Multicentre retrospective analysis on pulmonary metastasectomy: an European perspective

OBJECTIVES

To assess the current practice of pulmonary metastasectomy at 15 European Centres. Short- and long-term outcomes were analysed.

METHODS

Retrospective analysis on patients ≥18 years who underwent curative-intent pulmonary metastasectomy (January 2010 to December 2018). Data were collected on a purpose-built database (REDCap). Exclusion criteria were: previous lung/extrapulmonary metastasectomy, pneumonectomy, non-curative intent and evidence of extrapulmonary recurrence at the time of lung surgery.

RESULTS

A total of 1647 patients [mean age 59.5 (standard deviation; SD = 13.1) years; 56.8% males] were included. The most common primary tumour was colorectal adenocarcinoma. The mean disease-free interval was 3.4 (SD = 3.9) years. Relevant comorbidities were observed in 53.8% patients, with a higher prevalence of metabolic disorders (32.3%). Video-assisted thoracic surgery was the chosen approach in 54.9% cases. Wedge resections were the most common operation (67.1%). Lymph node dissection was carried out in 41.4% cases. The median number of resected lesions was 1 (interquartile range 25-75% = 1-2), ranging from 1 to 57. The mean size of the metastases was 18.2 (SD = 14.1) mm, with a mean negative resection margin of 8.9 (SD = 9.4) mm. A R0 resection of all lung metastases was achieved in 95.7% cases. Thirty-day postoperative morbidity was 14.5%, with the most frequent complication being respiratory failure (5.6%). Thirty-day mortality was 0.4%. Five-year overall survival and recurrence-free survival were 62.0% and 29.6%, respectively.

CONCLUSIONS

Pulmonary metastasectomy is a low-risk procedure that provides satisfactory oncological outcomes and patient survival. Further research should aim at clarifying the many controversial aspects of its daily clinical practice.

National Multicenter Study on the Comparison of Robotic and Open Thymectomy for Thymic Neoplasms in Myasthenic Patients: Surgical, Neurological and Oncological Outcomes

Thymectomy is the gold standard in the treatment of thymic neoplasm and plays a key role in the therapeutic path of myasthenia gravis. For years, sternotomy has been the traditional approach for removing anterior mediastinal lesions, although the robotic thymectomy is now widely performed. The literature is still lacking in papers comparing the two approaches and evaluating long-term oncological and neurological outcomes. This study aims to analyze the postoperative results of open and robotic thymectomy for thymic neoplasms in myasthenic patients. Surgical, oncological and neurological data of myasthenic patients affected by thymic neoplasms and surgically treated with extended thymectomy, both with the open and the robotic approach, in six Italian Thoracic Centers between 2011 and 2021 were evaluated. A total of 213 patients were enrolled in the study: 110 (51.6%) were treated with the open approach, and 103 (48.4%) were treated with robotic surgery. The open surgery, compared with the robotic, presented a shorter operating time (p < 0.001), a higher number of postoperative complications (p = 0.038) and longer postoperative hospitalization (p = 0.006). No other differences were observed in terms of surgical, oncological or neurological outcomes. The robotic approach can be considered safe and feasible, comparable to the open technique, in terms of surgical, oncological and neurological outcomes.

Spontaneous Pneumothorax Secondary to Bullous Lung Emphysema Positive for Cannabinoids upon Toxicological Examination

Cannabis can be related to respiratory diseases, but the relationship between smoking marijuana and the development of a pneumothorax has scarcely been investigated. We aimed to analyze, in patients with a history of cannabis smoking abuse submitted to lung apicectomy for a primary spontaneous pneumothorax (PSP), the correlation between the presence of cannabinoids in the resected lung and the detection of bullous emphysema within the same tissue. Patients undergoing lung apicectomy for a PSP were prospectively enrolled, and the correlation between the presence of cannabinoids in the resected lung tissue and histological finding of bullous emphysema was investigated with Fisher's exact test. There were 21 male patients, with a median age of 27 years. The cannabinoids found by the toxicological examination in surgical specimens were mainly delta-9-tetrahydrocannabinol (THC), cannabinol (CBN), and cannabidiol (CBD). In 14/21 patients, cannabinoids were detected in the resected lung tissue, and bullous emphysema was present in 13/14 of these (93%), while bullous emphysema was found in only 1/7 (14%) of the remaining patients who were negative for cannabinoids in the lung tissue, and the difference was found to be statistically significant (p < 0.0009). Our study demonstrated the presence of bullous emphysema in most cannabinoid-positive patients and its absence in most of those who were cannabinoid-negative, supporting the correlation between cannabinoids in the lung tissue and bullous emphysema with the development of a "secondary" spontaneous pneumothorax.

THYMECTOMY IN SEVERE (MGFA CLASS IV-V) GENERALIZED MYASTHENIA GRAVIS: IS THE GAME REALLY WORTH THE CANDLE?

OBJECTIVES

Total thymectomy in addition to medical treatment is an accepted standard therapy for myasthenia gravis. Patients with severe generalized myasthenia gravis present life-threatening events, poor prognosis and higher risk of postoperative myasthenic crisis. Aim of our study is to investigate neurological and surgical results in patients with MGFA class IV and V MG following thymectomy.

METHODS

Data on 76 myasthenia gravis patients with preoperative MGFA class IV and V who underwent thymectomy were retrospectively collected. Primary end-points included short-term surgical outcomes and long-term neurological results including the achievement of complete stable remission and any improvement as defined by MGFA postintervention status criteria.

RESULTS

There were 27(35.5%) males and 49(64.5%) females; 53(69.7%) were classified as MGFA class IV and 23(30.3%) as class V. Thymectomy was performed through sternotomy in 25(32.9%) patients, by VATS in 5(6.6%) and RATS in 46(60.5%). Median operative time was 120(IQR 95; 148) min. In-hospital mortality was observed in 1(1.3%) patient, postoperative complications in 14 (18.4%). Median postoperative hospital stay was 4(IQR 3; 6) days. Pathological examination revealed 31(40.8%) thymic hyperplasia/other benign and 45(59.2%) thymomas. Cumulative complete stable remission and improvement probabilities were 20.6% and 83.7% at 5-year, and 66.9% and 97.6% at 10-year, respectively. A significant improvement rate was found in patients with age at time of thymectomy of ≤ 50 years(p = 0.0236), MGFA class V(p = 0.0154), and AchR-antibodies positivity(p = 0.0152).

CONCLUSIONS

Thymectomy in patients with severe myasthenia gravis yields good perioperative outcomes and satisfactory long-term neurological improvement, especially for patients younger than 50 years, with MGFA class V and anti-AChR+ myasthenia gravis.

Successful uniportal thoracoscopic removal of a new generation implantable loop recorder accidentally migrated into the left pleural cavity and concomitant re-implantation: A case report

INTRODUCTION

With the spread of the use of implantable loop recorders (ILRs) by cardiologists for outpatient cardiac monitoring, intrathoracic migration represents a rare but possible complication occurring after the placement of these devices. Very few cases of ILRs intrathoracic migration into the pleural cavity have been reported, followed in even fewer cases by surgical removal of the devices, but in none re-implantation was performed.

PRESENTATION OF CASE

We report the first case of a patient with a new generation ILR accidentally migrated into the postero-inferior costophrenic recess of the left pleural cavity, successfully removed by uniportal video-assisted thoracic surgery (VATS) and submitted to re-implantation of a new ILR in the same operating session.

DISCUSSION

To reduce the risk of ILRs intrathoracic displacement, the insertion technique must be performed in the most suitable part of the chest wall, with the correct incision and angle of penetration, by an expert operator. When migrated into the pleural cavity, surgical removal should be performed to avoid the onset of early and late complications. A mini-invasive surgical approach by uniportal VATS could be considered as the first choice, ensuring a favourable patient outcome. Re-implantation of a new ILR can be safely performed in the same operating session.

CONCLUSION

In case of intrathoracic migration of ILRs, early removal by mini-invasive approach is recommended as well as concomitant re-implantation. Beyond periodic monitoring of ILRs by cardiologists, strict radiological follow-up with chest X-ray is advisable after implantation, in order to early identify any abnormalities and correctly manage them.

Not only acute respiratory failure: COVID-19 and the post-intubation/tracheostomy upper airways lesions†

Background

An increasing number of patients have been subjected to prolonged invasive mechanical ventilation due to COVID-19 infection, leading to a significant number of post-intubation/tracheostomy (PI/T) upper airways lesions. The purpose of this study is to report our early experience in endoscopic and/or surgical management of PI/T upper airways injuries of patients surviving COVID-19 critical illness.

Materials and Methods

We prospectively collected data from patients referred to our Thoracic Surgery Unit from March 2020 to February 2022. All patients with suspected or documented PI/T tracheal injuries were evaluated with neck and chest computed tomography and bronchoscopy.

Results

Thirteen patients (8 males, 5 females) were included; of these, 10 (76.9%) patients presented with tracheal/laryngotracheal stenosis, 2 (15.4%) with tracheoesophageal fistula (TEF) and 1 (7.7%) with concomitant TEF and stenosis. Age ranged from 37 to 76 years. Three patients with TEF underwent surgical repair by double layer suture of oesophageal defect associated with tracheal resection/anastomosis (1 case) or direct membranous tracheal wall suture (2 cases) and protective tracheostomy with T-tube insertion. One patient underwent redo-surgery after primary failure of oesophageal repair. Among 10 patients with stenosis, two (20.0%) underwent primary laryngotracheal resection/anastomosis, two (20.0%) had undergone multiple endoscopic interventions before referral to our Centre and, at arrival, one underwent emergency tracheostomy and T-tube positioning and one a removal of a previously positioned endotracheal nitinol stent for stenosis/granulation followed by initial laser dilatation and, finally, tracheal resection/anastomosis. Six (60.0%) patients were initially treated with rigid bronchoscopy procedures (laser and/or dilatation). Post-treatment relapse was experienced in 5 (50.0%) cases, requiring repeated rigid bronchoscopy procedures in 1 (10.0%) for definitive resolution of the stenosis and surgery (tracheal resection/anastomosis) in 4 (40.0%).

Conclusions

Endoscopic and surgical treatment is curative in the majority of patients and should always be considered in PI/T upper airways lesions after COVID-19 illness.

Catamenial pneumothorax: Not only VATS diagnosis

Background

Catamenial pneumothorax (CP) is a rare type of spontaneous, recurring pneumothorax occurring in women, from the day before menstruation until 72 hours after its beginning. Conservative treatment is generally associated with recurrence of CP. Video-assisted thoracic surgery (VATS) approach allows not only to obtain diagnosis but also to guide definitive treatment of causing lesions, such as ectopic endometrial implants or diaphragmatic defects and fenestrations. We report our experience in VATS management of CP to focus on its role in CP.

Materials and methods

In this retrospective observational study, we collected data from women referred to our center for CP, from January 2019 to April 2022. All patients underwent VATS approach, with muscle-sparing thoracotomy when diaphragmatic fenestrations were detected, to perform selective diaphragmatic plication and/or partial diaphragmatic resection. Results were analyzed in terms of pneumothorax recurrence after surgical treatment. All patients were referred to gynecologists for medical therapy.

Results

Eight women (median age 36 years, range: 21-45), all with right side CP, were included; three already had pelvic endometriosis and two had already undergone lung apicectomy at other institutions. VATS allowed us to detect diaphragmatic fenestrations in seven patients (87.5%) and apical bullae in five (62.5%). Apicectomy was performed in five cases (62.5%), selective diaphragmatic plication in two (25%), and partial diaphragmatic resection in five (62.5%). Chemical pleurodesis with talc was performed in all to minimize the risk of recurrence. Pathological diagnosis of endometriosis on the resected diaphragm was achieved in five patients (62.5%). No recurrence occurred, except for one woman who stopped medical treatment for endometriosis.

Conclusions

In the management of patients with CP, VATS should be recommended not only to obtain an explorative diagnosis of ectopic endometrial implants or diaphragmatic fenestrations but also to allow the most appropriate surgical treatment and obtain pathological specimens for confirmation and definitive diagnosis of thoracic endometriosis. Medical therapy to achieve ovarian rest is mandatory in the postoperative period and should not be discontinued.

The Overweight Paradox: Impact of Body Mass Index on Patients Undergoing VATS Lobectomy or Segmentectomy

The aim of this study was to assess the impact of BMI on perioperative outcomes in patients undergoing VATS lobectomy or segmentectomy. Data from 5088 patients undergoing VATS lobectomy or segmentectomy, included in the VATS Group Italian Registry, were collected. BMI (kg/m²) was categorized according to the WHO classes: underweight, normal, overweight, obese. The effects of BMI on outcomes (complications, 30-days mortality, DFS and OS) were evaluated with a linear regression model, and with a logistic regression model for binary endpoints. In overweight and obese patients, operative time increased with BMI value. Operating room time increased by 5.54 minutes (S.E. = 1.57) in overweight patients, and 33.12 minutes (S.E. = 10.26) in obese patients (P < 0.001). Compared to the other BMI classes, overweight patients were at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications. In the overweight range, a BMI increase from 25 to 29.9 did not significantly affect the length of stay, nor the risk of any complications, except for renal complications (OR: 1.55; 95% CI: 1.07-2.24; P = 0.03), and it reduced the risk of prolonged air leak (OR: 0.8; 95% CI: 0.71-0.90; P < 0.001). 30-days mortality is higher in the underweight group compared to the others. We did not find any significant difference in DFS and OS. According to our results, obesity increases operating room time for VATS major lung resection. Overweight patients are at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications following VATS resections. The risk of most postoperative complications progressively increases as the BMI deviates from the point at the lowest risk, towards both extremes of BMI values. Thirty days mortality is higher in the underweight group, with no differences in DFS and OS.

Case report: Mesothelioma and BAP1 tumor predisposition syndrome: Implications for public health

BRCA-1 associated protein 1 (BAP1) tumour predisposition syndrome (TPDS) is a hereditary condition characterised by germline mutation of the tumour suppressor BAP1. This disorder is associated with the development of various benign and malignant tumours, mainly involving the skin, eyes, kidneys, and mesothelium. In this article, we report the case of a man recruited through the Apulia (Southern Italy) Mesothelioma Regional Operational Centre of the National Register of Mesotheliomas, who suffered from uveal melanoma, renal cancer, and mesothelioma, and a familial cluster of BAP1 germline mutations demonstrated by molecular analyses. The family members of the proband developed multiple malignancies. As tumours arising in this context have specific peculiarities in terms of clinical behaviour, identification of this condition through appropriate genetic counselling should be considered for adequate primary, secondary, and tertiary prevention measures for offspring.

Case report: Successful multimodal assessment and management of chemothorax

Dislocation or wrong placement of central venous catheters into the pleural cavity is rare, but if undiagnosed, may cause major, sometimes life-threatening, complications (pneumothorax, hemothorax, infection, and migration) and accidental pleural effusion due to intravenous injection of fluids containing drugs (i.e. chemotherapy, antibiotics, parenteral nutrition, other). We report a rare case of pleural effusion consisting of chemotherapy (chemothorax) directly injected into the pleural cavity due to the wrong placement of a central venous catheter (Porth-A-Cath) in a woman with breast cancer. A multidisciplinary management consisting of antidote administration, followed by removal of the venous device and washing of the pleural cavity through video-assisted thoracic surgery (VATS), avoided any major complication related to the adverse event.

Case Report: Inferior Bilobectomy for Lung Cancer to Allow Weaning From Veno-Venous Extracorporeal Membrane Oxygenation

In recent years, veno-venous extracorporeal membrane oxygenation (V-V ECMO) has allowed complex lung and airways resections in patients with a compromised perioperative respiratory function. In the following report, we present a case of successful weaning from V-V ECMO in a patient who underwent an inferior bilobectomy for lung cancer.

A RARE CASE OF MEDIASTINAL MASSON'S TUMOR MIMICKING A THYMOMA

Masson's tumor or intravascular papillary endothelial hyperplasia (IPEH) is a rare non-malignant pseudotumoral disease, arising in different anatomic sites, that can clinically and radiologically mimic various benign and malignant tumors. We report the first case in the literature of a mediastinal Masson's tumor, mimicking a thymoma, in a 48-year old man, successfully treated with surgery. Though surgical removal may be technically difficult due to the intrinsic hypervascularized nature of these pseudotumoral benign lesions, resection is generally recommended as they represent a locus minoris resistentiae of blood vessels, potentially causing fatal bleedings.

A risk stratification scheme for synchronous oligometastatic non-small cell lung cancer developed by a multicentre analysis

BACKGROUNDS

Oligometastatic Non-Small Cell Lung Cancer (NSCLC) patients represent a category without a standard therapeutic approach. However, in selected oligometastatic NSCLC, radical surgery seems to offer a good prognosis. This retrospective study aimed to analyse the long-term outcomes of synchronous oligometastatic patients treated with curative intent and identify the factors associated with better results and the proposal of a risk stratification system for classifying the synchronous oligometastatic NSCLC.

METHODS

The medical records of patients from 18 centres with pathologically diagnosed synchronous oligometastatic NSCLC were retrospectively reviewed. The inclusion criteria were synchronous oligometastatic NSCLC, radical surgical treatment of the primary tumour with or without neoadjuvant/adjuvant therapy and radical treatment of all metastatic sites. The Kaplan - Meier method estimated survivals. A stratified backward stepwise Cox regression model was assessed for multivariable survival analyses.

RESULTS

281 patients were included. The most common site of metastasis was the brain, in 50.89 % patients. Median overall survival was 40 months (95 % CI: 29-53). Age ≤65 years (HR = 1.02, 95 % CI: 1.00-1.05; p = 0.019), single metastasis (HR = 0.71, 95 % CI: 0.45-1.13; p = 0.15) and presence of contralateral lung metastases (HR = 0.30, 95 % CI: 0.15 - 0.62; p = 0.001) were associated with a good prognosis. The presence of pathological N2 metastases negatively affected survival (HR = 2.00, 95 % CI: 1.21-3.32; p = 0.0065). These prognostic factors were used to build a simple risk classification scheme.

CONCLUSIONS

Treatment of selected synchronous oligometastatic NSCLC with curative purpose could be conducted safely and at acceptable 5-year survival levels, especially in younger patients with pN0 disease.

Lung Ultrasound for Detection of Pulmonary Complications in Critically Ill Obstetric Patients in a Resource-Limited Setting

Critically ill parturients have an increased risk of developing pulmonary complications. Lung ultrasound (LUS) could be effective in addressing the cause of respiratory distress in resource-limited settings with high maternal mortality. We aimed to determine the frequency, timing of appearance, and type of pulmonary complications in critically ill parturients in an obstetric unit in Sierra Leone. In this prospective observational study, LUS examinations were performed on admission, after 24 and 48 hours, and in case of respiratory deterioration. Primary endpoint was the proportion of parturients with one or more pulmonary complications, stratified for the presence of respiratory distress. Secondary endpoints included timing and types of complications, and their association with “poor outcome,” defined as a composite of transfer for escalation of care or death. Of 166 patients enrolled, 35 patients (21% [95% CI: 15–28]) had one or more pulmonary complications, the majority diagnosed on admission. Acute respiratory distress syndrome (period prevalence 4%) and hydrostatic pulmonary edema (4%) were only observed in patients with respiratory distress. Pneumonia (2%), atelectasis (10%), and pleural effusion (7%) were present, irrespective of respiratory distress. When ultrasound excluded pulmonary complications, respiratory distress was related to anemia or metabolic acidosis. Pulmonary complications were associated with an increased risk of poor outcome (odds ratio: 5.0; 95% CI: 1.7–14.6; P = 0.003). In critically ill parturients in a resource-limited obstetric unit, LUS contributed to address the cause of respiratory distress by identifying or excluding pulmonary complications. These were associated with a poor outcome.

Age and Clinical Presentation for Primary Spontaneous Pneumothorax

Primary spontaneous pneumothorax (PSP) is a commonly known condition due to the accumulation of air in the pleural space in otherwise healthy people, without apparent underlying lung disease. To date, the exact pathogenesis of PSP is unclear, but it still represents a public health issue. We performed a review of the literature concerning the epidemiology of PSP, examining age of onset and presentation symptoms, in order to assess the possible correlation between these characteristics and its occurrence. Data concerning age, signs, and symptoms were collected. For description purposes, information regarding aetiological and anthropomorphic data was also gathered. In total, 265 papers were evaluated. Regarding age of onset, PSP is a disease that can occur in a broad age group with a double cluster (15-30 and 40-45 yr). Regarding symptoms, pain and dyspnoea (in its various forms) are the most described in PSP. Pain was recorded in 69.25% (range, 9-100%) of the population studied, whereas dyspnoea was present in an average of 54.55% (range, 27-77.1%). Tobacco exposure seems to play an important role in the early onset of PSP. Concerning age at presentation, this review highlights that PSP can occur over a broad age range. The literature appears to be consistent in reporting PSP occurrence mostly below 45 years of age. Asymptomatic PSP is an almost unseen entity. Finally, of pollutants, cigarette smoking should be considered as the most significant exogenous risk factor in the development of PSP.

How to identify intersegmental planes in performing sublobar anatomical resections

Pulmonary segmentectomy is a common surgical procedure in thoracic surgery nowadays. Though this technique helps preventing postoperative pulmonary function loss, potential challenges are the management of air leaks and the difficulty of palpating ground-glass components during surgery, as well as how to deal with the intersegmental planes. Several techniques have been proposed for the identification and treatment of the intersegmental planes during sublobar anatomical resections: this review focuses on preoperative planning and workup and intraoperative strategies. Three-dimensional computed tomography bronchography and angiography (3D-CTBA), virtual-assisted mapping (VAL-MAP) using bronchoscopy multi-spot dye marking and three-dimensional computed tomography (3D-CT) are preoperative tools that may facilitate the planning of operation. Inflation-deflation techniques, infrared-fluorescence-enhanced method combined with bronchial and intravenous injection of indocyanine green (ICG) and near-infrared fluorescence (NIF) mapping with ICG have been described as intraoperative strategies to identify the intersegmental plane. The treatment and section of the intersegmental planes is mainly accomplished by stapler and electrocautery or energy devices. The use of staplers reduces postoperative air leaks, bleeding risks and operative time but seems to reduce preserved lung volume, compromising adjacent lung expansion; in addition, higher costs and sometimes non-adequate oncological margins, being a non-anatomical technique have been described. The electrocautery and energy devices allow for a more anatomical and precise dissection maintaining safe oncological margins, with a better lung expansion and so an increased postoperative lung function. Time consuming procedure and frequent requirement of aero-haemostatic tools to treat air and blood leaks are the main drawbacks. In conclusion, there are several methods to identify and treat the intersegmental planes but there are no significant differences between the different tools, therefore the use of one technique rather than another depends overall on surgeon's preference and the location of the segment.

Correction to: Predictors of nodal upstaging in patients with cT1-3N0 non-small cell lung cancer (NSCLC): results from the Italian VATS Group Registry

In the original publication, Carlo Curcio was not included in the author list. The correct author list is included in this Correction.

Sternochondral replacement: use of cadaveric allograft for the reconstruction of anterior chest wall

Background

Sternum may be involved by different diseases such as trauma, infection after cardiac surgery, tumors (primary and secondary) or chest wall deformities. Surgical excision with a safety margin is the primary goal after sternal resection for tumors, prevention of respiratory impairment due to flail chest and deformity and protection of surrounding organs are other important aims. Various techniques and materials have been used for this operation. We describe the use of cadaveric sternal allograft to reconstruct the chest wall in fourteen patients.

Methods

Between October 2008 and February 2017, five males and nine females underwent surgical procedure because of primary sternal neoplasm, single-site metastatic disease, neuroendocrine thymic carcinoma and sternal dehiscence after cardiac surgery.

Results

Fourteen sternectomy were undertaken. A muscle flap of pectoralis major was prepared to cover the graft in 9 patients. Adjuvant chemotherapy and radiotherapy were performed after surgery in three patients. No postoperative complications happened in 11 cases (84.6%). One (7.1%) patient died 9 days after surgery because of pulmonary embolism. Two patients (15.4%) had complications: one presented fever caused by systemic candidiasis and one had a muscle flap bleeding. Hospitalization median time was 11 days (range, 6-31 days). At follow up, 7 patients were alive in absence of disease, 1 patient is alive with recurrence, 6 patients died but nor infection neither rejection of the graft happened. No respiratory impairment or flail chest were registered in any patients.

Conclusions

This technique for sternal replacement in our experience can be considered safe with long term results, providing optimal chest wall stability. The allograft resulted well-tolerated permitting an optimal graft integration in the host.

Right thoracotomy approach for treatment of left bronchopleural fistula after pneumonectomy for tubercolosis

Pneumonectomy for pulmonary tuberculosis is a rare option but can sometimes be necessary in cases of destroyed lung, resulting from a previous or persistent chronic infection. Bronchopleural fistula on the bronchial stump may develop as a postoperative complication, favoured by the long-lasting infectious disease and the poor nutritional status. Right-sided approach can be used for treatment of left bronchopleural fistula after pneumonectomy. We report a rare case of left bronchopleural fistula after pneumonectomy for pulmonary tuberculosis in a 38-year-old woman, treated by re-closure and re-stapling of the left main bronchial stump through a right thoracotomy approach. The patient is in excellent general condition and without evidence of bronchopleural fistula and tuberculosis at 3 years from re-closure of the left bronchial stump through right thoracotomy. This approach allowed a successful and safe management of our case of left bronchopleural fistula after pneumonectomy for tuberculosis, without short and long-term complications.

Predictors of nodal upstaging in patients with cT1-3N0 non-small cell lung cancer (NSCLC): results from the Italian VATS Group Registry

PURPOSE

Accurate staging of early non-small cell lung cancer is fundamental for selecting the best treatment. The aim of this study was to identify risk factors for nodal upstaging after video-assisted thoracoscopic lobectomy for clinical T1-3N0 tumors.

METHODS

From 2014 to 2017, 3276 thoracoscopic lobectomies were recorded in the prospective database "Italian VATS Group". Linear and multiple logistic regression models were adapted to identify independent predictors of nodal upstaging and factors associated with progression in postoperative N status.

RESULTS

Nodal upstaging was found in 417 cases (12.7%), including 206 cases (6.2%) of N1-positive nodes, 81 cases of N2 nodes (2.4%), and 130 cases (4%) of involvement of both N1 + N2 nodes. A total of 241 (7.3%) patients had single-station nodal involvement, whereas 176 (5.3%) had multiple-station involvement. In the final regression model, the tumor grade, histology, pathologic T status, and > 12 resected nodes were independent predictors of nodal upstaging.

CONCLUSIONS

The number of resected lymph nodes seems to predict nodal upstaging better than the type of intraoperative lymph node management. Other preoperative risk factors correspond to those for which the current guidelines of the European Society of Thoracic Surgery recommend more extensive preoperative mediastinal staging.

Cannabinoids determination in bronchoalveolar lavages of cannabis smokers with lung disease

Background Cannabis smoke affects the lungs similarly to tobacco smoke, causing symptoms such as increased cough, sputum, hyperinflation and chronic bronchitis. Chronic use can also cause serious lung diseases and airway obstruction. We developed and validated a method for the identification and quantification of cannabinol (CBN), cannabidiol (CBD), Δ-9-tetrahydrocannabinol (THC) and its metabolites 11-hydroxy-THC (11-OH-THC) and 11-nor-9-carboxy-THC (THC-COOH) in bronchoalveolar lavages (BALs) from hospitalized former or current tobacco smoking patients with lung disease and a long history of cannabis consumption and limited current tobacco use. Methods For the extraction of cannabinoids from BALs, a 1 mL sample was added with 300 µL of 0.1 N NaOH and 3 mL of hexane/ethyl acetate (9:1). The solvent was then evaporated to dryness. Trimethylsilyl derivatives were prepared and then analyzed by gas chromatography/mass spectrometry. Results The method was linear for the analytes under investigation with coefficients of determination of at least 0.99. Absolute analytical recovery was always better than 80%, imprecision and inaccuracy was always under 15%. Six cases out of 15 were positive for THC, CBN and CBD. In two BALs samples, the presence of 11-OH-THC was also measured while THC-COOH was not detected. In the six positive cases, the last cannabis smoking occurred in the previous 2-14 days. Conclusions This is the first time that cannabinoids have been detected in BALs, demonstrating the presence of a drug with its metabolites in a target organ of consumers who present with a lung disease. This occurrence let us hypothesize a role of cannabinoids in the development of the disease and prompted an investigation on possible associations between cannabis smoking and clinical outcomes in patients with lung disease and eventually evaluate a cytotoxic effect of cannabinoids themselves.

Pulmonary and mediastinal paragangliomas: rare endothoracic malignancies with challenging diagnosis and treatment

Background

Pulmonary and mediastinal paragangliomas are rare tumors that may have neuroendocrine activity or be non-functional, incidental, in asymptomatic patients, or causing mass effect symptoms. Although being low-grade tumors, they can display an aggressive behaviour, developing local infiltration and distant metastases. We report our experience with three endothoracic paragangliomas and a Literature review, to point out diagnostic difficulties and problems related to surgical treatment.

Methods

From 2009 to 2017, we treated 3 patients with histological diagnosis of paraganglioma: 2 pulmonary, 1 mediastinal. No one presented catecholamine-secreting syndromes; pulmonary cases were asymptomatic, while the mediastinal one had aspecific cough and dyspnea. Imaging diagnosis was based on chest computerized tomography (CT) and magnetic resonance imaging (MRI) scan. No patient had preoperative histological diagnosis. Intraoperative pathological examination was suggestive for malignancy: in pulmonary cases, wedge resection and lobectomy were performed; the middle mediastinal mass was completely removed after challenging dissection, isolation and section of numerous vascular pedicles.

Results

Postoperative course was uneventful in all cases. No patient received adjuvant treatments. At a median follow-up of 47 months (range, 6-102 months), two patients are alive, without local or distant recurrence; one patient died 6 months after surgery, due to disease progression.

Conclusions

Endothoracic paragangliomas, rare and often asymptomatic tumors, are of difficult diagnosis and should be considered malignant tumors, due to the potential aggressive behaviour of cases with high mitotic index and the frequent possibility of recurrence and metastases. Surgical resection is the treatment of choice and careful intraoperative manipulation is recommended, due to the high vascularity of these tumors, to prevent complications. After complete excision, long-term prognosis is generally good. However, even after surgical removal, a close, periodical and life-long follow-up is mandatory.

Teenage pregnancies in Mozambique: the experience of "Servicios Amigos dos Adolescentes" clinics in Beira

The purpose of this article is to provide insights into the demand for pregnancy-related health services by adolescent girls and young women in Mozambique. We analysed the patient registers for the first year of operation (2014) of the Servicios Amigos dos Adolescentes (SAAJ) [Friendly Services for Adolescents] clinics in Beira, Mozambique. These registers provide details of the service demands of, and services provided to the 8 290 adolescent girls and young women who accessed the 6 SAAJ clinics in 2014. Analysis of that record, with disaggregation of the patients according to age (9 years or less; 10-14; 15-19; 20-24; 25 and older), show that 3 021 (36%) were pregnant or had previously been pregnant; most being girls in the 15-19 age band (59%). Being pregnant or having been pregnant previously was associated with dropping out of school. Of all the girls and women, 60% agreed to HIV testing and counselling; the HIV prevalence rate amongst this group was 4-5% amongst adolescents and 25% amongst women 25 years and older. A minority of the girls and women who were pregnant or had been pregnant previously agreed to HIV testing and counselling. Notwithstanding the limitations for analysis, the results were alarming: substantially high HIV prevalence rates were indicated (2% amongst 10-14 year old girls; 8% amongst 15-19 year olds; 10% amongst 20-24 year olds; and 28% amongst >24 year olds). The data from the SAAJ clinics and results pertain only to conditions in Beira. However, as the first empirical assessment of pregnancy-related service demand amongst adolescent girls and young women in the country and involving a relatively large sample, we contend that this study affirms the need for expansion of sexual and reproductive health (SRH) services, including HIV services, for adolescent girls and young women in Mozambique.

Pathologic Grading of Malignant Pleural Mesothelioma: An Evidence-Based Proposal

INTRODUCTION

A pathologic grading system (PGS) for malignant pleural mesothelioma (MPM) is warranted to better identify different risk categories of patients, plan therapeutic options, and activate clinical trials.

METHODS

A series of 940 patients with MPM (328 in a training set and 612 in a validation set) that was diagnosed between October 1980 and June 2015 at the participant institutions was retrospectively assembled. A PGS was constructed by attributing to each histologic parameter, independent at multivariate analysis with excellent reproducibility (κ > 0.75), different scores based on the increase in corresponding hazard ratios. The relevant PGS score thus ranged from 0 to 8 points for individual patients with MPM.

CONCLUSIONS

The PGS was constructed by taking into consideration the histological subtyping of MPM (epithelioid/biphasic = 0 points; sarcomatoid = 2 points), necrosis (absent = 0 points versus present = 1 point), mitotic count per 1 mm² (cutoffs as follows: 1-2 = 0 points, 3-5 = 1 point, 6-9 = 2 points, or ≥10 = 4 points), and Ki-67 labeling index based on 2000 cells (<30% = 0 points versus ≥30 = 1 point), all of which are independent factors in both patient sets after adjustment for stage and age at diagnosis. No heterogeneity was seen across the validation centers (p = 0.19). Epithelioid/biphasic MPM patterning and biopsy versus resection did not affect survival, whereas the PGS outperformed mitotic count and Ki-67 LI in both the training (area under the curve receiver operating characteristic = 0.76) and validation sets (area under the curve receiver operating characteristic = 0.73) (p < 0.01). Patient survival progressively deteriorated from a score of 0 (median times of 26.3 and 26.9 months) to a score 1 to 3 (median times of 12.8 and 14.4 months) and a score of 4 to 8 (median times of 3.7 and 7.7 months) in both sets of patients, with the hazard ratio for a 1-point increase in score being 1.46 (95% confidence interval: 1.36-1.56) in the training set and 1.28 (95% confidence interval: 1.22-1.34) in the validation set (after adjustment for age and [when available] tumor stage). The PGS was effective even in subgroup analysis (epithelioid, biphasic, and sarcomatoid tumors).

DISCUSSION

A simple and reproducible multiparametric PGS effectively predicted survival in patients with MPM.

Video-assisted thoracoscopic surgery lobectomy learning curve: what program should be offered in a residency course?

Video-assisted thoracoscopic (VAT) procedures are emerging for treatment of both benign and malignant thoracic diseases and substituting classical approaches, such as thoracotomies, thanks to several advantages concerning postoperative morbidity rates and overall patients' outcome (i.e., postoperative pain, chronic pain and quality of life). However, a VAT approach needs an established learning curve making procedures as safe as in open surgery. With regard of trainee surgeons, notwithstanding an increasing number of learning tools and strategies, such as simulation programs (i.e., black-boxes, wet labs, cadaver or animal labs, 3D virtual reality simulators) and direct observation both of live surgery and videos with a supportive evidence base from benchtop studies, there remains inconsistent adoption in surgical educations.

Emergency surgery due to diaphragmatic hernia: case series and review

Background

Congenital diaphragmatic hernia (CDH) is a congenital abnormality, rare in adults with a frequency of 0.17–6%. Diaphragmatic rupture is an infrequent consequence of trauma, occurring in about 5% of severe closed thoraco-abdominal injuries. Clinical presentation ranges from asymptomatic cases to serious respiratory or gastrointestinal symptoms. Diagnosis depends on anamnesis, clinical signs and radiological investigations.

Methods

From May 2013 to June 2016, six cases (four females, two males; mean age 58 years) of diaphragmatic hernia were admitted to our Academic Department of General Surgery with respiratory and abdominal symptoms. Chest X-ray, barium studies and CT scan were performed.

Results

Case 1 presented left diaphragmatic hernia containing transverse and descending colon. Case 2 showed left CDH which allowed passage of stomach, spleen and colon. Case 3 and 6 showed stomach in left hemithorax. Case 4 presented left diaphragmatic hernia which allowed passage of the spleen, left lobe of liver and transverse colon. Case 5 had stomach and spleen herniated into the chest. Emergency surgery was always performed. The hernia contents were reduced and defect was closed with primary repair or mesh. In all cases, post-operative courses were uneventful.

Conclusion

Overlapping abdominal and respiratory symptoms lead to diagnosis of diaphragmatic hernia, in patients with or without an history of trauma. Chest X-ray, CT scan and barium studies should be done to evaluate diaphragmatic defect, size, location and contents. Emergency surgical approach is mandatory reducing morbidity and mortality.

Chest wall stabilization and reconstruction: short and long-term results 5 years after the introduction of a new titanium plates system

BACKGROUND

We report short and long-term results with the dedicated Synthes(®) titanium plates system, introduced 5 years ago, for chest wall stabilization and reconstruction.

METHODS

We retrospectively analyzed (January 2010 to December 2014) 27 consecutive patients (22 males, 5 females; range 16-83 years, median age 60 years), treated with this system: primary [3] and secondary [8] chest wall tumor; flail chest [5]; multiple ribs fractures [5]; sternal dehiscence-diastasis [3]; sternal fracture [1]; sternoclavicular joint dislocation [1]; Poland syndrome [1]. Short-term results were evaluated as: operating time, post-operative morbidity, mortality, hospital stay; long-term results as: survival, plates-related morbidity, spirometric values, chest pain [measured with Verbal Rating Scale (VRS) and SF12 standard V1 questionnaire].

RESULTS

Each patient received from 1 to 10 (median 2) titanium plates/splints; median operating time was 150 min (range: 115-430 min). Post-operative course: 15 patients (55.6%) uneventful, 10 (37%) minor complications, 2 (7.4%) major complications; no post-operative mortality. Median post-operative hospital stay was 13 days (range: 5-129 days). At a median follow-up of 20 months (range: 1-59 months), 21 patients (78%) were alive, 6 (22%) died. Three patients presented long-term plates-related morbidity: plates rupture [2], pin plate dislodgment [1]; two required a second surgical look. One-year from surgery median spirometric values were: FVC 3.31 L (90%), FEV1 2.46 L (78%), DLCO 20.9 mL/mmHg/min (76%). On 21 alive patients, 7 (33.3%) reported no pain (VRS score 0), 10 (47.6%) mild (score 2), 4 (19.1%) moderate (score 4), no-one severe (score >4); 15 (71.5%) reported none or mild, 6 (28.5%) moderate pain influencing quality of life.

CONCLUSIONS

An optimal chest wall stabilization and reconstruction was achieved with the Synthes(®) titanium plates system, with minimal morbidity, no post-operative mortality, acceptable operating time and post-operative hospital stay. Long-term restoration of a normal respiratory function was achieved, with minimal plates-related morbidity and chest pain.

Early and late outcome after surgical treatment of acquired non-malignant tracheo-oesophageal fistulae

OBJECTIVES

Tracheo-oesophageal fistula (TOF) is a rare, life-threatening condition. We report our results of surgical treatment and evaluation of the outcome of acquired non-malignant TOF.

METHODS

Twenty-five patients (aged 49 ± 21 years) with TOF were operated on between 2001 and 2011. Tracheo-oesophageal fistula was due to prolonged intubation/tracheostomy (84%), was secondary to other surgery (8%) or trauma (4%) or was idiopathic (4%). The tracheal defect was 2.4 ± 1.3 cm long and was associated with tracheal stenosis in seven (28%) patients. Surgical treatment consisted of direct suturing of the oesophageal defect in two layers (or end-to-end oesophageal resection and anastomosis in one case) associated with tracheal suturing (n = 15; 60%), tracheal resection and anastomosis (n = 8; 32%) or covering of a large tracheal defect by an intercostal muscle flap or by a resorbable patch with muscle apposition (n = 2; 8%). The surgical approach was cervicotomy (n = 14; 56%), cervicotomy plus median sternotomy or split (n = 6; 24%), thoracotomy (n = 4; 16%) or cervicotomy plus sternal spit plus thoracotomy (n = 1; 4%). In 18 (72%) cases a muscular flap was used and in six (24%) a protective tracheostomy was performed.

RESULTS

No perioperative deaths occurred. Morbidity occurred in eight (32%) patients; none of them required a second surgical look. At median follow-up of 41 months, the outcome was excellent or good for 22 patients (88%), two (8%) are still dependent on jejunostomy and tracheostomy for neurological diseases and one (4%) is under mechanical ventilation for end-stage respiratory failure.

CONCLUSIONS

Surgical treatment of TOF is associated with good results in terms of control of acute symptoms and long-term outcome, particularly concerning oral intake and spontaneous breathing.

Propranolol as first-line treatment of a severe subglottic haemangioma

Subglottic haemangioma (SGH) is a rare, benign tumour in children, which is potentially life-threatening because of airway obstruction. We report the case of a full-term 2-month-old infant girl admitted to our institution with stridor, dyspnoea and oxygen desaturation caused by a SGH and treated with propranolol. Neck-chest computed tomography (CT) revealed a contrast-enhancing, 10-mm, subglottic elliptic lesion, referable to SGH. Pre-treatment fibrobronchoscopy showed a sub-occlusive SGH closing more than 75% of the laryngotracheal airway. In agreement with our neonatologists and ear, nose and throat (ENT) specialists, we decided to begin oral propranolol therapy, which rapidly and dramatically improved respiratory symptoms. Fibrobronchoscopy six days after treatment confirmed a reduction of subglottic narrowing. Six months later the patient is doing well and without respiratory symptoms. To the best of our knowledge, this is the first reported case of the successful treatment with propranolol of an SGH obstructing more than 75% of the airway. The case is evidence of the effectiveness of oral propranolol as first-line treatment in the management of severely-obstructive paediatric SGH and the importance of CT and fibrobronchoscopy in the diagnosis; it also demonstrates the importance of multidisciplinary cooperation between thoracic surgeons, anaesthesiologists, neonatologists and ENT specialists in the treatment of these patients.

Surgical treatment of a rare case of epithelioid hemangioendothelioma of the azygos vein

Epithelioid hemangioendothelioma (EHE) of soft tissues is a rare low-grade vascular tumour, with variable malignancy. Mediastinal localization is exceptional. We report the first case of a radically resected EHE of the azygos vein (AV). A 47-year old man presented to our institution with an asymptomatic incidental neck-chest computerized tomography (CT) evidence of a 3 cm mediastinal mass, resembling a station 4R lymphadenopathy, with rather distinct margins, strictly adjacent to the AV. (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET)/CT revealed a SUV max of 2.3. Fiberbronchoscopy with EBUS-trans-tracheal needle aspiration of station 4R yielded nondiagnostic cytology result. A right lateral thoracotomy revealed an ovoidal mediastinal mass originating from the AV, unresectable from it but showing cleavage from the superior vena cava. The mass with the involved AV was resected en bloc by vascular stapler. Histopathology revealed a venous EHE arising from the AV. For the low mitotic rate and small tumour size, no adjuvant therapy was administered. Total body CT scan at one year from surgery shows neither local recurrence, nor distant metastases. EHE should be considered in the differential diagnosis of mediastinal masses in adult patients. After radical removal prognosis is generally favourable, but strict follow-up must be performed because aggressive forms have been described.

Surgical treatment of a rare case of tracheal inflammatory pseudotumor in pediatric age

Tracheal inflammatory pseudotumor (IPT) is a rare solid lesion with an unpredictable biological course. Treatment can vary and surgical resection may sometimes be necessary, even in pediatric age. We report the case of a 12-year-old male patient who presented to our institution with sudden dyspnoea after some months of wheezing and cough, wrongly considered and treated as asthma. Neck-chest CT-scan and fiberbronchoscopy showed an intraluminal tracheal mass, originating from the left antero-lateral wall at the level of the 5th cartilagineous tracheal ring, involving three rings, that was removed by rigid bronchoscopy. Histopathology revealed a tracheal IPT. Due to rapid tendency to recurrence of the lesion, two more endoscopic recanalizations were performed, but a new recurrence appeared, with CT evidence of transmural involvement of the tracheal wall. Resection of the three involved tracheal rings and termino-terminal tracheal anastomosis were successfully performed through cervicotomy and sternal split. CT-scan and fiberbronchoscopy at 17 months from surgery show a stable tracheal lumen without signs of recurrence. A tracheal IPT should be suspected in any pediatric patients with tracheal mass and asthmatic symptoms. After radical removal prognosis is generally excellent and recurrences after tracheal resection are rare.