Survival outcome after surgery in patients with thymoma distant recurrence

OBJECTIVE

Aim of this study is to describe characteristics and survival outcome of patients who underwent surgical treatment for distant thymoma relapse according to the International Thymic Malignancy Interest Group definition(ITMIG).

METHODS

Data of patients affected by thymoma recurrence from 4 different Institution were collected and retrospectively reviewed.Patients with loco-regional metastases, who underwent non-surgical therapies and with incomplete data on follow-up were excluded.According to the ITMIG distant recurrence definition,patients with recurrence due to hematogenic localization were included. Clinical and pathological characteristics were described using descriptive statistics while survival outcome was calculated using Kaplan-Meier curves and Cox regression analysis.

RESULTS

The analysis was conducted on 40 patients.A single localization was present in 13 patients,the relapse was intrathoracic in 28(70%),involving the lung in 26cases. Liver was operated in 7 cases, while other kind of abdominal involvement was detected in 8 cases.Adjuvant treatment was administered in 22cases(55%). Five and 10 year OS resulted 67% and30%. Univariable analysis identified as significant favorable factor a low-grade histology(A,B1, B2):5YOS 92.3% vs53.3% in high-grade (B3-C)(p=0.035). Site of recurrence and number of localization did not influence the prognosis, while in patients with adjuvant therapy administration there were a survival advantage also if not statistically significant:5YOS 84.8%vs54.5% in patients without adjuvant therapy(p=0.101). Multivariable analysis confirmed as independent prognostic factor low grade histology:HR=0.176,95% CI 0.042-0.744,p=0.018.

CONCLUSIONS

Our study showed a good survival outcome in patients who underwent surgery for distant thymoma recurrence,independently from the number and site of the relapse localization. Patients with A,B1,B2 histology presented a significantly better survival than patients with B3-C.

Uniportal Video-Assisted Thoracoscopic Surgery Completion Lobectomy Long after Wedge Resection or Segmentectomy in the Same Lobe: A Bicenter Study

BACKGROUND

Completion lobectomy (CL) following a prior resection in the same lobe may be complicated by severe pleural or hilar adhesions. The role of uniportal video-assisted thoracoscopic surgery (U-VATS) has never been evaluated in this setting.

METHODS

Data were collected from two Italian centers. Between 2015 and 2022, 122 patients (60 men and 62 women, median age 67.7 ± 8.913) underwent U-VATS CL at least 4 weeks after previous lung surgery.

RESULTS

Twenty-eight (22.9%) patients were affected by chronic obstructive pulmonary disease (COPD) and twenty-five (20.4%) were active smokers. Among the cohort, the initial surgery was performed using U-VATS in 103 (84.4%) patients, triportal-VATS in 8 (6.6%), and thoracotomy in 11 (9.0%). Anatomical segmentectomy was the initial surgery in 46 (37.7%) patients, while hilar lymphadenectomy was performed in 16 (13.1%) cases. CL was performed on 110 (90.2%) patients, segmentectomy on 10 (8.2%), and completion pneumonectomy on 2 (1.6%). Upon reoperation, moderate pleural adhesions were observed in 38 (31.1%) patients, with 2 (1.6%) exhibiting strong adhesions. Moderate hilar adhesions were found in 18 (14.8%) patients and strong adhesions in 11 (9.0%). The median operative time was 203.93 ± 74.4 min. In four (3.3%) patients, PA taping was performed. One patient experienced intraoperative bleeding that did not require conversion to thoracotomy. Conversion to thoracotomy was necessary in three (2.5%) patients. The median postoperative drainage stay and postoperative hospital stay were 5.67 ± 4.44 and 5.52 ± 2.66 days, respectively. Postoperative complications occurred in 34 (27.9%) patients. Thirty-day mortality was null. Histology was the only factor found to negatively influence intraoperative outcomes (p = 0.000). Factors identified as negatively impacting postoperative outcomes at univariate analyses were male sex (p = 0.003), age > 60 years (p = 0.003), COPD (p = 0.014), previous thoracotomy (p = 0.000), previous S2 segmentectomy (p = 0.001), previous S8 segmentectomy (p = 0.008), and interval between operations > 5 weeks (p= 0.005). In multivariate analysis, only COPD confirmed its role as an independent risk factor for postoperative complications (HR: 5.12, 95% CI (1.07-24.50), p = 0.04).

CONCLUSIONS

U-VATS CL seems feasible and safe after wedge resection and anatomical segmentectomy.

The Efficacy of Continuous Serratus Anterior and Erector Spinae Plane Blocks vs Intercostal Nerve Block in Uniportal-Vats Surgery: A Propensity-Matched Prospective Trial

BACKGROUND

To evaluate the analgesic efficacy of continuous erector spinae plane block(c-ESPB) and serratus anterior plane block(c-SAPB) versus the intercostal nerve block (ICNB) in Uniportal-VATS in terms of pain control, drug consumption, and complications.

METHODS

Ninety-three consecutive patients, undergone one of the three peripheral nerve blocks after Uniportal-VATS, were prospectively enrolled. A 1:1 propensity score matching was used to minimize bias.

RESULTS

C-ESPB and c-SAPB groups had no difference in morphine request upon awakening compared to ICNB. A higher VAS-score was recorded in c-ESPB compared to ICNB in the first 12 h after surgery. A significantly lower consumption of paracetamol in II postoperative day (p.o.d.) and tramadol in I and II p.o.d. was recorded in the c-ESPB group compared to the ICNB group. A higher dynamic VAS score was recorded at 24 h and 48 h in the ICNB group compared to the c-SAPB. No difference was found in safety, VAS-score and drug consumption between c-ESPB and c-SAPB at any given time, except for a higher tramadol request in c-SAPB in II p.o.d.

CONCLUSIONS

C-ESPB and c-SAPB appear to have the same safety and analgesic efficacy when compared between them and to ICNB in Uniportal-VATS approach. C-ESPB showed a delayed onset of analgesic effect and a lower postoperative drug consumption compared to ICNB.

Are the Efficacy and Safety of Chest Tubes in Uniportal Video-Assisted Thoracic Surgery Related to the Level of Intercostal Space Insertion or to the Drain Type? A Prospective Multicenter Study

OBJECTIVES

The aim of this study is to evaluate if the efficacy and safety of chest tube placement are influenced by the level of intercostal space insertion (uniportal VATS vs. biportal VATS) or by the type of drain employed (standard vs. smart coaxial drain).

METHODS

Data on patients who underwent either uniportal or biportal VATS upper lobectomies with lymphadenectomy were prospectively collected in three European centers. The uniportal VATS group with a 28 Fr standard chest tube (U-VATS standard) was compared with the uniportal VATS group with a 28 Fr smart drain (U-VATS smart), and U-VATS smart was also compared with biportal VATS with a 28 Fr smart drain inserted in the VIII intercostal space (Bi-VATS smart).

RESULTS

When comparing the U-VATS standard group with the U-VATS smart, a higher fluid output was recorded in the U-VATS smart (p: 0.004) in the III post-operative day (p.o.) and overall (p: 0.027), with a lower 90-day re-admission in the U-VATS smart (p: 0.04). The Bi-VATS smart group compared to U-VATS smart showed a higher fluid output in the I p.o. (p < 0.001), with no difference in total fluid amount or hospitalization. The Bi-VATS smart recorded a lower incidence (p < 0.001) of residual pleural space or effusion (p: 0.004) at chest X-rays prior to drain removal but a higher level of pain and chronic intercostal neuralgia (p: 0.03).

CONCLUSIONS

Chest tube insertion through the same incision space in uniportal VATS seems to be safe and effective. Smart drains can improve the fluid output in uniportal VATS, as if the drainage were inserted in a lower space (i.e., biportal VATS), but with less discomfort.

The Role of Human Papilloma Virus (HPV) in Primary Lung Cancer Development: State of the Art and Future Perspectives

Non-small cell lung cancer (NSCLC) is the leading cause of cancer-related mortality worldwide. Notably, the incidence of lung cancer among never-smokers, predominantly women, has been rising in recent years. Among the various implicated risk factors, human papilloma virus (HPV) may play a role in the development of NSCLC in a certain subset of patients. The prevalence of high-risk HPV-DNA within human neoplastic lung cells varies across the world; however, the carcinogenetic role of HPV in NSCLC has not been completely understood. Bloodstream could be one of the routes of transmission from infected sites to the lungs, along with oral (through unprotected oral sex) and airborne transmission. Previous studies reported an elevated risk of NSCLC in patients with prior HPV-related tumors, such as cervical, laryngeal, or oropharyngeal cancer, with better prognosis for HPV-positive lung cancers compared to negative forms. On the other hand, 16% of NSCLC patients present circulating HPV-DNA in peripheral blood along with miRNAs expression. Typically, these patients have a poorly differentiated NSCLC, often diagnosed at an advanced stage. However, HPV-positive lung cancers seem to have a better response to target therapies (EGFR) and immune checkpoint inhibitors and show an increased sensitivity to platinum-based treatments. This review summarizes the current evidence regarding the role of HPV in NSCLC development, especially among patients with a history of HPV-related cancers. It also examines the diagnostic and prognostic significance of HPV, investigating new future perspectives to enhance cancer screening, diagnostic protocols, and the development of more targeted therapies tailored to specific cohorts of NSCLC patients with confirmed HPV infection.

Unsolved Issues in Thymic Epithelial Tumour Stage Classification: The Role of Tumour Dimension

According to the different classifications now in use, thymic tumours are staged by the extent of local invasiveness, and tumour size is not included as a major determinant for the T category. The aim of this double-site retrospective study is to analyse the correlation between tumour dimension and overall survival (OS) in patients who underwent surgical treatment. From January 2000 to December 2020, patients with thymic epithelial tumours who underwent surgical resection were included in this study. Data from a total of 332 patients were analysed. Five- and ten-year overall survival (5-10 YOS) was 89.26% and 87.08%, respectively, while five- and ten-year disease-free survival (DFS) was 88.12% and 84.2%, respectively. Univariate analysis showed a significant correlation between male sex (p-value 0.02), older age (p-value < 0.01), absence of myasthenia gravis (p-value < 0.01), increase in pTNM (pathological Tumor Node Metastasis) (p-value 0.03) and increase in the number of infiltrated organs (p-value 0.02) with an increase in tumour dimension. Tumour dimension alone was not effective in the prediction of DFS and OS, both when considered as a continuous variable and when considered with a cut-off of 3 and 5 cm. However, with multivariate analysis, it was effective in predicting OS in the aforementioned conditions (p-value < 0.01). Moreover, multivariate analysis was also used in the thymoma and Masaoka I subgroups. In our experience, the role of tumour dimension as a descriptor of the T parameter of the TNM (Tumor Node Metastasis) staging system seemed to be useful in improving this system.

Surgical Resection of Pulmonary Metastases from Melanoma in Oligometastatic Patients: Results from a Multicentric Study in the Era of Immunoncology and Targeted Therapy

In the last decade, the emergence of effective systemic therapies (ESTs) in the form of both targeted and immuno-based therapies has revolutionized the treatment of patients with advanced stage III and stage IV melanoma. Even though lungs represent the most frequent site of melanoma metastases, only limited data are available on the role of surgery in isolated pulmonary metastases from malignant melanoma (PmMM) in the era of ESTs. The aim of this study is to describe the outcomes of patients who underwent metastasectomy of PmMM in the era of ESTs, in order to identify prognostic factors affecting survival and to provide a framework for more informed patient selection of treatmeant with lung surgery in the future. Clinical data of 183 patients who underwent metastasectomy of PmMM between June 2008 and June 2021 were collected among four Italian Thoracic Centers. The main clinical, surgical and oncological variables reviewed were: sex, comorbidities, previous oncological history, melanoma histotypes and primary site, date of primary cancer surgical treatment, melanoma growth phase, Breslow thickness, mutation pattern disease, stage at diagnosis, metastatic sites, DFI (Disease Free Interval), characteristics of lung metastases (number, side, dimension, type of resection), adjuvant therapy after lung metastasectomy, site of recurrence, disease-free survival (DFS) and cancer-specific survival (CSS; defined as the time interval between the first melanoma resection or lung metastasectomy and death from cancer). All patients underwent surgical resection of the primary melanoma before lung metastasectomy. Twenty-six (14.2%) patients already had a synchronous lung metastasis at the time of primary melanoma diagnosis. A wedge resection was performed in 95.6% of cases to radically remove the pulmonary localizations, while an anatomical resection was necessary in the remaining cases. The incidence of major post-operative complications was null, while only 21 patients (11.5%) developed minor complications (mainly air leakage followed by atrial fibrillation). The mean in-hospital stay was 4.46 ± 2.8 days. Thirty- and sixty-day mortality were null. After lung surgery, 89.6% of the population underwent adjuvant treatments (47.0% immunotherapy, 42.6% targeted therapy). During a mean FUP of 107.2 ± 82.3 months, 69 (37.7%) patients died from melanoma disease, 11 (6.0%) from other causes. Seventy-three patients (39.9%) developed a recurrence of disease. Twenty-four (13.1%) patients developed extrapulmonary metastases after pulmonary metastasectomy. The CSS from melanoma resection was: 85% at 5 years, 71% at 10 years, 54% at 15 years, 42% at 20 years and 2% at 25 years. The 5- and 10-year CSS from lung metastasectomy were 71% and 26%, respectively. Prognostic factors negatively affecting CSS from lung metastasectomy at multivariable analysis were: melanoma vertical growth (p = 0.018), previous metastatic sites other than lung (p < 0.001) and DFI < 24 months (p = 0.007). Our results support the evidence that surgical indication confirms its important role in stage IV melanoma with resectable pulmonary metastases, and selected patients can still benefit from pulmonary metastasectomy in terms of overall cancer specific survival. Furthermore, the novel systemic therapies may contribute to prolonged survival after systemic recurrence following pulmonary metastasectomy. Patients with long DFI, radial growth melanoma phase and no site of metastatization other than lung seem to be the best candidate cases for lung metastasectomy; however, to drive stronger conclusions, further studies evaluating the role of metastasectomy in patients with iPmMM are needed.

Reducing Post-Operative Alveolo-Pleural Fistula by Applying PGA-Sheets (Neoveil) after Major Lung Resection: A Historical Case-Control Study

Alveolo-pleural fistula remains a serious post-operative complication in lung cancer patients after surgery, which is associated with prolonged hospital stay and higher healthcare costs. The aim of this study is to evaluate the efficacy of a polyglycol acid (PGA)-sheet known as Neoveil in preventing post-operative air-leak in cases of detected intra-operative air-leak after lung resection. Between 11/2021 and 7/2022, a total of 329 non-small cell lung cancer (NSCLC) patients were surgically treated in two institutions. Major lung resections were performed in 251 cases. Among them, 44 patients with significant intra-operative air-leak at surgery were treated by reinforcing staple lines with Neoveil (study group). On the other hand, a historical group (selected by propensity score matched analysis) consisting of 44 lung cancer patients with significant intra-operative air leak treated by methods other than the application of sealant patches were considered as the control group. The presence of prolonged air-leak (primary endpoint), pleural drainage duration, hospital stay, and post-operative complication rates were evaluated. The results showed that prolonged air-leak (>5 days after surgery) was not observed in study group, while this event occurred in four patients (9.1%) in the control group. Additionally, a substantial reduction (despite not statistically significant) in the chest tube removal was noted in the study group with respect to the control group (3.5 vs. 4.5, p = 0.189). In addition, a significant decrease in hospital stay (4 vs. 6 days, p = 0.045) and a reduction in post-operative complications (2 vs. 10, p = 0.015) were observed in the study group when compared with the control group. Therefore, in cases associated with intra-operative air-leak after major lung resection, Neoveil was considered a safer and more effective aerostatic tool and represents a viable option during surgical procedures.

Trocar vs. Seldinger small bore pleural drains: does the technique influence the outcomes? A prospective single-centre study

OBJECTIVE

The aim of this study is to compare two positioning techniques of 12-French (Fr) thoracic drains in terms of efficacy, safety, and patient comfort.

PATIENTS AND METHODS

This is a prospective, non-randomized, competitive, non-inferiority study comparing the Seldinger vs. Trocar technique. The primary endpoint was an analysis of the factors that led to unsuccessful drainage positioning. Between the two groups, clinical variables, procedure times, pain, and complications were compared.

RESULTS

Seventy-two patients were enrolled in group 1 (Seldinger) and 45 in group 2 (Trocar). The mean procedural time was 7.93±3.02 min vs. 7.09±3.67 min, respectively (p: 0.33). The mean VAS for procedural pain was 2.22±1.47 vs. 2.80±1.88, p: 0.07, and the mean at day 2 was 3.6±1.2 in the SBWGD group vs. 2.7±1.1 in the Unico Group (p: 0.04). There was no difference in terms of complications, residual effusion, and pneumothorax at the first post-procedural chest X-ray. Four days after the procedure, the drain removal rate was 11.6% in group 1 vs. 25% in group 2 p: 0.063). The chest tube was removed after a mean period of 8.87±7.20 days after resolution of pleural effusion or tube dislodgement (7 cases in group 1 vs. 11 in group 2, p: 0.053).

CONCLUSIONS

The two techniques resulted in comparable pain and complication rates. Both drains are well-tolerated and efficient at draining pleural effusion, with very low rates of complications and failure. We recommend inserting a longer tube for patients who require chest drainage for an extended period of time.

Uniportal-VATS vs. open McKeown esophagectomy: Surgical and long-term oncological outcomes

Background

Till now there are very few reports about surgical results of Uniportal-VATS esophagectomy and no one about long-term outcomes. This study is the first comparing surgical and oncological outcomes of Uniportal-VATS with open McKeown esophagectomy, with the largest reported series and longest oncological follow-up.

Methods

The prospectively collected clinical, surgical and oncological data of 75 patients, undergone McKeown esophagectomy at our Thoracic Surgery Department, from January 2012 to August 2022, were retrospectively analyzed. Nineteen patients underwent esophagectomy by thoracotomy and reconstruction according to McKeown technique while 56 by Uniportal-VATS approach. Gastric tubulization was performed totally laparoscopic or through a mini-laparatomic access and cervical anastomosis was made according to Orringer's technique.

Results

The mean operative thoracic time was similar in both accesses (102.34 ± 15.21 min in Uniportal-VATS vs. 115.56 ± 23.12 min in open, p: 0.646), with a comparable number of mediastinal nodes retrieved (Uniportal-VATS:13.40 ± 8.12 vs. open:15.00 ± 6.86, p: 0.275). No case needed conversion from VATS to open. The learning curve in Uniportal-VATS was completed after 34 cases, while the Mastery was reached after 40. Both approaches were comparable in terms of minor post-operative complications (like pneumonia, lung atelectasis, anemization, atrial fibrillation, anastomotic-leak, left vocal cord palsy, chylothorax), while the number of re-operation for major complications (bleeding or mediastinitis) was higher in open group (21.0% vs. 3.6%, p: 0.04). Both techniques were also effective in terms of surgical radicality and local recurrence but VATS approach allowed a significantly lower chest tube length (11.89 ± 9.55 vs. 25.82 ± 24.37 days, p: 0.003) and post-operative stay (15.63 ± 11.69 vs. 25.53 ± 23.33, p: 0.018). The 30-day mortality for complications related to surgery was higher in open group (p: 0.002). The 2-, 5- and 8-year survival of the whole series was 72%, 50% and 33%, respectively. Combined 2- and 5-year OS in Uniportal-VATS group was 76% and 47% vs. 62% and 62% in open group, respectively (Log-rank, p: 0.286; Breslow-Wilcoxon: p: 0.036). No difference in DFS was recorded between the two approaches (5 year-DFS in Uniportal-VATS: 86% vs. 72%, p: 0.298). At multivariate analysis, only pathological stage independently affected OS (p: 0.02), not the surgical approach (p: 0.276).

Conclusions

Uniportal-VATS seems to be a safe, feasible and effective technique for performing McKeown esophagectomy, with equivalent surgical and long-term oncological results to standard thoracotomy, but with a faster and unharmed recovery, and a quite short learning curve.

Risk Factors Associated with Post-Operative Complications in Multidisciplinary Treatment of Descending Necrotizing Mediastinitis

BACKGROUND

Descending necrotizing mediastinitis (DNM) is a severe, life-threatening complication of oropharyngeal infections with cervical necrotizing fasciitis. In this study, we aimed to identify any possible factors that correlate with favorable outcomes.

METHODS

We retrospectively analyzed our series of 18 patients who underwent surgical treatment for DNM from a cervical abscess. Gender, age, symptoms, etiopathogenesis, comorbidities, time to surgery from diagnosis, degree of diffusion, identified microorganisms, surgical procedure, days in the intensive care unit, need for tracheostomy, complications, and surgical outcomes were reviewed.

RESULTS

The main type of surgery was thoracotomy + cervicotomy in eight cases (50.0%), followed by cervicotomy +VATS in four (22.2%). Seven patients (38.9%) had two or more surgeries; a bilateral operation was necessary for four patients. Evaluating the risk factors associated with post-operative complications, age ≥ 60 years (p:0.031), cervicotomy alone as surgical approach (p = 0.040), and the bilateral approach (p = 0.048) resulted in significance in terms of the univariate analysis; age ≥ 60 years (p = 0.04) and cervical approach (p = 0.05) maintained their significance in terms of the multivariate analysis.

CONCLUSIONS

The low mortality of our series emphasizes the importance of an extensive and immediate surgical drainage of both the neck and the mediastinum. Mediastinal drainage from cervicotomy seems to be a risk factor for post-operative complications. Minimally invasive surgery on the chest cavity, such as with Uniportal-VATS, could be a good approach above all in elderly patients and all those cases where bilateral access is required.

Learning Curve of Robot-Assisted Thymectomy: Single Surgeon's 7-Year Experience

Background

Robot-assisted thymectomy (RAT) has rapidly emerged as the preferred approach over open trans-sternal or video-assisted thoracoscopy for the surgical treatment of thymomas and non-thymomatous myasthenia gravis (MG). The aim of this study was to describe and discuss the learning curve (LC) of a single surgeon performing 113 consecutive RATs.

Methods

A single-center retrospective analysis of prospectively collected clinical data was performed on all patients who had been operated on by the same surgeon in an RAT setting between October 2013 and February 2020. The cumulative sum (CUSUM) analysis of the operative time was used to define the completion of the learning curve (CLC) in RAT. The CLC was separately calculated for myasthenic patients, non-myasthenic patients, and docking time.

Results

In myasthenic patients, the CLC cut-off was found in 19 patients. Considering the CLC cut-off of 19 patients, the mean operative time in phase 1 (first 19 cases) was 229.79 ± 93.40 min, while it was 167.35 ± 41.63 min in phase 2 (last 51 cases), p≪0.001. In non-myasthenic patients, the CLC cut-off was found in 16 cases. The mean operative time in phase 1 (first 16 cases) was 277.44 ± 90.50 min, while it was 169.63 ± 61.10 min in phase 2 (last 27 cases), p = 0.016. The LC for docking time was reached at 46 cases, recording a significant reduction of time after the first phase (28.09 ± 5.37 min vs. 19.75 ± 5.51 min, p≪0.001). The intraoperative and 30-day mortality were null in all phases of the LC in both myasthenic and non-myasthenic patients. There were no differences between the two phases of the LC in terms of blood loss, duration of postoperative drainage, and postoperative stay in both myasthenic and non-myasthenic groups. However, significantly higher hospital readmission at 30 days post surgery was recorded for myasthenic patients operated on during the first phase of the LC (2 cases vs. 0, p = 0.02).

Conclusions

According to our data, LC in RAT seems to be steep, and RAT confirms to be safe even before reaching CLC.

Does Myasthenia Gravis Affect Long-Term Survival in Thymic Carcinomas? An ESTS Database Analysis

Background: Thymic carcinoma is a rare and highly malignant tumor with a dismal prognosis, which occasionally coexists with myasthenia gravis (MG). This study aims to investigate the MG incidence on a surgical cohort of patients with thymic carcinoma and to explore its influence on long-term survival. Methods: the prospectively collected data from the ESTS database on thymic epithelial tumors were reviewed. Clinical, pathological, and survival information on thymic carcinoma were analyzed. Results: the analysis was conducted on 203 patients, with an equal gender distribution (96 males and 107 females). MG was detected in 22 (10.8%) patients, more frequently elderly (>60 years, p = 0.048) and male (p = 0.003). Induction therapy was performed in 22 (10.8%) cases. After surgery, 120 (59.1%) patients had a Masaoka stage II−III while complete resection (R0) was achieved in 158 (77.8%). Adjuvant therapy was performed in 68 cases. Mean follow-up was 60 (SD = 14) months. The 3-year, 5-year and 10-year survival rates were 79%, 75% and 63%, respectively. MG did not seem to influence long-term survival (5-year survival in non-MG−TCs 78% vs. 50% in MG−TCs, p = ns) as age < 60 years, female gender, early Masaoka stage, and postoperative radiotherapy did, conversely. Conclusions: myasthenia occurred in about 10% of thymic carcinomas and it did not seem to affect significantly the long-term prognosis in surgically treated thymic carcinoma-patients.

Role of Peripheral Blood Markers for Detecting Response and Predicting Prognosis in Patients with Non-small-cell Lung Cancer Undergoing Neoadjuvant Therapy and Surgery

INTRODUCTION

To date, no validated predictors of response before neoadjuvant therapy (NAD) are currently available in locally advanced non-small-cell lung cancer (NSCLC). In this study, different peripheral blood markers were investigated before NAD (pre-NAD) and after NAD/before surgery (post-NAD) to evaluate their influence on the treatment outcomes.

METHODS

Patients affected by locally advanced NSCLC (cT1-T4/N0-2/M0) who underwent NAD followed by surgery from January 1996 to December 2019 were considered for this retrospective analysis. The impact of peripheral blood markers on downstaging post-NAD and on overall survival (OS) was evaluated using multivariate logistic and Cox regression models. Time to event analysis was performed by means of Kaplan-Meier survival curves and Log Rank tests at 5 years from surgery.

RESULTS

Two hundred and seventy-two consecutive patients were included. Most of the patients had Stage III NSCLC (83.5%). N2 disease was reported in 188 (69.1%) patients. Surgical resection was performed in patients with stable disease or downstaging post-NAD. Nodal downstaging was observed in 80% of clinical N2 (cN2) patients. The median follow-up of the total series was 74 months (range 6-302). Five-year OS in the overall population and in N2 population was 74.6% and 73.5%, respectively. The pre-surgery platelets level (PLT) (p = 0.019) and the variation (pre-NAD/post-NAD) of the neutrophil/lymphocyte ratio (p = 0.024) were identified as independent prognostic factors of OS. The preoperative PLT value (p value = 0.031) was confirmed as the only predictor of NAD response.

CONCLUSIONS

The clinical role of peripheral blood markers in locally advanced NSCLC needs to be further investigated. Based on these preliminary results, these factors may be used as auxiliary markers for the prediction of response to neoadjuvant treatment and as prognostic factors for stratification in multimodal approaches.

A predictive model of lymph node metastasis for thymic epithelial tumours

OBJECTIVES

Thymic epithelial tumours (TETs) are relatively rare indolent malignancies in the mediastinum. Lymph node metastasis (LNM) is an important prognostic indicator for TETs; however, the pattern of LNM involved in TETs has yet to be elucidated.

METHODS

Patients diagnosed with histologically confirmed thymoma (A-B3), thymic carcinomas and thymic neuroendocrine tumours, between 1988 and 2016 were identified from the Surveillance, Epidemiology, and End Results database. Univariable and multivariable logistic regression analyses were applied to identify the predictors for LNM. The predictive nomogram was built from the independent risk factors and measured using the concordance statistic.

RESULTS

The overall proportion of TETs with LNM was 18.5% (200/1048). The rate of LNM in thymoma, thymic carcinomas and thymic neuroendocrine tumours was 6.8% (42/622), 30.2% (100/331) and 61.1% (58/95), respectively. According to the logistic regression analysis, histology type and T stage were independent factors correlated with LNM. A predictive nomogram model was developed with a concordance statistic of 0.807 (95% confidence interval: 0.773-0.841), which was significantly better than the T stage (P < 0.001) while had limited benefit to the histology type (P = 0.047). The calibration curve for the nomogram comparing the predicted and actual probabilities after bias correction showed good agreement.

CONCLUSIONS

Nodal involvement was not uncommon in TETs. Main factors related to LNM in TETs were histology type and T stage. The probability of LNM could be well calculated using the predictive model.

Surgical Effectiveness of Uniportal-VATS Lobectomy Compared to Open Surgery in Early-Stage Lung Cancer

Background

Although the feasibility and safety of Uniportal-Video-Assisted thoracic surgery (U-VATS) has been proven, its surgical effectiveness is still debated. The aim of this study is to assess the equivalence of the U-VATS approach compared with an open technique in terms of surgical (nodal-upstaging, complications, and post-operative results) and short-term survival outcomes.

Methods

The clinical data of patients undergoing lobectomy for NSCLC at our center, from January 2014 to December 2019, were analyzed retrospectively. All patients undergoing open or U-VATS lobectomy with lymphadenectomy for early-stage lung cancer (cT1-T3N0, stages IA-IIB) were included in the study. Only 230 patients satisfied the inclusion criteria. Group bias was reduced through 1:1 propensity score matching, which resulted in 46 patients in each group (open surgery and U-VATS).

Results

The intra- and post-operative mortality were null in both groups. There was no difference in the post-operative complications (p: 1.00) between U-VATS and open lobectomy. There was also no recorded difference in the pathological nodal up-staging [11 (23.9%) after thoracotomy vs. 8 (17.4%) after U-VATS, p: 0.440). The chest tube duration was longer in the open group (p: 0.025), with a higher post-operative pain (p: 0.001). Additionally, the 3-year overall survival (OS) was 78% after U-VATS lobectomy vs. 74% after open lobectomy (p: 0.204), while 3-year disease-specific survival (DSS) was 97 vs. 89% (p: 0.371), respectively. The 3-year disease-free survival (DFS) was 62% in the U-VATS group and 66% in the thoracotomy group, respectively (p: 0.917).

Conclusions

Uniportal-VATS lobectomy for the treatment of early-stage lung cancer seems to be a safe and effective technique with similar surgical and short-term survival outcomes as open surgery, but with lower post-operative pain and shorter in-hospital stay.

The combination of computed tomography features and circulating tumor cells increases the surgical prediction of visceral pleural invasion in clinical T1N0M0 lung adenocarcinoma

Background

Visceral pleural invasion (VPI) is a clinical manifestation associated with a poor prognosis, and diagnosing it preoperatively is highly imperative for successful sublobar resection of these peripheral tumors. We evaluated the roles of computed tomography (CT) features and circulating tumor cells (CTCs) for improving VPI detection in patients with clinical T1N0M0 invasive lung adenocarcinoma.

Methods

Three hundred and ninety-one patients were reviewed retrospectively in this study, of which 234 presented with a pleural tag or pleural contact on CT images. CTCs positive for the foliate receptors were enriched and analyzed prior to surgery. Logistic regression analyses were performed to assess the association of CT features and CTCs with VPI, and the receiver operating characteristic (ROC) curve was generated to compare the predictive power of these variables.

Results

Patients mostly underwent either segmentectomies (18.9%) or lobectomies (79.0%). Only 49 of the 234 patients with pleural involvement on CT showed pathologically confirmed VPI. Multivariate logistic regression analysis revealed that CTC level ≥10.42 FU/3 mL was a significant VPI risk factor for invasive adenocarcinoma cases ≤30 mm [adjusted odds ratio (OR) =4.62, 95% confidence interval (CI): 2.05–10.44, P<0.001]. Based on CT features, subgroup analyses showed that the solid portion size was a statistically significant independent predictor of VPI for these peripheral nodules with pleural tag, while the solid portion length of the interface was an independent predictor of pleural contact. The receiver operating curve analyses showed that the combination of CTC and CT features were highly predictive of VPI [area under the curve (AUC) =0.921 for pleural contact and 0.862 for the pleural tag, respectively].

Conclusions

CTC, combined with CT features of pleural tag or pleural contact, could significantly improve VPI detection in invasive lung adenocarcinomas at clinical T1N0M0 stage prior to the patient’s surgery.

Prognostic factors for survival in patients with lung metastases from gynaecological tract cancers

OBJECTIVES

Lung metastases from gynaecological tract cancers are rare, and prognostic factors are still undefined. The goal of this study was to analyse prognostic factors for survival in this group of patients.

METHODS

Data of patients with lung metastases from gynaecological tract cancers who underwent surgical resections from 1 January 2005 to 31 May 2019 were reviewed retrospectively. All patients were treated surgically if the primitive tumour was under control and the lung was the only organ involved. Clinical and pathological data associated with metastatic patterns and previous treatment types were correlated with overall survival (OS) and disease-free survival using Kaplan-Meier curves, whereas the log-rank test was used to assess differences between subgroups.

RESULTS

The analysis was conducted on 55 patients. OS was 65% at 5 years. With univariable analysis, age >45 years (P = 0.022) and the absence of pleural infiltration (P = 0.001) were determined to be favourable prognostic factors. The 5-year OS was 69.9% versus 53.3% in patients with pleural involvement. Multivariable analysis confirmed the absence of pleural infiltration as a favourable independent prognostic factor; the hazard ratio was 0.06; the 95% confidence interval was 0.00-0.23 (P = 0.011).At univariable analysis, the absence of pleural infiltration was determined to be a favourable prognostic factor (P = 0.034) for disease-free survival. The numbers and dimensions of the metastases did not influence survival in these patients.In uterine cancers of endometrial or cervical origin, the presence of pleural infiltration (P = 0.001), lymph node involvement (P = 0.001) and young age (P = 0.044) were considered unfavourable prognostic factors for OS.

CONCLUSIONS

Surgical treatment in technically resectable gynaecological tract metastases may represent an important option. Pleural infiltration and lymph node metastases seem to be adverse prognostic factors.

Is Surgery Worthwhile in Locally-advanced NSCLC Patients with Persistent N2-disease After Neoadjuvant Therapy?

AIMS

To explore the long-term survival in lung cancer patients with persistent mediastinal lymph nodal disease after neoadjuvant followed by surgical resection and to analyse prognostic factors in this specific subset of patients.

BACKGROUND

Surgery in non-small-cell lung cancer (NSCLC) patients with N2-disease after neoadjuvant therapy (NAD) has been debated and has been even more questioned with the advent of immunotherapy.

OBJECTIVE

Describe long-term results of a multimodal approach in locally-advanced NSCLC patients with persistence of N2-disease and identify prognostic factors to target the strategy of care.

METHODS

We retrospectively reviewed data of 121 consecutive Stage IIIA-N2 NSCLC patients who underwent NAD (chemoradiotherapy or chemotherapy) from 01/00 to 12/19, focusing our analysis on 37 patients with persistent N2s status after surgery. Kaplan-Meier and Cox regression analysis explored the associations between mortality and potential risk factors.

RESULTS

The 5-year survival was 29.8%. Cox regression analysis suggested that young age (HR=0.98, C.I.95%: 0.97- 1.00; p=0.062), male sex (HR=3.8,C.I.95%:1.06-13.73;p=0.04), and adjuvant therapy (HR=6.81,C.I.95%:0.96-53.94;p=0.06) influenced long-term outcomes in these patients.

CONCLUSION

We herein observed suboptimal long-term results in this NSCLC patient subset, and, considering emerging results adopting immunotherapy following chemoradiotherapy, surgery should be carefully considered in very selected cases (young and clinically fit patients) and combined with adjuvant therapy after surgery.

Multimodal therapy for synchronous bone oligometastatic NSCLC: The role of surgery

OBJECTIVES

The study aimed to assess the feasibility of radical surgical treatment for selected bone-oligometastatic non-small cell lung cancer (NSCLC) patients and to identify prognostic factors associated with survival.

MATERIALS AND METHODS

The clinical records of 27 patients with bone synchronous oligometastatic NSCLC were retrospectively analyzed.

RESULTS

Thirteen (48.1%) bone metastases were treated by surgery and 14 (51.9%) by local radiotherapy. Eighteen (66.7%) patients underwent induction chemotherapy before lung surgery, and 3 (11.1%) concurrent radiotherapy. Pulmonary surgery was a major lung resection in 23 (85.2%) cases. Intraoperative and 30-days mortality was null. Only one major (ARDS) and 10 (37.04%) mild complications (like air leakage, arrhythmia, and mucus retention) were recorded. 1-year and 5-years OS from the diagnosis and 1-year, 3- years disease-free survival (DFS) were 96%, 38%, and 66%, 30%, respectively. After stepwise Cox regression analysis, local recurrence (p = 0.05) and metachronous metastases (p = 0.04) maintained their independent prognostic value as overall survival negative determinants. Nodal upstaging (p = 0.04) and nonsurgical treatment of bone lesion (p = 0.03) turned out to be independent risk factors for shorter DFS; the vertebral localization of bone metastases showed only a remarkable trend towards significance (p = 0.06) as a risk factor for a worse DFS.

CONCLUSIONS

In selected patients, surgical treatment of primary NSCLC and bone synchronous metastasis seems to be safe and feasible and rewarding survivals may be expected.

Prognostic factors for survival in advanced thymomas: The role of the number of involved structures

BACKGROUND AND OBJECTIVES

The Masoka-Koga and tumor node metastases staging systems for thymoma are based on structures involved, but the prognostic role of the number of infiltrated/involved structures is still debated. We analyzed the prognostic role of involved structures and their combinations in locally advanced thymomas patients.

METHODS

Data on 174 surgically treated locally advanced thymoma patients from 1/01/1990 to 31/12/2015 were reviewed. Clinical and pathological characteristic, involved structures, number of involved structures and different combinations were correlated to cancer specific survival (CSS) using Kaplan-Meier product-limit method.

RESULTS

Five and 10-year CSS was 92% and 87%. Masaoka Stage 3 (p < 0.001), absence of pericardial involvement (p = 0.001), number of involved structures (p = 0.018), R0 (p < 0.001) and adjuvant radiotherapy (p = 0.008) were favorable prognostic CSS factors. A significant better prognosis was present in ≤2 involved structures vs >2 involved structures (5- and 10-year CSS: 95% and 93% vs. 80% and 51%). Multivariable analysis confirmed as independent prognostic factor R0 (p = 0.033, hazard ratio [HR]: 0.093, 95% confidence interval [CI] 0.010-0.827) and number of involved structures (p = 0.046, HR: 0.187, 95% CI: 0.036-0.968). In Masaoka Stage 3, patients with ≤2 involved structures had a significant better CSS than patients with >2 (10-year CSS: 98% vs. 73%, p = 0.008).

CONCLUSIONS

The number of involved structures and the concomitant involvement of the pericardium seems to be associated with a poor prognosis in surgically treated advanced thymoma patients.

The International Thymic Malignancy Interest Group Classification of Thymoma Recurrence: Survival Analysis and Perspectives

INTRODUCTION

The International Thymic Malignancy Interest Group (ITMIG) classifies thymoma recurrences on the basis of the topographic location, but its effectiveness in prognosis prediction has not been well investigated yet. Aims of this study are to analyze survival outcome of patients surgically treated for thymoma recurrence according to the ITMIG recurrence classification and to investigate possible alternatives.

METHODS

From January 1, 1990, to January 7, 2017, data on 135 surgically treated patients for thymoma recurrence from three high-volume centers were collected and retrospectively analyzed. Patients were classified according to the ITMIG classification as local, regional, and distant. The ITMIG classification and alternative classifications were correlated to overall survival (OS).

RESULTS

According to the ITMIG classification, recurrence was local in 17 (12.5%), regional in 97 (71.8%), and distant in 21 (15.7%) patients, with single localization in 38 (28.2%) and multiple localizations in 97 (71.8%). The 5- and 10-year OS were 79.9% and 49.7% in local, 68.3% and 52.6% in regional, and 66.3% and 35.4% in distant recurrences, respectively, but differences were not statistically significant (p = 0.625). A significant difference in survival was present considering single versus multiple localizations: 5- and 10-year OS of 86.2% and 81.2% versus 61.3% and 31.5% (p = 0.005, hazard ratio = 7.22, 95% confidence interval: 0.147-0.740), respectively. Combining the localization number with the recurrence site, ITMIG locoregional single recurrence had a statistically significant better survival compared with patients with ITMIG locoregional multiple recurrence or ITMIG distant recurrence (p = 0.028). Similarly, a significant difference was present considering intrathoracic single versus intrathoracic multiple versus distant recurrence (p = 0.024).

CONCLUSIONS

The ITMIG classification for thymoma recurrence did not have significant survival differences comparing local, regional, and distant recurrences. Integrating this classification with the number of the localizations may improve its effectiveness in prognosis prediction.

Prognostic Factors Affecting Survival after Pulmonary Resection of Metastatic Renal Cell Carcinoma: A Multicenter Experience

Simple Summary

This multicentric paper aimed at evaluating the role of pulmonary metastasectomy in patients affected by metastatic renal cell carcinoma. The impact of pulmonary metastasectomy was analysed with respect to long-term survival and disease-free survival in a wide population of patients affected by pulmonary metastases from renal cell carcinoma. The prognostic value of factors affecting survival, disease-free interval and disease-free survival was evaluated. Our results aid clinicians in identifying those patients affected by pulmonary metastases from renal cell carcinoma who are more likely to benefit from pulmonary metastasectomy.

Abstract

In this paper we aimed to address the role of pulmonary metastasectomy (PM) in patients affected by Lung Metastases (LM) from Renal Cell Carcinoma (RCC) and to analyse prognostic factors affecting overall survival (OS), disease-free interval (DFI) between primary RCC and first LM, and disease-free survival (DFS) after PM and before lung recurrence. Medical records of 210 patients who underwent PM from RCC in 4 Italian Thoracic Centres, from January 2000 to September 2019, were collected and analysed. All patients underwent RCC resection before lung surgery. The main RCC histology was clear cells (188, 89.5%). The 5- and 10-year OS from the first lung operation were 60% and 34%, respectively. LM synchronous with RCC (p = 0.01) and (Karnofsky Performance Status Scale) KPSS < 80% (p < 0.001) negatively influenced OS. Five- and 10-year DFI were 54% and 28%, respectively. The main factors negatively influencing DFI were: male gender (p = 0.039), KPSS < 80% (p = 0.009) and lactate dehydrogenase > 1.5 times 140 U/L (p = 0.001). Five- and 10-year disease-free survival were 54% and 28%, respectively; multiple LM (p = 0.036), KPSS < 80% (p = 0.001) and histology of RCC other than clear cells negatively influenced disease-free survival. Conclusions: patients with KPSS > 80%, single metachronous LM with a long DFI from RCC diagnosis, and clear cell histology, benefit from pulmonary metastasectomy.

Prognostic role of standard uptake value according to pathologic features of lung adenocarcinoma

OBJECTIVE

To evaluate the influence of lung adenocarcinoma second predominant pattern on the maximal standard uptake value (SUVmax) and its prognostic effect in different histologic groups.

METHODS

We retrospectively collected surgically resected pathologic stage I and II lung adenocarcinoma from nine European institutions. Only patients who underwent preoperative PET-CT and with available information regarding SUVmax of T (SUVmaxT) and N1 (SUVmaxN1) component were included.

RESULTS

We enrolled 344 patients with lung adenocarcinoma. SUVmaxT did not show any significant relation according to the second predominant pattern (p = 0.139); this relationship remained nonsignificant in patients with similar predominant pattern. SUVmaxT influenced the disease-free survival in the whole cohort (p = 0.002) and in low- and intermediate-grade predominant pattern groups (p = 0.040 and p = 0.008, respectively). In the high-grade predominant pattern cohort and in the pathologic N1 cases, SUVmaxT lost its prognostic power. SUVmaxN1 did not show any significant correlation with predominant and second predominant patterns and did not have any prognostic impact on DFS.

CONCLUSIONS

SUVmaxT is influenced only by the adenocarcinoma predominant pattern, but not by second predominant pattern. Concurrently, in high-grade predominant pattern and pN1 group the prognostic power of SUVmaxT becomes nonsignificant.

Dynamic nomogram for long-term survival in patients with non-small cell lung cancer after pneumonectomy

Background

The study aims to identify prognostic factors of overall survival (OS) in patients who had pneumonectomy, in order to develop a practical dynamic nomogram model.

Methods

A total of 2,255 patients with non-small cell lung cancer (NSCLC) who underwent pneumonectomy were identified from 2010-2015 in the Surveillance, Epidemiology, and End Results (SEER) database. The cohort was divided into a training (2011-2015) and a validation [2010] cohort. A nomogram and a risk classification system were constructed from the independent survival factors in multivariable analysis. The predictive accuracy of the nomogram was measured through internal and external validation.

Results

Independent prognostic factors associated with OS were gender, age, pathology, tumor size, N stage, chemotherapy, and radiotherapy. The C-index of the nomogram for OS was 0.675 (95% CI: 0.655-0.694). Similarly, the AUC of the model was 0.733, 0.709, and 0.701 for the 1-, 3-, and 5-year OS, respectively. The calibration curves for survival demonstrated good agreement. Significant statistical differences were found in the OS of patients within different risk groups. An online calculation tool was established for clinical use.

Conclusions

This novel nomogram was able to provide a reliable prognosis for survival in patients with NSCLC undergoing pneumonectomy.

Long-Term Outcomes after Surgical Resection for Synchronous or Metachronous Hepatic and Pulmonary Colorectal Cancer Metastases

BACKGROUND/AIMS

At present, benefits of surgical resection and appropriate selection criteria in patients affected by both hepatic and pulmonary metastases of colorectal cancer (CRC) are under discussion. Our analysis focused on a surgical series of such patients and our final aim consisted in identifying potential prognostic factors.

METHODS

Eighty-five patients undergoing resection of both hepatic and pulmonary metastases at 2 Healthcare Institutions from January 1993 to June 2015 were retrospectively reviewed as concerned clinical information, surgical notes and pathological features. Patient, treatment, and outcome variables were analyzed by use of log-rank tests, Cox regression, and Kaplan-Meier methods.

RESULTS

Liver turned out as the first site of metastasis in 75% patients, lung in 13% patients, and both sites in 12% patients. Multiple hepatic metastases were detected in 67% patients and pulmonary metastases in 31% patients. Two hundred eighteen surgical interventions were performed (mean 2.56 for each patient). Overall survival (OS) rates at 3-, 5-, and 10-year follow-up from colorectal resection were 94, 79, and 38% respectively. Median OS was 8.31 years. Survival turned out significantly longer for patients with disease-free interval (DFI) exceeding 1 year between first metastasectomy and diagnosis of second metastases and in patients affected by metachronous pulmonary metastases.

CONCLUSIONS

Surgical resection of both hepatic and pulmonary metastases of CRC represents a safe and effective treatment. It might lead to rewarding long-term survival rates in high selected patients. Shorter DFIs between first metastasectomy and diagnosis of second metastases can determine worse prognoses. In addition, poor outcomes could be predicted also for patients affected by synchronously detected pulmonary CRC metastases, although further confirmatory analyses are strongly required.

Prognostic impact of lung adenocarcinoma second predominant pattern from a large European database

BACKGROUND AND OBJECTIVES

Adenocarcinoma patterns could be grouped based on clinical behaviors: low- (lepidic), intermediate- (papillary or acinar), and high-grade (micropapillary and solid). We analyzed the impact of the second predominant pattern (SPP) on disease-free survival (DFS).

METHODS

We retrospectively collected data of surgically resected stage I and II adenocarcinoma.

SELECTION CRITERIA

anatomical resection with lymphadenectomy and pathological N0. Pure adenocarcinomas and mucinous subtypes were excluded. Recurrence rate and factors affecting DFS were analyzed according to the SPP focusing on intermediate-grade predominant pattern adenocarcinomas.

RESULTS

Among 270 patients, 55% were male. The mean age was 68.3 years. SPP pattern appeared as follows: lepidic 43.0%, papillary 23.0%, solid 14.4%, acinar 11.9%, and micropapillary 7.8%. The recurrence rate was 21.5% and 5-year DFS was 71.1%. No difference in DFS was found according to SPP (p = .522). In patients with high-grade SPP, the percentage of SPP, age, and tumor size significantly influenced DFS (p = .016). In patients with lepidic SPP, size, male gender, and lymph-node sampling (p = .005; p = .014; p = .038, respectively) significantly influenced DFS.

CONCLUSIONS

The impact of SPP on DFS is not homogeneous in a subset of patients with the intermediate-grade predominant patterns. The influence of high-grade SPP on DFS is related to its proportion in the tumor.

Effect of Lymph Node Dissection on the Prognosis of Thymic Carcinomas and Thymic Neuroendocrine Tumors

We aimed to analyze the effect of lymph node dissection (LND) and accurate lymph node (LN) status on the survival and prognosis of patients with thymic carcinomas (TCs) and thymic neuroendocrine tumors (TNETs) undergoing surgical treatment. The Surveillance, Epidemiology, and End Results database was queried for patients who underwent surgical resection for TCs and TNETs during 1998-2016. LN status were defined as no LND (LND-), pathologically negative with LND (N0), and LN metastasis positive (N+). We investigated outcomes of LN status together with other clinicopathological features for overall survival (OS). Subgroup analyses were performed between LND-, N0, and N+ cohorts using propensity score matching, to analyze the significance of LND in prognosis. A total of 812 patients were enrolled, including 623 with TCs and 189 with TNETs. The proportion of LN metastasis positive in TNETs was 58.8% which was significantly higher than that in TCs (30%) (P < 0.001). In multivariable Cox analysis of OS, patients with LND- had a significantly worse prognosis than those with N0 (P = 0.018); there was no difference between N+ and LND- (P = 0.560). After propensity score matching, patients with N0 still had better survival than those with LND- and N+ in subgroup univariable and multivariable analyses of OS; however, the survival of patients with LND- and N+ was not significantly different in multivariable analysis. It was demonstrated that LND in TCs and TNETs can clarify the status of LN metastasis, to more accurately evaluate patients' long-term prognosis.

Regenerative medicine approaches for the management of respiratory tract fistulas

Respiratory tract fistulas (or fistulae) are abnormal communications between the respiratory system and the digestive tract or the adjacent organs. The origin can be congenital or, more frequently, iatrogenic and the clinical presentation is heterogeneous. Respiratory tract fistulas can lead to severely reduced health-related quality of life and short survival. Therapy mainly relies on endoscopic surgical interventions but patients often require prolonged hospitalization and may develop complications. Therefore, more conservative regenerative medicine approaches, mainly based on lipotransfer, have also been investigated. Adipose tissue can be delivered either as unprocessed tissue, or after enzymatic treatment to derive the cellular stromal vascular fraction. In the current narrative review, we provide an overview of the main tissue/cell-based clinical studies for the management of various types of respiratory tract fistulas or injuries. Clinical experience is limited, as most of the studies were performed on a small number of patients. Albeit a conclusive proof of efficacy cannot be drawn, the reviewed studies suggest that grafting of adipose tissue-derived material may represent a minimally invasive and conservative treatment option, alternative to more aggressive surgical procedures. Knowledge on safety and tolerability acquired in prior studies can lead to the design of future, larger trials that may exploit innovative procedures for tissue processing to further improve the clinical outcome.

Management of Pleural Effusions in the Emergency Department

BACKGROUND

In symptomatic patients, admitted in emergency department for acute chest pain and dyspnea, who require an urgent treatment, a rapid diagnosis and prompt management of massive pleural effusion or hemothorax can be lifesaving.

AIM

The aim of this review was to summarize the current diagnostic and therapeutic approaches for the management of the main types of pleural effusions that physicians can have in an emergency department setting.

METHODS

Current literature about the topic was reviewed and critically reported, adding the experience of the authors in the management of pleural effusions in emergency settings.

RESULTS

The paper analyzed the main types of pleural effusions that physicians can have to treat. It illustrated the diagnostic steps by the principal radiological instruments, with a particular emphasis to the role of ultrasonography, in facilitating diagnosis and guiding invasive procedures. Then, the principal procedures, like thoracentesis and insertion of small and large bore chest drains, are indicated and illustrated according to the characteristics and the amount of the effusion and patient clinical conditions.

CONCLUSION

The emergency physician must have a systematic approach that allows rapid recognition, clinical cause identification and definitive management of potential urgent pleural effusions.

Uniportal VATS approach to sub-lobar anatomic resections: literature review and personal experience

Surgical scientific literature contains relatively little information regarding the surgical outcomes of anatomic sublobar resections performed with the uniportal video-assisted thoracoscopic surgery (U-VATS) technique. This paper attempts to evaluate the role of U-VATS segmentectomies in the landscape of a minimally invasive approach to the treatment of early stage non small cell lung cancer (NSCLC).

Devising the guidelines: the concept of uniportal video-assisted thoracic surgery-instrumentation and operatory room staff

In the last years, uniportal video-assisted thoracic surgery (VATS) has been gaining more and more popularity, becoming a common procedure in several thoracic centers all over the world not only for minor procedures but also for major and complex cases. This technique combines the advantages of the less invasiveness with the oncological principles of open surgery. A standardization of the different peri- and intraoperative steps can help in the establishment and development of this technique. The aim of this paper is to set the basic steps for operating room set-up and instrumentation for starting or improving a uniportal VATS program in thoracic surgery centers.