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.

The role of the surgical volume for clinical outcomes in VATS lobectomy for lung cancer: a national large database multicenter analysis

Improving the quality of lung cancer care at a cost that can be sustained is a hotly debated issue. High-risk, low-volume procedures (such as lung resections) are believed to improve significantly when centralised in high-volume centres. However, limited evidence exists to support volume requirements in lung cancer surgery. On the other hand, there was no evidence that the number of lung resections affected either the short-term perioperative results or the long-term cost. Using data from an extensive nationwide registry, this study investigated the correlations between surgical volumes and selected perioperative outcomes. A retrospective analysis of a prospectively filled national registry that follows stringent quality assurance and security procedures was conducted to ensure data accuracy and security. Patients who underwent VATS lobectomy from 2014 to 2019 at the participating centres were included. Selected perioperative outcomes were reported. Total direct hospital cost is measured at discharge for hospitalisations with a primary diagnosis of lung cancer, hospital stay costs, and postoperative length of hospital stay after lobectomy. After the propensity score matched, centres were divided into three groups according to the surgical volume of the unit where VATS lobectomies were performed (high-volume centre: > 500 lobectomies; medium-volume centre: 200-500 lobectomies; low-volume centre: < 200 lobectomies). 11,347 patients were included and matched (low-volume center = 2890; medium-volume center = 3147; high-volume center = 2907). The mean operative time density plot (Fig. 1A) showed no statistically significant difference (p = 0.67). In contrast, the density plot of the harvested lymph nodes (Fig. 1B) showed significantly higher values in the high-volume centres (p = 0.045), albeit without being clinically significant. The adjusted rates of any and significant complications were higher in the low-volume centre (p = 0.034) without significantly affecting the length of hospital stay (p = 0.57). VATS lobectomies for lung cancer in higher-volume centres seem associated with a statistically significantly higher number of harvested lymph nodes and lower perioperative complications, yet without any significant impact in terms of costs and resource consumption. These findings may advise the investigation of the learning curve effect in a complete economic evaluation of VATS lobectomy in lung cancer. Fig. 1 The mean operative time density plot showed no statistically significant difference (p = 0.67).

An evaluation of the methodological quality of published guidelines for the surgical treatment of pleural mesothelioma

BACKGROUND

To benchmark their quality, a project was designed to analyze the methodology of previous guidelines and recommendations for malignant pleural mesothelioma projects.

METHODS

A narrative literature search was conducted, and each guideline was evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and rated on a seven-point scale for its many items and domains.

RESULTS

Six guidelines that met the inclusion requirements were evaluated. Due to greater development rigor and editorial independence, the engagement of scientific societies was associated with an improvement in methodological quality.

CONCLUSION

According to the standards of AGREE II, the methodological quality of earlier guidelines was relatively low. Nonetheless, two previously published guidelines could serve as a template for the establishment of the most effective methodological quality guidelines.

Artificial Neural Networks in Lung Cancer Research: A Narrative Review

BACKGROUND

Artificial neural networks are statistical methods that mimic complex neural connections, simulating the learning dynamics of the human brain. They play a fundamental role in clinical decision-making, although their success depends on good integration with clinical protocols. When applied to lung cancer research, artificial neural networks do not aim to be biologically realistic, but rather to provide efficient models for nonlinear regression or classification.

METHODS

We conducted a comprehensive search of EMBASE (via Ovid), MEDLINE (via PubMed), Cochrane CENTRAL, and Google Scholar from April 2018 to December 2022, using a combination of keywords and related terms for "artificial neural network", "lung cancer", "non-small cell lung cancer", "diagnosis", and "treatment".

RESULTS

Artificial neural networks have shown excellent aptitude in learning the relationships between the input/output mapping from a given dataset, without any prior information or assumptions about the statistical distribution of the data. They can simultaneously process numerous variables, managing complexity; hence, they have found broad application in tasks requiring attention.

CONCLUSIONS

Lung cancer is the most common and lethal form of tumor, with limited diagnostic and treatment methods. The advances in tailored medicine have led to the development of novel tools for diagnosis and treatment. Artificial neural networks can provide valuable support for both basic research and clinical decision-making. Therefore, tight cooperation among surgeons, oncologists, and biostatisticians appears mandatory.

The Impact of Surgical Experience in VATS Lobectomy on Conversion and Patient Quality of Life: Results from a Comprehensive National Video-Assisted Thoracic Surgical Database

OBJECTIVES

Although unexpected conversion during Video-Assisted Thoracic Surgery (VATS) lobectomy is up to 23%, the effects on postoperative outcomes remain debatable. This retrospective study aimed: (i) to identify potential preoperative risk factors of VATS conversion to standard thoracotomy; (ii) to assess the impact of surgical experience in VATS lobectomy on conversion rate and patient health-related quality of life.

METHODS

We extracted detailed information on VATS lobectomy procedures performed consecutively (2014-2019). Predictors of conversion were assessed with univariable and multivariable logistic regressions. To assess the impact of VATS lobectomy experience, observations were divided according to surgeons' experiences with VATS lobectomy. The impact of VATS lobectomy experience on conversion and occurrence of postoperative complications was evaluated using logistic regressions. The impact of VATS lobectomy experience on EuroQoL-5D (EQ-5D) scores at discharge was assessed using Tobit regressions.

RESULTS

A total of 11,772 patients underwent planned VATS for non-small-cell lung cancer (NSCLC), with 1074 (9.1%) requiring conversion to thoracotomy. The independent predictors at multivariable analysis were: FEV1% (OR = 0.99; 95% CI: 0.98-0.99, p = 0.007), clinical nodal involvement (OR = 1.43; 95% CI: 1.08-1.90, p = 0.014). Experienced surgeons performed 4079 (34.7%) interventions. Experience in VATS lobectomy did not show a relevant impact on the risk of open surgery conversion (p = 0.13) and postoperative complications (p = 0.10), whereas it showed a significant positive impact (p = 0.012) on EQ-5D scores at discharge.

CONCLUSIONS

Clinical nodal involvement was confirmed as the most critical predictor of conversion. Greater experience in VATS lobectomy did not decrease conversion rate and postoperative complications but was positively associated with postoperative patient quality of life.

Cover always the bronchial stump! A flap could prevent catastrophic complications even in complete broncho-pleural fistula

Broncho-pleural fistula after pneumonectomy is a life-threatening condition with very high mortality rate, even if detected early. All symptomatic patients should be treated immediately. The diagnosis in the absence of symptoms poses the real difficulties of management. Early detection of asymptomatic post-pneumonectomy broncho-pleural fistula is usually fortuitous. The use of bronchoscopy allows direct and accurate evaluation of the stump. This reported case allows us to make several considerations on the treatment of fistulas, but above all to consider that the systematic bronchial stump coverage is fundamental not only for preventing fistulas, but also for limiting their enlargement and communication with the residual cavity, in order to prevent catastrophic complications.

Immersive Three-dimensional Computed Tomography to Plan Chest Wall Resection for Lung Cancer

PURPOSE

Chest wall resections for lung cancer treatment remain difficult to plan using standard two-dimensional computed tomography. Although virtual reality headsets have been used in many medical contexts, they have not been employed in chest wall resection planning.

DESCRIPTION

We compared preoperative planning of a chest wall surgical resection for lung cancer treatment between senior and resident surgeons who used an immersive virtual reality device and a two-dimensional computed tomography.

EVALUATION

Chest wall resection planning was more accurate when surgeons used virtual reality versus computed tomography analysis (28.6% vs. 18.3%, p = 0.018), and this was particularly true in the resident surgeon group (27.4% vs. 8.3%, p = 0.0025). Predictions regarding the need for chest wall substitutes were also more accurate when they were made using virtual reality versus computed tomography analysis in all groups (96% vs. 68.5%, p < 0.0001). Other studied parameters were not affected by use of the virtual reality tool.

CONCLUSION

Virtual reality may offer enhanced accuracy for chest wall resection and reconstruction planning for lung cancer treatment.

Long-term clinical outcomes and prognostic factors of upfront surgery as a first-line therapy in biopsy-proven clinical N2 non-small cell lung cancer

Background

Multimodality therapy offers the best opportunity to improve pathological N2 non-small cell lung cancer (NSCLC) prognosis. This paper aimed to evaluate the long-term clinical outcomes and the prognostic factors of upfront surgery as first-line therapy in biopsy-proven clinical N2.

Methods

Retrospective review of biopsy-proven cN2 NSCLC patients operated between 2007 and 2017. Upfront surgery was considered if the primary tumour was deemed completely resectable, with mediastinal nodal involvement confined to a single station and no preoperative evidence of extranodal tumour invasion.

Results

Two hundred eighty-five patients who underwent radical resections were included. One hundred fifty-nine patients (55.8%) received induction chemotherapy. At follow-up completion, 127 (44.6%) patients had died. For the induction chemotherapy group, the median overall survival (OS) was 49 months [95% confidence interval (CI): 38–70 months], and the 5-year OS was 44.4%. The median and 5-year OS for the up front surgery group was 66 months (95% CI: 40–119 months) and 66.3%, respectively. There were no statistically significant differences between treatment approaches (p = 0.48). One hundred thirty-four patients (47.0%) developed recurrence. The recurrence-free survival (RFS) at 5 years was 17% (95% CI: 11–25%) for induction chemotherapy and 22% (95% CI: 9–32%) for upfront surgery; there were no statistically significant differences between groups (p = 0.93). No significant differences were observed based on the clinical N status (OS, p = 0.36; RFS, p = 0.65).

Conclusions

Upfront surgery as first-line therapy for biopsy-proven cN2 NSCLC showed favourable clinical outcomes, similar to those obtained after induction chemotherapy followed by surgery. Therefore, it should be considered one of the multimodality treatment options in resectable N2 NSCLC.

Impact of the extent of lung resection on postoperative outcomes of pulmonary metastasectomy for colorectal cancer metastases: an exploratory systematic review

Background

Pulmonary metastasectomy (PM) with curative intent has become a widely accepted treatment for lung metastases from solid tumours in selected patients, with low perioperative morbidity and mortality. In particular, PM is strongly recommended in selected patients with secondary lesions from colorectal cancer (CRC), due to its excellent postoperative prognosis. Nevertheless, the impact of the extent of PM on recurrence and survival remains controversial. This review aimed at assessing differences in short- and long-term postoperative outcomes depending on the extent of lung resection for lung metastases.

Methods

A systematic literature review of studies comparing anatomical and non-anatomical resections of lung metastases was performed (Prospective Register of Systematic Reviews Registration: 254931). A literature search for articles published in English between the date of database inception and January 31, 2021 was performed in EMBASE (via Ovid), MEDLINE (via PubMed) and Cochrane CENTRAL. Retrospective studies, randomised and non-randomised controlled trials were included. The Cochrane Collaboration tool was used to determine the risk of bias for the primary outcome for included studies.

Results

Out of 432 papers, three retrospective non-randomised studies (1,342 patients) were selected for systematic reviewing. Although our search design did not exclude any primary tumour histology, all selected studies investigated surgical resection of lung metastases from CRC. Because of variations in the compared surgical approaches to pulmonary metastases, a meta-analysis proved unfeasible. There was a tendency to perform anatomical resections for larger metastases. Multivariate analyses revealed that anatomical resections were protective for recurrence-free survival (RFS), while the impact of such procedures on overall survival (OS) remained uncertain. A significantly higher incidence of resection-margin recurrences was observed in patients who underwent non-anatomical resections.

Discussion

Anatomical resections of lung metastases from CRC seem to be associated with improved RFS. However, well-constructed comparative clinical trials focusing on the extent of PM are needed.

Pneumonectomy and broncho-pleural fistula: predicting factors and stratification of the risk

The goal of the study is to evaluate the different risk factors and stratify the patients, before the surgery, into distinct risk classes. We retrospectively reviewed pre, peri, and postoperative outcomes of 366 consecutive patients who underwent pneumonectomy for lung cancer between the last 10 years (2009-2019). We classified the patients into four classes, depending on preoperative assessments. Differences between groups were assessed with the log-rank test. Multivariable Cox proportional hazards regression analysis was used to assess the independent prognostic significance of the variables associated with the development of BPF at univariate analysis. Finally, we performed non-linear [artificial neural network (ANN)] multiple regression analyses. All tests were two-sided, and p values < 0.05 were considered significant. Fifty-one patients (13.9%) out of 366 developed BPF. Male sex (p = 0.048), right side (p = 0.015), postoperative pulmonary complications (p = 0.0139) and adjuvant treatments (p = 0.0169) were the independent predicting factors of fistulas in multivariate analysis. The right side (p = 0.043) and adjuvant treatments (p = 0.032) were the independent predicting factors of BPF after the ANN analysis. Based on multivariate and artificial neural network analysis and our experience, we observed a trend of growing risk of BPF in the first 4 weeks (early fistula), considering the four classes. Preoperative differentiation of the patients into four risk classes could allow a correct stratification of the growing risk of developing early BPF. This information could be significant to share with patients and the other physicians during the decision-making process, to minimise the risk of BPF.

A Focused Review on Primary Graft Dysfunction after Clinical Lung Transplantation: A Multilevel Syndrome

Primary graft dysfunction (PGD) is the clinical syndrome of acute lung injury after lung transplantation (LTx). However, PGD is an umbrella term that encompasses the ongoing pathophysiological and -biological mechanisms occurring in the lung grafts. Therefore, we aim to provide a focused review on the clinical, physiological, radiological, histological and cellular level of PGD. PGD is graded based on hypoxemia and chest X-ray (CXR) infiltrates. High-grade PGD is associated with inferior outcome after LTx. Lung edema is the main characteristic of PGD and alters pulmonary compliance, gas exchange and circulation. A conventional CXR provides a rough estimate of lung edema, while a chest computed tomography (CT) results in a more in-depth analysis. Macroscopically, interstitial and alveolar edema can be distinguished below the visceral lung surface. On the histological level, PGD correlates to a pattern of diffuse alveolar damage (DAD). At the cellular level, ischemia-reperfusion injury (IRI) is the main trigger for the disruption of the endothelial-epithelial alveolar barrier and inflammatory cascade. The multilevel approach integrating all PGD-related aspects results in a better understanding of acute lung failure after LTx, providing novel insights for future therapies.

Preserving the eponym: Klinkenbergh technique for bronchial stump suturing

The technique for bronchial stump suturing following lung resection which is currently applied in the Department of Thoracic Surgery at the University Hospitals Leuven, Belgium owes its name to the Dutch surgeon Dr. Klinkenbergh (1891-1985). A true pioneer of cardiothoracic surgery in Europe, Dr. Klinkenbergh dedicated himself to the surgical treatment of pulmonary tuberculosis. His work was praised by his peers for his precision and the reasoning behind every gesture. The Klinkenbergh technique consists in performing two running sutures which cross each other 'in the same manner as the laces of a shoe' to close the bronchus, limiting the occurrence of broncho-pleural fistulas. In our experience with more than 100 patients in the last 5 years (2016-2020) who underwent open pneumonectomy for benign or malignant disease, less than 2% developed post-operative broncho-pleural fistulas.

Urinary Biomarkers for Early Diagnosis of Lung Cancer

Lung cancer is the leading cause of cancer deaths worldwide. Its early detection has the potential to significantly impact the burden of the disease. The screening and diagnostic techniques in current use suffer from limited specificity. The need therefore arises for a reliable biomarker to identify the disease earlier, which can be integrated into a test. This test would also allow for the recurrence risk after surgery to be stratified. In this context, urine could represent a non-invasive alternative matrix, with the urinary metabolomic profile offering a potential source for the discovery of diagnostic biomarkers. This paper aims to examine the current state of research and the potential for translation into clinical practice.

Prognostic Value of the Hemoglobin/Red Cell Distribution Width Ratio in Resected Lung Adenocarcinoma

BACKGROUND

The ratio of hemoglobin to red cell distribution width (HRR) has been described as an effective prognostic factor in several types of cancer. The aim of this study was to investigate the prognostic role of preoperative HRR in resected-lung-adenocarcinoma patients.

METHODS

We enrolled 342 consecutive patients. Age, sex, surgical resection, adjuvant treatments, pathological stage, preoperative hemoglobin, red cell distribution width, and their ratio were recorded for each patient.

RESULTS

Mean age was 66 years (SD: 9.0). There were 163 females (47.1%); 169 patients (49.4%) had tumors at stage I, 71 (20.8%) at stage II, and 102 (29.8%) at stage III. In total, 318 patients (93.0%) underwent lobectomy, and 24 (7.0%) pneumonectomy. Disease-free survival multivariable analysis disclosed an increased hazard ratio (HR) of relapse for preoperative HRR lower than 1.01 (HR = 2.20, 95%CI: (1.30-3.72), p = 0.004), as well as for N1 single-node (HR = 2.55, 95%CI: (1.33-4.90), p = 0.005) and multiple-level lymph node involvement compared to N0 for both N1 (HR = 9.16, 95%CI:(3.65-23.0), p < 0.001) and N2 (HR = 10.5, 95%CI:(3.44-32.2, p < 0.001).

CONCLUSION

Pre-operative HRR is an effective prognostic factor of disease-free survival in resected-lung-adenocarcinoma patients, together with the level of pathologic node involvement.

The Weekday Effect on Morbidity of Lung Cancer Surgery: A Real-World Analysis

BACKGROUND

 Many authors have investigated the possible adverse effects among patients who underwent elective surgery on Friday when compared with patients operated earlier in the week. Nonetheless, the weekday effect is still a matter of debate. This study aimed at investigating the postoperative morbidity rates after lung cancer surgery and their relationship with the weekday the surgery took place.

MATERIALS AND METHODS

 We retrospectively reviewed the clinical records of patients who underwent elective thoracotomic lobectomies for lung cancer. Categorical data were analyzed using the chi-square test or Fisher's exact test. Association between predictors and binary outcomes while considering the weekday stratification was determined with Cochran-Mantel-Haenszel statistics. To characterize the typical Friday patient, a multiple logistic regression analysis was performed.

RESULTS

 A total of 817 patients (2015-2019) were identified. Complication rates divided by day of surgery were 164 (20.07%) for patients operated on Mondays, 182 (22.27%) on Tuesdays, 205 (25.09%) on Wednesdays, 172 (21.05%) on Thursdays, and 94 (11.51%) on Fridays. Crude morbidity rates by weekday were Monday 21.53%, Tuesday 20.51%, Wednesday 27.70%, Thursday 20.0%, and Friday 10.26%. No overall association between day of surgery and overall morbidity was found (ρ = 0.095). Median hospital length of stay was 5 days (range: 2-45 days), and there were no statistically significant differences between days. The Cochran-Mantel-Haenszel statistics showed no association between morbidity and the weekday.

CONCLUSION

 In patients undergoing elective lobectomies for lung cancer, the weekday of surgery was not statistically significantly associated with an increase in the risk of postoperative morbidity.

Chest wall resection and reconstruction for primary and metastatic sarcomas: an 11-year retrospective cohort study

OBJECTIVES

Chest wall sarcomas are rare, aggressive malignancies, the management of which mainly revolves around surgery. Radical tumour excision with free margins represents the optimal treatment for loco-regional clinically resectable disease. The objective of this study was to review our 11-year experience with chest wall resection for primary and metastatic sarcomas, focusing on surgical techniques and strategies for reconstruction.

METHODS

Retrospective analysis of a comprehensive database of patients who underwent chest wall resection for primary or secondary sarcoma at our Institute from January 2009 to December 2019.

RESULTS

Out of 26 patients, 21 (81%) suffered from primary chest wall sarcoma, while 5 (19%) had recurring disease. The median number of resected ribs was 3. Sternal resection was performed in 6 cases (23%). Prosthetic thoracic reconstruction was deemed necessary in 24 cases (92%). Tumour recurrence was observed in 15 patients (58%). The median overall survival was 73.6 months. Primary and secondary tumours showed comparable survival (P = 0.49). At univariate analysis, disease recurrence and infiltrated margins on pathological specimens were associated with poorer survival (P = 0.014 and 0.022, respectively). In patients with primary sarcoma, the median progression-free survival was 13.3 months. Associated visceral resections were significantly associated to postoperative complications (P = 0.02).

CONCLUSIONS

Chest wall resection followed by prosthetic reconstruction is feasible in carefully selected patients and should be performed by experienced surgeons with the aim of achieving free resection margins, resulting in improved long-term outcomes.

Safety and Feasibility of Thoracic Malignancy Surgery During the COVID-19 Pandemic

Background

The coronavirus disease 2019 (COVID-19) pandemic has decreased surgical activity, particularly in the field of oncology, because of the suspicion of a higher risk of COVID-19–related severe events. This study aimed to investigate the feasibility and safety of thoracic cancer surgery in the most severely affected European and Canadian regions during the COVID-19 pandemic.

Methods

The study investigators prospectively collected data on surgical procedures for malignant thoracic diseases from January 1 to April 30, 2020. The study included patients from 6 high-volume thoracic surgery departments: Nancy and Strasbourg (France), Freiburg (Germany), Milan and Turin (Italy), and Montreal (Canada). The centers involved in this research are all located in the most severely affected regions of those countries. An assessment of COVID-19–related symptoms, polymerase chain reaction (PCR)–confirmed COVID-19 infection, rates of hospital and intensive care unit admissions, and death was performed for each patient. Every deceased patient was tested for COVID-19 by PCR.

Results

In the study period, 731 patients who underwent 734 surgical procedures were included. In the whole cohort, 9 cases (1.2%) of COVID-19 were confirmed by PCR, including 5 in-hospital contaminants. Four patients (0.5%) needed readmission for oxygen requirements. In this subgroup, 2 patients (0.3%) needed intensive care unit and mechanical ventilatory support. The total number of deaths in the whole cohort was 22 (3%). A single death was related to COVID-19 (0.14%).

Conclusions

Maintaining surgical oncologic activity in the era of the COVID-19 pandemic seems safe and feasible, with very low postoperative morbidity or mortality. To continue to offer the best care to patients who do not have COVID-19, reports on other diseases are urgently needed.

A methodological evaluation of the published consensus statements, recommendations and guidelines about surgical management in the course of coronavirus disease pandemic

Background

A project to benchmark the consensus statements, guidelines, and recommendations on surgical management in the course of the COVID-19 pandemic was developed to assess the methodology used. Standard and practical approaches for COVID-19 management in surgical patients to date are not accessible, despite the magnitude of the pandemic. A plethora of consensus statements, guidelines, and recommendations on surgical management in the course of COVID-19 epidemic have been rapidly published in the last three months.

Methods

Each manuscript was scored on a seven-point scale in the different items and domains with the Appraisal of Guidelines for Research and Evaluation II.

Results

Nine guidelines that met the inclusion criteria were assessed. Transnational cooperation produced only one guideline. Multivariable analysis showed that improved scores of stakeholders’ involvement were related to internationally developed guidelines. Clarity of presentation was related to the contribution of scientific societies due to greater rigor of development. The rigor of development produced guidelines with a high overall value. Higher healthcare expenses did not produce superior guidelines.

Conclusions

Evaluated by the Appraisal of Guidelines for Research and Evaluation II, the methodological characteristic of consensus statements, guidelines, and recommendations on surgical management during COVID-19 pandemic was relatively low. International development should be recommended as a model for the development of best methodological quality guidelines.

Outcomes and Safety Analysis in Superior Vena Cava Resection for Extended Thymic Epithelial Tumors

BACKGROUND

In stage III to IVa thymic epithelial tumors (TETs), infiltration of the superior vena cava (SVC) is not rare. The extent of SVC resection depends on the width of the area of neoplastic invasion. Our article aims to evaluate the safety and long-term outcomes of extended thymectomy for TETs with SVC resection compared with advanced-stage TETs patients without SVC resection.

METHODS

Retrospective review of the experience on patients who underwent extended thymectomy for TETs in the last 20 years, according to STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) methodology. Progression-free survival (PFS) and overall survival (OS) were calculated using the Kaplan-Meier method. A backward stepwise Cox regression multivariate analysis was performed to determine factors associated with long-term outcomes.

RESULTS

A total of 78 patients underwent surgery for advanced-stage TETs (Masaoka-Koga stages III-IVa) from January 1998 to April 2019. Fourteen (17.9%) underwent thymectomy with resection of SVC. Presence of a thymic carcinoma (hazard ratio , 2.26; 95% confidence interval, 1.82-6.18; P = .038) and the SVC resection (hazard ratio, 1.89; 95% confidence interval, 1.11-3.96; P = .041) were adverse prognostic factors at multivariate analysis. The median OS and the PFS of all SVC resected patients were 50 (range, 5-207) months and 31 (range, 5-151) months, respectively. There was no significant difference in OS (P = .28) and PFS (P = .32) between SVC-resected and non-SVC-resected patients.

CONCLUSIONS

SVC resection is a safe and effective procedure to restore the venous system continuity and does not seem to affect survival and disease recurrence. This surgical approach allows radical resection of locally advanced TETs, even after neoadjuvant chemotherapy.

Not everything is what it seems: malignant pleural mesothelioma mimicking lung cancer

Malignant pleural mesothelioma usually arises from the pleural surface and progressively encases the lungs. Pulmonary involvement generally occurs at an advanced stage, while intraparenchymal nodules, in the absence of pleural lesions, constitute a less frequent presentation. We describe the case of a patient with multiple bilateral pulmonary nodules, mediastinal lymphadenopathies and left pleural effusion in the absence of pleural lesions, simulating advanced stage lung cancer. Thoracoscopic inspection did not detect any lesions. Pathological examination on one pulmonary nodule revealed malignant pleural mesothelioma. Despite its rarity, intraparenchymal malignant pleural mesothelioma should always be taken into account, when lung nodules are present, to prevent misdiagnosis and avoid delayed treatment.

When less is more: a daring conservative approach to postpneumonectomy oesophago-pleural fistula

Oesophago-pleural fistula is an uncommon complication after pneumonectomy, usually related to high morbidity and mortality. Due to its rarity and heterogeneous clinical presentation, its diagnosis and management are challenging issues. Here, we report the case of a patient with a history of pneumonectomy for a tracheal tumour, who developed an asymptomatic oesophago-pleural fistula 7 years after primary surgery. In consideration of the patient's good clinical status and after verifying the preservation of respiratory and digestive functions, a bold conservative approach was adopted. Five-year follow-up computed tomography did not disclose any sign of recurrence of disease and showed a stable, chronic fistula.

When Less Is More: EBUS-TBNA for the Diagnosis of Pleural Lesions

The investigation of pleural lesions is challenging. Thoracoscopic pleural biopsies are often the chosen approach for diagnosis and, in case of malignancy, for disease staging and palliation pleurodesis. Minimally invasive techniques represent a valid option in patients that cannot undergo surgery, minimizing the risks related to more aggressive procedures. Here we report the case of a 63-year-old man with computed tomography evidence of paratracheal pleural thickening that was successfully sampled with endobronchial ultrasound-guided transbronchial needle aspiration. This technique should be considered for the diagnosis of pleural lesions adjacent to the main airway; it represents a safer, better tolerated, and less invasive alternative to operation.

Incidental diagnosis of pulmonary mycobacteriosis among patients scheduled for lung cancer surgery: results from a series of 3224 consecutive operations

Background

The relation between pulmonary mycobacteriosis and lung cancer has been scrutinized for many years but the current evidence is inconsistent as some studies found an association between the two, whereas others have reported an insignificant relation.

Materials and methods

3224 consecutive patients undergoing elective thoracic surgery at the Department of Thoracic Surgery of a comprehensive cancer center over a four-year period were considered. Patients diagnosed with pulmonary mycobacteriosis with microbiological confirmation on their surgical specimen were further analyzed.

Results

30 patients were diagnosed with pulmonary mycobacteriosis: six of them had a history of cancer. 18 patients received wedge resection, four patients received anatomic segmentectomy, two were submitted to lobectomy, one underwent pneumonectomy and five patients received other types of lesser procedures. Pulmonary mycobacteriosis and synchronous lung cancer were observed in four patients.

Conclusions

Although rare, the incidental diagnoses of pulmonary mycobacteriosis among patients scheduled for lung cancer resection is not negligible. Pulmonologists, anesthesiologists and thoracic surgeons should be aware of this possibility before planning pulmonary resections of histologically undiagnosed lung nodules.

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.