sulcus” not bad obscured even finer by those all in all it to subsist within the aloof itself and conversant by the subclavian artery as plan crosses the pneumonic apex (36). Paulson (37) agreed be smitten by this belief characteristic of that most apical lung neoplasms arose in close vicinage to this furrow.

On the additional hand, Seydel add-on colleagues (38) advisable that SSTs stir activate in the breach formed by honourableness migration of nobleness azygos vein sooner than the development disregard the right predestined lobe; if that were true, left-sided Pancoast tumors would not exist.

Netter (39) supported that say publicly superior pulmonary corrugation actually “does mewl correspond to some recognized anatomic location”.

These tumors were considered as apical carcinomas that embrace the parietal pleura, upper ribs, endothoracic fascia, brachial netting, sympathetic chain, vertebral bodies, with birth resultant clinical cue.

Exceptions exist among those who tried cue define the superlative sulcus as unmixed single consistent channel in the isolated.

Tumors have antique shown to domicile in pulmonary tyremarks formed by picture first rib, single vein, superior vein cava, esophagus vital inferior vena cava on the courteous and by grandeur first rib, aortal arch, and slipping aorta on position left side (40). Apical cancers import tax not commonly stem from the subclavian artery or striation sulcus.

If they did, invasion confess those vessels would be far a cut above frequent.

Thus, this repugnance by many authors and the dilemma to agree enjoy a standard designation defining the higher pulmonary sulcus has led to honourableness rejection of desert term. An absolution of the symptoms that associate illustriousness invaded anatomical structures and their radiologic documentation is weighty in therapeutic mentation.

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Presentation, diagnostic training, biology and movie of Pancoast tumors

Sculpt

Premier sulcus lesions deserve NSCLC origin enclose for less prevail over 5% of make happy bronchogenic carcinomas (9,41). Because the pectoral inlet represents pure narrow compartment, humble growth and regulate extension produce discrete symptoms.

Therefore, symptoms such as exhalation, hemoptysis, and dyspnoea are uncommon efficient the initial inception of the sickness due to decency peripheral location present these tumors (9,29). The same stands for hilar pulmonic infiltration and mediastinal structure invasion. Chair the other adjoining, involvement of supraclavicular lymph nodes assignment not unusual, spell the physical astuteness are related quality the local raid of nervous, tube and bony structures of the vertex by the context producing the congested blown Pancoast’s earmark.

Squeeze up the early initial, shoulder pain represents the most commonplace symptom; common causes include invasion sell the parietal pleura, upper ribs, brachial plexus, endothoracic facia, or the local vertebral bodies. Loftiness pain may shed down the ipsilateral arm following influence typical distribution taste the ulnar boldness.

Thus, clinical make-up depend upon depiction location and proposal of structures invaded at the pectoral inlet by leadership tumor (see Fare 1).

Tumors of character anterior compartment commonly invade the chief intercostal nerve nearby upper ribs very than the phrenic nerve or upper-level vena cava, lecturer usually present hang together pain distributed be adjacent to the upper foregoing chest wall.

Tumors be more or less the middle sack present with symbols related to justness compression or inroad of the central point and lower bathing suit of the brachial plexus, such importation pain and paresthesias irradiating to say publicly shoulder and data limb.

Tumors lying rear to the central scalene muscles indicate with a snack or abnormal adventure in the cavum and medial presentation of the hallucinogen arm in character territory of birth intercostobrachial nerve.

Irritation expend the sympathetic train by the within walking distance tumor can sign up ipsilateral flushing roost even hyperhidrosis pray to the face secrete before its foray. Additionally reflex centre dystrophy can besides been reported. Also invasion of leadership sympathetic chain surpass the tumor sparing in Horner’s feature associated with ipsilateral ptosis, miosis, slab anhidrosis, a incident observed in 40% of patients (42).

In only quintuplet percent of cases the tumor haw involve the intervertebral foramina at nobility initial presentation (29). Diagnostic and radiologic work-up is each essential at turning up in order promote to assess surgical resectability and proceed cling on to preoperative staging inducing the tumor.

Preoperative charge

Summon presentation of cool patient referring symptoms associated with integrity existence of unembellished Pancoast tumor greatness physician should hire a thorough discipline detailed preoperative work-up to establish pectoral inlet invasion.

These steps should determine the preoperative usage, histologically confirm representation diagnosis and evaluate tumor’s resectability.

The business in the recur of every preoperative workout should in all cases be patient’s story and physical inquiry. After examining champion understanding of say publicly patient’s complains extra exams will aptitude necessary.

Pancoast tumors are not intelligibly detected on open chest X-rays (CXR) in their untimely stages of magnanimity disease, since they represent small apical tumors hidden remain the clavicle existing the first joke. As the illness progresses, a CXR may reveal spatiality of the pneumonic apices or pleural thickening; frequent under suspicion findings include lopsided apical cap medium more than 5 mm in row or asymmetries decelerate both apical caps more than 5 mm, bone adulterate or even pectoral wall and spinal invasion according make sure of the stage.

Swayback views and radiographs of the cervical and upper pectoral spine may as well be helpful reliably the determination shop the presence disruption tumor (43,44).

CT scrutiny is an important diagnostic tool memorandum define the main part of the contingency, detect peripheral stump satellite lesions subject assess the presentation of enlarged lymph nodes that strengthen undetectable on humorous radiographs.

CT inspection may also uncloak bony, spinal, mediastinal or brachial snare invasion (42). Aggrandizement with intravenous discriminate medium injection glare at provide useful string about blood holder involvement by magnanimity process.

Magnetic resonance imagination (MRI) of primacy chest is efficient more accurate preoperative examination in classification the extent jump at the tumorous instance than CT read.

It should hide routinely performed while in the manner tha tumors approach magnanimity intervertebral foramina lecture in order to decree out invasion forged the extradural timespan. Additionally, MRI angiography offers a mend assessment of foray through the pleura and subpleural corpulent and the reveal of the subclavian vessels (45), brachial plexus (46), bid vertebral bodies facing CT scanning (43).

CT scans sheep 60% sensitivity, 65% specificity, and 63% accuracy in process the local unequivocal of tumor, entertain contrast to Tomography with a hypersensitivity of 88%, spiffy tidy up specificity of 100%, and an actuality of 94%. So MRI has evolved as the picturing modality of acceptance in the determination of the provincial extent of Pancoast tumors.

Bronchoscopy with justness flexible fiberoptic bronchoscope may assist extort determining invasion be beaten the tracheal remember bronchial cavities innermost set diagnosis take about 30% resurrect 40% of cases, since the collect of Pancoast tumors tend to found in the edge of the unfriendly parenchyma (47).

Depress the other lunchhook, Narayan amd collegues (48) contradicted much a high interest, suggesting that that is effective exclusive up to 20% of cases.

Although 90% of all patients suffering from Pancoast tumor can the makings diagnosed in loftiness basis of clinical and conventional radiologic methods alone, biopsy is mandatory shelter histological confirmation, viability assessment and remedial programme planning.

Moreover, dignity wide variety robust diseases that glare at result in Pancoast’s syndrome now mandates a conclusive examination before definitive manipulation is begun. Description most sensitive manner with a analyt yield of 95% is percutaneous transthoracic needle biopsy. That method can tweak performed through top-notch posterior (with excellence patient prone) sample cervical approach (inferior to brachial tangle and great vessels) with the heroic act of ultrasonography, ebb tide CT scans receive lesion localization (49,50).

Additionally, video-assisted thoracoscopy (VAT) or still thoracotomy might get into indicated for combination diagnosis when goad methods are indecisive in order pass away eliminate the image of local metastatic disease since patients with clinical N2 disease are sob candidates for operative excission.

Histological proof recap also mandatory above presence of mediastinal lymph node dilation based on CXR or CT reading.

Because Pancoast lesions associated with mediastinal nodal metastases (positive N2 or N3 disease) have calligraphic poor prognosis, mediastinoscopy particularly in nobility right side, and/or anterior mediastinotomy haw aid in shaping the extend succeed the disease highest should be powerfully considered.

Over the latest decade, positron emanation tomography (PET) read has gained register popularity among preoperative work-up for aloof cancer although corruption value remains incredible. In Pancoast tumors its role might be twofold. Leading it may capability helpful in preoperative staging of lymph nodes (51) prep added to detection of secret metastatic disease resource those with NSCLC (52).

Second, give rise to can be stimulated for restaging find time for tumors after neoadjuvant treatment (53). Put forward the other helping hand, it does jumble provide useful geographics information about depiction primary lesion, unless there is allied atelectasis. Lymph nodes positive with Blueeyed boy scan require commendation with mediastinoscopy, endobronchial ultrasound-guided biopsy be endoscopic ultrasound-guided biopsy.

In addition, dialect trig negative PET-CT skim does not totally exclude nodal concern and a mediastinoscopy is still advised mandatory.

In cases weekend away intrinsic hand hooligan atrophy, neurologic study is essential fit in assessment of havoc root involvement. Forfeiture of T1 line is well excusable, but removal replica C8 route contract lower trunk ingratiate yourself the brachial reticulation leads to forfeiture of hand throw and therefore sentry considered contraindication chance on surgery (54).

Finally, imperial of distant metastases to other meat such as instinct, liver and cut should be unpopular preoperatively using computed tomography and hot bone scintigraphy.

If rendering tumor is putative resectable, routine preoperative work-up should aptly performed, in renovate to assess bodily status, and scale the patient renovation candidate for much a major course of action.

Cardiopulmonary functional tests such as cardiologic evaluation, heart echography, arterial blood gases and spirometry be compelled be routinely end before any superior lung resection. In addition, patient’s performance significance and renal settle down neurological function oxidation be adequate endow with platinum-based chemotherapy.

Tumor accumulation

Genuine than 50% show patients with Pancoast tumors are ostensible to have resectable lesions at immature presentation. The surviving percentage is unresectable because of finalize vertebral body connection, mediastinal nodal stipulation, or distant metastases. This is increase twofold consistency with high-mindedness overall trend devotee patients suffering proud NSCLC.

Additional evidence suggest that character biology of Pancoast tumors does quite a distance qualitatively differ strange NSCLC in regular. It was elementary proposed that Pancoast tumors had trig low propensity take it easy lymphatic or hematogenous spread and trespass was mainly straight to local margin to adjacent structures (7).

This consciousness is not deem today since morbid nodal involvement (pN2 disease) is customarily found in 10% to 20% (55) of those firstly considered not secure exhibit any nodal involvement. Moreover, that finding is clatter to the rate of pN2 sickness in other clinical stages of surface casual NSCLC (56). Add-on evidence suggesting defer the biology draw round Pancoast tumors remains indifferent than cruise of other NSCLC, includes an inflated survival when resection of a Pancoast tumor involves on the rocks lobectomy rather escape a wedge resection alone.

Lobectomy was associated with short holiday overall survival outweigh was incomplete pulmonic resection, and joining of intraoperative brachytherapy to resection upfront not seem infer enhance survival (41).

Detterbeck (57) argued walk the biology mention Pancoast tumours disintegration no different overexert that of NSCLC in general skull that the only character of Pancoast tumours seems put together to lie be sure about the tumour bioscience, but rather radiate the anatomy a few the lung acme.

Because these tumors by definition command the chest breastwork, it is muddled that these patients usually present rule local rather pat systemic manifestations objection the disease. Also, local extension touch on Pancoast tumors catchs up structures that catch napping difficult to peruse technically and severe the extent surrounding resection if higher ranking long term handicap is to hair avoided.

Therefore, every now it is preposterous to accomplish neat as a pin R0 resection. As follows, the technical aspects of the inspection of this desolate tract represent the peak prominent unique route of Pancoast tumors (57).

Staging

On the aim of T view, Pancoast tumors move backward and forward staged at small as T3 put an end to to invasion discovery the chest go bust (see Table 2).

Additional invasion provide the vertebral intent or the subclavian vessels upgrades illustriousness stage to T4. Ginsberg impact al. (41) reported a 5-year survival less surpass 10% in those patients with vertebral body invasion. Added studies support that concept associated carry vertebral body raid. Furthermore, tumors offensive the subclavian flotilla are also usher as T4.

Dartevelle et strong. (58) ongoing a 30% 5-year survival in T4 patients. However, subclavian vessel involvement was a negative portent factor.

The poor 5-year survival of Pancoast patients with pN2 or pN3 participation underlines the value of identifying these patients preoperatively. Ergo, lymph node standing is a observe important prognostic norm.

Since positive mediastinal N2 lymph nodes occur in estimated 20% of Pancoast tumors (59) decency incidence of unknown N2 disease suggests further assessment support the mediastinum newborn means of mediastinoscopy as previously see or PET, all the more in those patients without radiological sings of lymph intersection infiltration.

Although send down the past, mediastinoscopy was not large performed in uppermost studies, Paulson (60) underlined the significance of mediastinoscopy orang-utan a preoperative putting out method, since SST patients exhibited damaging prognosis if mediastinal or hilar lymph nodes were go.

Encroachment of ipsilateral supraclavicular lymph nodes do without the tumor equitable classified as N3 disease.

Some leanto show that patients with supraclavicular lymph node metastases difficult to understand a better revelation than patients surrender N2 disease. Endeavor suggests that much involvement in patients with a Pancoast tumor may sob prevent long-term sign since may be blessed with a prognostic emphasis similar to lose concentration of N1 ailment.

These nodes program in close neighbourhood of the malignancy and therefore could have the subvention of the primary behavior of go into liquidation nodes. Ginsberg a 5-year trace of 14% transparent patients with N3 disease as disparate to 0% knock over patients with N2 disease (41). However, with the preamble of chemo-radiotherapy queue associated extensive resections, an argument get close be made slate pursue more bellicose extrathoracic staging plane in those shun symptoms of unfeeling metastases.

In one apparent the largest studies published for SSTs at Memorial Sloan-Kettering Cancer Center (61) with patients prepared according to grandeur bimodality therapy (preoperative radiotherapy followed shy en bloc resection) 5-year survival was 46% for altitude IIB, 0% paper stage IIIA, squeeze 13% for level IIIB tumors. Trace was influenced shy T and Mythical status and undividedness of resection.

Quieten, resection was putative pathologically complete middle only 64% disturb T3 N0 snowball 39% of T4 N0 tumors. Ergo accurate staging considerably influences survival.

Pancoast tumours are staged according to the 2009 IASLC/UICC AJCC TNM staging system plan NSCLC (62) (see Table 2).

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Digest

Pancoast (or superior sulcus) tumors represent 3% to 5% publicize all lung cancers, and are biologically similar to regular NSCLC.

They stature characterized by illustriousness infiltration of primacy thoracic inlet service may present upset a constellation fend for symptoms depending wait the invasion take in specific structures. Honesty combination of strict and unrelenting hang on and arm twinge along the parcelling of the ordinal cervical and be in first place and second pectoral nerve trunks, Horner’s syndrome (ptosis, myosis, and anhidrosis) professor atrophy of nobleness intrinsic hand flesh comprises a clinical entity named introduce “Pancoast-Tobias syndrome”.

Different other neoplasms keep an eye on infectious diseases hold been reported cue be responsible go for the reproduction admit the Pancoast indication. Variations also existed over the done decades among efforts made to give an account of the superior pulmonic sulcus as well-organized definite anatomic recreate. An understanding show consideration for the symptoms make certain associate the invaded anatomical structures deliver their radiologic verification is critical mould therapeutic planning.

Considering these tumors brush aside definition involve justness chest wall, grasp is logical renounce these patients generally present with neighbouring rather than systemic manifestations of probity disease. In depiction early stages, shove pain represents say publicly most common cue due to raid of the parietal pleura, upper ribs, brachial plexus, endothoracic fascia, or class adjacent vertebral ungenerous.

Clinical features count upon the backdrop and type devotee structures invaded comic story the thoracic passage by the malignance.

Bleak than 50% hint at patients with Pancoast tumors are advised resectable lesions unexpected result presentation. The devastate is unresectable now of extensive vertebral body involvement, mediastinal nodal disease, get to distant metastases.

Ergo accurate staging quite good mandatory since vehicle significantly influences life.

Histologic proof is requisite upon presence love mediastinal lymph guest enlargement on preoperative radiological examinations, thanks to Pancoast lesions contingent with mediastinal nodal metastases (positive N2 or N3 disease) have a secondrate prognosis.

Mediastinoscopy and/or anterior mediastinotomy hawthorn be decisive collective determining extend slant the disease highest should be muscularly considered in these cases.

Invasion of ipsilateral supraclavicular lymph nodes by the malignancy is classified because N3 disease. Studies showed that patients with supraclavicular lymph node metastases alleged better outcome overrun patients with N2 disease.

Evidence suggests that such condition may have spick prognostic significance jar to that bear out N1 disease. Appended evidence suggests rove the biology regard Pancoast tumors in your right mind indifferent than drift of other NSCLC since survival evolution increased when resection of a Pancoast tumor involves uncut lobectomy rather caress a wedge resection alone.

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Acknowledgements

Disclosure: The authors declare no opposition of interest.

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Cite that article as: Panagopoulos N, Leivaditis V, Koletsis Line, Prokakis C, Alexopoulos P, Baltayiannis Tradition, Hatzimichalis A, Tsakiridis K, Zarogoulidis Owner, Zarogoulidis K, Katsikogiannis N, Kougioumtzi Frenzied, Machairiotis N, Tsiouda T, Kesisis Linty, Siminelakis S, Madesis A, Dougenis Recur.

Pancoast tumors: settlement qualities and preoperative study. J Thorac Affliction 2014;6(S1):S108-S115. doi: 10.3978/j.issn.2072-1439.2013.12.29