Contrast-enhanced Ultrasound Using Intradermal Microbubble Sulfur Hexafluoride in Non-invasive Axillary Staging in Breast Cancer: Are we Missing a Chance?

BACKGROUND/AIM

In the context of surgical de-escalation in early breast cancer (EBC), this study aimed to evaluate the contrast enhancement ultrasound (CEUS) sentinel lymph node (SLN) procedure as a non-invasive axillary staging procedure in EBC in comparison with standard SLN biopsy (SLNB).

PATIENTS AND METHODS

A subanalysis of the AX-CES study, a prospective single-arm, monocentric phase 3 study was performed (EudraCT: 2020-000393-20). The study included patients with EBC undergoing upfront surgery and SLN resection, with no prior history of locoregional treatment, and weighing between 40-85 kg. All patients underwent the CEUS SLN procedure as a non-invasive axillary staging procedure, with CEUS SLN accumulation marked using blue dye. After the CEUS SLN procedure, all patients underwent the standard mapping procedure. Data on success rate, systemic reactions, mean procedure time, mean surgical procedure, mean procedure without axillary staging, CEUS SLN appearance (normal/pathological), SLN number, and concordance with standard mapping procedure were collected.

RESULTS

After the CEUS SLN procedure, 29 LNs among 16 patients were identified and marked. In all cases, CEUS SLN revealed at least one LN enhancement. Six (37.50%) LNs were defined as pathological after the CEUS SLN procedure. Definitive staining of CEUS SLN pathology revealed metastatic involvement in four (66.67%) of the cases. Two SLNs were identified during the CEUS SLN procedure; however, owing to the low disease burden, no change in the surgical plan was reported.

CONCLUSION

The CEUS SLN procedure shows promise as a technique for non-invasive assessment of the axilla, potentially enabling safe axillary de-escalation in EBC by estimating the axillary disease burden.

Surgical De-Escalation for Re-Excision in Patients with a Margin Less Than 2 mm and a Diagnosis of DCIS

The current surgical guidelines recommend an optimal margin width of 2 mm for the management of patients diagnosed with ductal carcinoma in situ (DCIS). However, there are still many controversies regarding re-excision when the optimal margin criteria are not met in the first resection. The purpose of this study is to understand the importance of surgical margin width, re-excision, and treatments to avoid additional surgery on locoregional recurrence (LRR). The study is retrospective and analyzed surgical margins, adjuvant treatments, re-excision, and LRR in patients with DCIS who underwent breast-conserving surgery (BCS). A total of 197 patients were enrolled. Re-operation for a close margin rate was 13.5%, and the 3-year recurrence was 7.6%. No difference in the LRR was reported among the patients subjected to BCS regardless of the margin width (p = 0.295). The recurrence rate according to margin status was not significant (p = 0.484). Approximately 36.9% (n: 79) patients had resection margins < 2 mm. A sub-analysis of patients with margins < 2 mm showed no difference in the recurrence between the patients treated with a second surgery and those treated with radiation (p = 0.091). The recurrence rate according to margin status in patients with margins < 2 mm was not significant (p = 0.161). The margin was not a predictive factor of LRR p = 0.999. Surgical re-excision should be avoided in patients with a focally positive margin and no evidence of the disease at post-surgical imaging.

Cavity Shave Margins in Breast Conservative Surgery a Strategy to Reduce Positive Margins and Surgical Time

Background: Resection of additional tissue circumferentially around the cavity left by lumpectomy (cavity shave) was suggested to reduce rates of positive margins and re-excision. Methods: A single center retrospective study which analyzed margins status, re-excision, and surgical time in patients who underwent breast conserving surgery and cavity shave or intraoperative evaluation of resection margins. Results: Between 2021 and 2023, 594 patients were enrolled in the study. In patients subjected to cavity shave, a significant reduction in positive, focally positive, or closer margins was reported 8.9% vs. 18.5% (p = 0.003). No difference was reported in terms of surgical re-excision (p < 0.846) (5% vs. 5.5%). Surgical time was lower in patients subjected to cavity shave (<0.001). The multivariate analysis intraoperative evaluation of sentinel lymph node OR 1.816 and cavity shave OR 2.909 were predictive factors for a shorter surgical time. Excluding patients subjected to intraoperative evaluation of sentinel lymph node and patients with ductal carcinoma in situ, patients that underwent the cavity shave presented a reduced surgical time (67.9 + 3.8 min vs. 81.6 + 2.8 min) (p = 0.006). Conclusions: Cavity shaving after lumpectomy reduced the rate of positive margins and it was associated with a significant reduction in surgical time compared to intraoperative evaluation of resection margins.

Blood-Derived Systemic Inflammation Markers and Risk of Nodal Failure in Stage Ia Non-Small Cell Lung Cancer: A Multicentric Study

BACKGROUND

Unexpected spread to regional lymph nodes can be found in up to 10% of patients with early stage non-small cell lung cancer (NSCLC), thereby affecting both prognosis and treatment. Given the known relation between systemic inflammation and tumor progression, we sought to evaluate whether blood-derived systemic inflammation markers might help to the predict nodal outcome in patients with stage Ia NSCLC.

METHODS

Preoperative levels of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic inflammation score (SII, platelets × NLR) were collected from 368 patients who underwent curative lung resection for NSCLC. After categorization, inflammatory markers were subjected to logistic regression and time-event analysis in order to find associations with occult nodal spread and postoperative nodal recurrence.

RESULTS

No inflammation marker was associated with the risk of occult nodal spread. SII showed a marginal effect on early nodal recurrence at a quasi-significant level (p = 0.065). However, patients with T1c tumors and elevated PLR and/or SII had significantly shorter times to nodal recurrence compared to T1a/T1b patients (p = 0.001), while patients with T1c and normal PLR/SII did not (p = 0.128).

CONCLUSIONS

blood-derived inflammation markers had no value in the preoperative prediction of nodal status. Nevertheless, our results might suggest a modulating effect of platelet-derived inflammation markers on nodal progression after the resection of tumors larger than 2 cm.

The effectiveness of chest T-tube drainage in uniportal video-assisted thoracic surgery

OBJECTIVES

Uniportal incision located at 4th or 5th intercostal space represents a problem for the correct drainage of distal areas of pleural cavity. The T-shaped tube can drain both the extremities of pleural space. In this study we evaluated the effectiveness of T-chest tube compared to classic chest tube after uniportal video-assisted thoracic surgery.

METHODS

We compared the effectiveness of T tube and classic 28 CH chest drainage after different surgical procedures in uniportal VATS: lobectomies, wedge resections, pleural and mediastinal biopsies. As primary end-points, drained effusion and evidence of pneumothorax at post-operative day 1, subcutaneous emphysema, tube kinking, obstruction and necessity of repositioning or post-operative thoracentesis were considered. Pain at 6 and 24 hours after surgery, pain at tube removal and mean hospitalization were analyzed as secondary end-points.

RESULTS

A total of 109 patients was selected for the study, 51 included to the T-tube group while the other 58 ones to the control group with classic drainage. Patients with T-tube showed a significantly lower rate of pneumothorax (29.4% vs 63.8%; p < 0.001), tube kinking (5.9% vs 27.6%; p = 0.003) and need of repositioning (2.0% vs 12.1%; p = 0.043). No significant results were obtained in subcutaneous emphysema (p = 0.26), tube obstruction (p = 0.32), drained effusion (p = 0.11) and need of post-operative thoracentesis (p = 0.18). Patients with T-tube complained of less pain 6 hours after surgery (p < 0.001). Conversely, T-tube removal was reported to be more painful (p < 0.001).

CONCLUSIONS

Chest T-tube can achieve significantly lower rate of postoperative pneumothorax, kinking and repositioning with less pain 6 hours after surgery compared to classic tube.

Anxiety and Fear of Breast Cancer Patients During and After the COVID-19 Era

BACKGROUND/AIM

Coronavirus-19 (COVID-19) pandemic had a huge impact on medical resource allocation. While it is clear that the surgery refusal rate of patients with breast cancer (BC) was higher during the pandemic, long-term effect of COVID-19 pandemic on hospital admission in the post-pandemic period has not been fully evaluated. This study aimed to estimate how patients' behavior changed following the pandemic and whether the cross-infection risk is still influencing patients' decision-making process.

PATIENTS AND METHODS

Between the 16^th of January and 18^th of March 2020, between 19^th of March 2020 and the 20^th of March 2020, and between 19^th of March 2023 and the 20^th of March 2023, 266 patients were enrolled and divided into PRE-COVID-19, COVID-19, and POST-COVID-19 groups, respectively. A total of 137 patients with a suspected breast lesion (SBL) were divided into 3 groups: PRE-COVID-19-SBL, COVID-19-SBL, and POST-COVID-19-SBL groups. In addition, 129 BC patients were divided into PRE-COVID-19-BC, COVID-19-BC and POST-COVID-19-BC groups. Patient characteristics including age, marital status, SBL/BC diameter, personal and family history of BC, clinical stage and molecular subtype were recorded. Procedure refusal (PR) and Surgical refusal (SR) were also recorded with their reason.

RESULTS

BC and SBL analysis showed no difference in pre-treatment characteristics (p>0.05). While higher rate of PR and SR rates were reported in COVID-19-SBL and COVID-19-BC groups when compared with PRE-COVID-19 (p=0.003, p=0.013, respectively) and POST-COVID-19 (p=0.005, p=0.004, respectively) groups, no statistical difference was found between PRE-COVID-19 and POST-COVID-19 subanalysis.

CONCLUSION

Thanks to preventive measures, COVID-19 does not currently seem to affect the decision-making process of patients with BC.

Thoracic surgery in the COVID-19 era: an Italian university hospital experience

Background

Aims of this study were to assess the results of anti-COVID19 measures applied to maintain thoracic surgery activity at an Italian University institution through a 12-month period and to assess the results as compared with an equivalent non-pandemic time span.

Methods

Data and results of 646 patients operated on at the department of Thoracic Surgery of the Tor Vergata University Policlinic in Rome between February 2019 and March 2021 were retrospectively analyzed. Patients were divided in 2 groups: one operated on during the COVID-19 pandemic (pandemic group) and another during the previous non-pandemic 12 months (non-pandemic group). Primary outcome measure was COVID-19 infection-free rate.

Results

Three patients developed mild COVID-19 infection early after surgery resulting in an estimated COVID-19 infection-free rate of 98%. At intergroup comparisons (non-pandemic vs. pandemic group), a greater number of patients was operated before the pandemic (352 vs. 294, p = 0.0013). In addition, a significant greater thoracoscopy/thoracotomy procedures rate was found in the pandemic group (97/151 vs. 82/81, p = 0.02) and the total number of chest drainages (104 vs. 131, p = 0.0001) was higher in the same group. At surgery, tumor size was larger (19.5 ± 13 vs. 28.2 ± 21; p < 0.001) and T3-T4/T1-T2 ratio was higher (16/97 vs. 30/56; p < 0.001) during the pandemic with no difference in mortality and morbidity. In addition, the number of patients lost before treatment was higher in the pandemic group (8 vs. 15; p = 0.01). Finally, in 7 patients admitted for COVID-19 pneumonia, incidental lung (N = 5) or mediastinal (N = 2) tumors were discovered at the chest computed tomography.

Conclusions

Estimated COVID-19 infection free rate was 98% in the COVID-19 pandemic group; there were less surgical procedures, and operated lung tumors had larger size and more advanced stages than in the non-pandemic group. Nonetheless, hospital stay was reduced with comparable mortality and morbidity. Our study results may help implement efficacy of the everyday surgical care.

Pre-pectoral Breast Reconstruction Does Not Affect Early Immunological Response: A BIAL 2.20 Study Subanalysis

BACKGROUND/AIM

Reduction of postoperative stress is a modern tenet in surgical oncology with the aim of reducing early postoperative lymphopenia. Our prospective study evaluated post-operative immune response at baseline and postoperative day (POD) 1 and 2 after direct-to-implant pre-pectoral (PP) breast reconstruction with titanium-coated polypropylene mesh versus subpectoral (SP) breast reconstruction.

PATIENTS AND METHODS

Between January and December 2020, 37 patients were randomized between PP (n=17) or SP (n=16) reconstruction. Baseline and operative data were analyzed. Postoperative pain assessment using numeric pain rating scale (NPRS), and a full blood count with lymphocyte subsets were collected before surgery, and on POD1 and POD2. Data were evaluated by two-way analysis of variance test.

RESULTS

Baseline data did not demonstrate any statistical difference. Inter-group analysis did not provide any statistically significant difference in leukocytes, total lymphocytes, and lymphocytes subsets among SP and PP reconstruction groups (p>0.05). However, compared to specificity, the PP group experienced shorter operative time, with a mean difference 30.19 min, lower blood loss (p=0.017), lower rate of postoperative anemia (p=0.039), and a more favorable profile in inter-group pain analysis (p<0.001).

CONCLUSION

PP reconstruction with titanium-coated polypropylene mesh does not increase immunological impairment in the early postoperative period when compared with SP reconstruction and provides lower postoperative pain, reduction of operative time, and lower rate of postoperative anemia.

Real-Time Pleural Elastography: Potential Usefulness in Nonintubated Video-Assisted Thoracic Surgery

Pleural adhesions are a major challenge in standard and nonintubated video-assisted thoracic surgery. The currently available imaging techniques help to assess the presence and extent of pleural adhesions, but do not provide information on tissue deformability, which is crucial for intraoperative management. In this report, we describe the utilization of real-time elastography mapping of pleural adhesions. This technique enabled us to detect areas with softer adhesions, and helped establish the surgical plan in a difficult case of a patient scheduled for nonintubated video-assisted thoracic surgery.

Systemic Inflammation after Uniport, Multiport, or Hybrid VATS Lobectomy for Lung Cancer

BACKGROUND

 Different video-assisted thoracic surgery (VATS) approaches can be adopted to perform lobectomy for non-small cell lung cancer. Given the hypothetical link existing between postoperative inflammation and long-term outcomes, we compared the dynamics of systemic inflammation markers after VATS lobectomy performed with uniportal access (UNIVATS), multiportal access (MVATS), or hybrid approach (minimally invasive hybrid open surgery, MIHOS).

METHODS

 Peripheral blood-derived inflammation markers (neutrophil-to-lymphocyte [NTL] ratio, platelet-to-lymphocyte [PTL] ratio, and systemic immune-inflammation index [SII]) were measured preoperatively and until postoperative day 5 in 109 patients undergoing UNIVATS, MVATS, or MIHOS lobectomy. Differences were compared through repeated-measure analysis of variance, before and after 1:1:1 propensity score matching. Time-to-event analysis was also done by measuring time to NTL normalization, based on the reliability change index for each patient.

RESULTS

 After UNIVATS, there was a faster decrease in NTL ratio (p = 0.015) and SII (p = 0.019) compared with other approaches. MVATS exhibited more pronounced PTL rebound (p = 0.011). However, all these differences disappeared in matched analysis. After MIHOS, NTL ratio normalization took longer (mean difference: 0.7 ± 0.2 days, p = 0.047), yet MIHOS was not independently associated with slower normalization at Cox's regression analysis (p = 0.255, odds ratio: 1.6, confidence interval: 0.7-4.0). Furthermore, surgical access was not associated with cumulative postoperative morbidity, nor was it with incidence of postoperative pneumonia.

CONCLUSION

 In this study, different VATS approaches resulted into unsubstantial differences in postoperative systemic inflammatory response, after adjusting for confounders. The majority of patients returned back to preoperative values by postoperative day 5 independently on the adopted surgical access. Further studies are needed to elaborate whether these small differences may still be relevant to patient management.

Breast Textured Implants Determine Early T-helper Impairment: BIAL2.20 Study

BACKGROUND/AIM

Surgical stress has been correlated with higher rate of postoperative complications. Breast implants' surfaces (textured or smooth) represent an immunological stimulus. Our prospective study (BIAL2.20) evaluated post-operative leukocytes response at baseline and postoperative day (POD) 1 and 2 after implant-based breast reconstruction.

PATIENTS AND METHODS

Between January and July 2020, 41 patients underwent reconstruction with textured (n=23) or smooth (n=18) implants. A full blood count and lymphocyte subsets were collected before surgery, on POD1 and POD2. Data were evaluated as difference and relative difference from baseline by two-way analysis of variance test (2-way-ANOVA). Mann-Whitney U-test was performed at each POD, whenever between-group 2-way-ANOVA reached statistical significance.

RESULTS

Within-group-analysis showed statistically significant total leukocytosis in both groups. Within-group-analysis of lymphocytes subsets demonstrated statistically significant lymphopenia in the textured group for T-lymphocytes, and T-helper cells. Between-group-analysis showed statistically significant lymphopenia in T-helper subsets in the textured group at POD1 and POD2, when compared with the smooth group.

CONCLUSION

Textured implants demonstrated a statistically significant impairment of T-helper trend during POD1 and POD2 when compared to smooth implants by between-group 2-way-ANOVA.

Case Report: Early Breast Cancer Recurrence Mimicking BIA-ALCL in a Patient With Multiple Breast Procedures

Breast reconstruction plays a fundamental role in the therapeutic process of breast cancer treatment and breast implants represents the leading breast reconstruction strategy. Breast Implant Associated-Anaplastic Large Cell Lymphoma (BIA-ALCL), locoregional recurrence in the skin flap, and skin flap necrosis are well-known complications following mastectomy and immediate breast reconstruction (IBR). We report a case of locoregional cancer recurrence in the mastectomy flap mimicking BIA-ALCL, in a patient who underwent 6 breast procedures in four facilities across 15 years including immediate breast reconstruction with macrotextured breast implants. Despite the rate and onset of the disease, clinicians should be aware of BIA-ALCL. Due to the risk of false negative results of fine needle aspiration, clinical suspicion of BIA-ALCL should drive clinicians' choices, aside from cytological results. In the present case, surgical capsulectomy of the abnormal periprosthesic tissue revealed locoregional recurrence.

Real-Time Pleural Elastography: Potential Usefulness in Nonintubated Video-Assisted Thoracic Surgery

Pleural adhesions are a major challenge in standard and nonintubated video-assisted thoracic surgery. The currently available imaging techniques help to assess the presence and extent of pleural adhesions, but do not provide information on tissue deformability, which is crucial for intraoperative management. In this report, we describe the utilization of real- time elastography mapping of pleural adhesions. This technique enabled us to detect areas with softer adhesions, and helped establish the surgical plan in a difficult case of a patient scheduled for nonintubated video-assisted thoracic surgery.

Subxiphoid completion thymectomy for refractory non-thymomatous myasthenia gravis

Background

Completion thymectomy may be performed in patients with non-thymomatous refractory myasthenia gravis (MG) to allow a complete and definitive clearance from residual thymic tissue located in the mediastinum or in lower neck. Hereby we present our short- and long-term results of completion thymectomy using subxiphoid video-assisted thoracoscopy.

Methods

Between July 2010 and December 2017, 15 consecutive patients with refractory non-thymomatous myasthenia, 8 women and 7 men with a median age of 44 [interquartile range (IQR) 38.5–53.5] years, underwent video-thoracoscopic completion thymectomy through a subxiphoid approach.

Results

Positron emission tomography (PET) showed mildly avid areas [standardized uptake value (SUV) more than or equal to 1.8] in 11 instances. Median operative time was 106 (IQR, 77–141) minutes. No operative deaths nor major morbidity occurred. Mean 1-day postoperative Visual Analogue Scale value was 2.53±0.63. Median hospital stay was 2 (IQR, 1–3.5) days. A significant decrease of the anti-acetylcholine receptor antibodies was observed after 1 month [median percentage changes −67% (IQR, −39% to −83%)]. Median follow-up was 45 (IQR, 21–58) months. At the most recent follow-up complete stable remission was achieved in 5 patients. Another 9 patients had significant improvement in bulbar and limb function, requiring lower doses of corticosteroids and anticholinesterase drugs. Only one patient remained clinically stable albeit drug doses were reduced. One-month postoperative drop of anti-acetylcholine receptor antibodies was significantly correlated with complete stable remission (P=0.002).

Conclusions

This initial experience confirms that removal of ectopic and residual thymus through a subxiphoid approach can reduce anti-acetylcholine receptor antibody titer correlating to good outcome of refractory MG.

Impact of Awake Breast Cancer Surgery on Postoperative Lymphocyte Responses

BACKGROUND

Surgical stress and anesthesia affect the patient's immune system. Analysis of the lymphocyte response after breast-conserving surgery was conducted to investigate the differences between effects after general and local anesthesia.

MATERIALS AND METHODS

Fifty-six patients with breast cancer were enrolled for BCS through local or general anesthesia. Total leukocytes, total lymphocytes, lymphocyte-subsets including CD3⁺, CD19⁺, CD4⁺, CD8⁺, CD16⁺CD56⁺ and CD4⁺/CD8⁺ ratio was examined at baseline and on postoperative days 1, 2 and 3.

RESULTS

Baseline data showed no statistical difference between the two groups. Within-group ANOVA test showed significant differences for total leukocyte count (p<0.001), total lymphocyte count (p=0.009) and proportion of natural-killer cells (p=0.01) in the control group. Between-group analysis showed lower median values of total lymphocytes in the awake surgery group on postoperative days 1, 2 and 3 (p=0.001, p=0.02 and p=0.01, respectively) when compared to the control group. Patients who underwent surgery under general anesthesia had higher total lymphocyte counts on postoperative day 2 (p=0.04).

CONCLUSION

In this randomized study, breast-conserving surgery plus local anesthesia had a lower impact on postoperative lymphocyte response when compared to the same procedure performed under general anesthesia.

Team Training for Nonintubated Thoracic Surgery

Nonintubated thoracic surgery arose as supplemental evolution of minimally invasive surgery and is gaining popularity. A proper nonintubated thoracic surgery unit is mandatory and should involve surgeons, anesthesiologists, intensive care physicians, physiotherapists, psychologists, and scrub and ward nurses. Surgical training should involve experienced and young surgeons. It deserves a step-by-step approach and consolidated experience on video-assisted thoracic surgery. Due to difficulty in reproducing lung and diaphragm movements, training with simulation systems may be of scant value; instead, preceptorships and invited proctorships are useful. Preoperatively, patients must be fully informed. Effective intraoperative communication with patients and among the surgical team is pivotal.

Thrombotic Thrombocytopenic Purpura Resistant to Plasma-exchange: Salvage Treatment with High-dose IgG or Vincristine

Even though plasmaexchange (PE), either alone or combined with cortisone or platelet anti-aggregating substances is the treatment of choice for TTP, 10-15% of patients is resistant to treatment. Since immunoglobulin (IgG) infusion was reported to cure the clinical symptoms of PE-resistant TTP, and vincristine (VCR) has been recently successful in treating TTP, we reviewed the results obtained with both drugs in 20 PE-resistant patients. Of 12 patients receiving IgG and 8 receiving VCR, 3 (25%) and 4 (50%), respectively, achieved complete remission. Even though no conclusions can be drawn from such results, if complete remission can be achieved in a however small number of PE-resistant patients, the use of these drugs is suggested as a salvage treatment for TTP.

Minimalist video-assisted thoracic surgery biopsy of mediastinal tumors

BACKGROUND

Mediastinal tumors often require surgical biopsy to achieve a precise and rapid diagnosis. However, subjects with mediastinal tumors may be unfit for general anesthesia, particularly when compression of major vessels or airways does occur. We tested the applicability in this setting of a minimalist (M) uniportal, video-assisted thoracic surgery (VATS) strategy carried out under locoregional anesthesia in awake patients (MVATS).

METHODS

We analyzed in a comparative fashion including propensity score matching, data from a prospectively collected database of patients who were offered surgical biopsy for mediastinal tumors through either MVATS or standard VATS. Tested outcome measures included feasibility, diagnostic yield, and morbidity.

RESULTS

A total of 24 procedures were performed through MVATS. Diagnostic yield was 100%. Median hospital stay and time interval to oncologic treatment were 2 days (IQR, 2-3 days) and 7 days (IQR, 5.5-11.5 days), respectively. At overall comparison (MVATS, N=24 vs. VATS, N=23), there was a significant difference in both frequency and severity of postoperative complication as measured by Clavien-Dindo classification (P<0.006). In a propensity score matched comparison (8 patients per group), grade 3 or 4 complications requiring aggressive management were found only in the general anesthesia group. Global time spent in the operating room was shorter in the MVATS group (P=0.05). Time interval to oncological treatment was the same between groups. Other differences were also found in SIRS score (P=0.05) and PaO₂/FiO₂ (P=0.04) thus suggesting better adaption to perioperative stress.

CONCLUSIONS

MVATS biopsy appears to be a reliable tool to optimize diagnostic assessment in patients with mediastinal tumors. It can offer high diagnostic accuracy due to large tissue samples, while reducing morbidity rate compared to the same operation under general anesthesia. More robust evaluation is needed to define the appropriateness of MVATS in this specific clinical setting.

Non-intubated video-assisted thoracic surgery: where does evidence stand?

In recent years, non-intubated video-assisted thoracic surgery (NIVATS) strategies are gaining popularity worldwide. The main goal of this surgical practice is to achieve an overall improvement of patients' management and outcome thanks to the avoidance of side-effects related to general anesthesia (GA) and one-lung ventilation. The spectrum of expected benefits is multifaceted and includes reduced postoperative morbidity, faster discharge, decreased hospital costs and a globally reduced perturbation of patients' well-being status. We have conducted a literature search to evaluate the available evidence on this topic. Meta-analysis of collected results was also done where appropriate. Despite some fragmentation of data and potential biases, the available data suggest that NIVATS operations can reduce operative morbidity and hospital stay when compared to equipollent procedures performed under GA. Larger, well designed prospective studies are thus warranted to assess the effectiveness of NIVATS as far as to investigate comprehensively the various outcomes. Multi-institutional and multidisciplinary cooperation will be welcome to establish uniform study protocols and to help address the questions that are to be answered yet.

Multi-reoperations for lung metastases

In this study, we investigated role and results of multi-reoperations for lung metastases. From 1986 to 2010, 113 consecutive patients (61 men and 52 women; mean age: 53.2 ± 12.8 years) underwent repeated lung metastasectomy with curative intent in our institution. Two procedures were performed in 113 patients, three in 54, four in 31, five in eight and six in three. There was no perioperative mortality. Cumulative 5-year survival was 65% and this was significantly higher than the value recorded for patients undergoing only one metastasectomy (42%; p = 0.021). Size, number of resections and probability of recurrence increased by number of operation whereas disease free interval reduced. At any metastasectomy both short disease-free interval and multiple metastases resulted in the most significant negative prognosticators. In conclusion, redo metastasectomy is worthwhile for the initial procedures, afterwards both disease-free and overall survivals decrease and surgery lose its efficacy.

Intrathymic ectopic parathyroid adenoma caused primary hyperparathyroidism with vitamin D deficiency several years after bariatric surgery

Up to 25% of patients with primary hyperparathyroidism have ectopic parathyroid adenoma. A 45-year-old formerly obese woman underwent extended thymectomy for a parathyroid adenoma located in hyperplastic thymic tissue, associated with primary hyperparathyroidism and severe vitamin D deficiency, but normal bone mineral density. At nine months follow-up, all laboratory test results were within normal limits and she presented no symptoms and no recurrence of disease. In this case, autonomous growth of a parathyroid adenoma was reasonably secondary to chronic calcium and vitamin D malabsorption, which often occurs after bariatric surgery for pathologic obesity.

Role of systemic inflammation scores in pulmonary metastasectomy for colorectal cancer

BACKGROUND

Patients with pulmonary metastases from colorectal cancer can benefit from surgical removal. However, the biological determinants of postsurgical outcome are not completely elucidated. We evaluated the role of host systemic inflammation status in this setting.

METHODS

The modified Glasgow prognostic score (based on serum C-reactive protein and albumin levels) and the neutrophil-to-lymphocyte (NTL) ratio were obtained from 44 patients who received curative-intent metastasectomy, and were used as indicators of systemic inflammation status. We tested the impact of both of these parameters on overall survival (OS) and progression-free survival (PFS), as well as their correlation with other well-known prognosticators.

RESULTS

Five-year PFS and OS rates were 18% and 49%, respectively. At univariate analysis, multiple metastases, disease-free interval <36 months, and a Glasgow score of 2 (P = 0.031) were significantly associated to a worse PFS rate. A NTL ratio >3 predicted disease progression in the short-term (P = 0.036), but the effect on late events was weaker (P = 0.079). Factors associated with worse OS were multiple metastasis (P = 0.002), elevated carcinoembryonic antigen (P = 0.009), a Glasgow score of 2 (P = 0.029), and a faster metastasis growth (P = 0.008). At Cox regression analysis, neither a Glasgow score of 2, nor elevated NTL ratio showed an independent effect on survival rates.

CONCLUSIONS

Systemic inflammation scores did not perform well as independent survival prognosticators in patients undergoing curative-intent pulmonary metastasectomy. Further investigation is warranted to evaluate whether these measurements could still be useful when restricting the analysis to specific patient subcategories or to diverse postoperative phases.

From "awake" to "monitored anesthesia care" thoracic surgery: A 15 year evolution

Although general anesthesia still represents the standard when performing thoracic surgery, the interest toward alternative methods is increasing. These have evolved from the employ of just local or regional analgesia techniques in completely alert patients (awake thoracic surgery), to more complex protocols entailing conscious sedation and spontaneous ventilation. The main rationale of these methods is to prevent serious complications related to general anesthesia and selective ventilation, such as tracheobronchial injury, acute lung injury, and cardiovascular events. Trends toward shorter hospitalization and reduced overall costs have also been indicated in preliminary reports. Monitored anesthesia care in thoracic surgery can be successfully employed to manage diverse oncologic conditions, such as malignant pleural effusion, peripheral lung nodules, and mediastinal tumors. Main non-oncologic indications include pneumothorax, emphysema, pleural infections, and interstitial lung disease. Furthermore, as the familiarity with this surgical practice has increased, major operations are now being performed this way. Despite the absence of randomized controlled trials, there is preliminary evidence that monitored anesthesia care protocols in thoracic surgery may be beneficial in high-risk patients, with non-inferior efficacy when compared to standard operations under general anesthesia. Monitored anesthesia care in thoracic surgery should enter the armamentarium of modern thoracic surgeons, and adequate training should be scheduled in accredited residency programs.

Erythrocyte osmotic resistance recovery after lung volume reduction surgery

OBJECTIVES

Alteration of erythrocyte osmotic resistance, with increment of reticulocytes, is common in emphysema. This fragility is probably due to an altered fatty acid membrane composition from lipid peroxidation, a reaction triggered by the disease-related increment of reactive oxidative species. We analysed the effects of lung volume reduction surgery (LVRS) on this anomaly compared with respiratory rehabilitation (RR) therapy.

METHODS

We retrospectively compared 58 male patients with moderate-to-severe emphysema who underwent LVRS with 56 similar patients who underwent standardized RR. Respiratory function parameters, erythrocyte osmotic resistance and antioxidant enzymes levels were evaluated before and 6 months after treatments.

RESULTS

Significant improvements in respiratory function, exercise capacity, unsaturated fatty acid content (+10.0%, P = 0.035), erythrocyte osmotic resistance (hyperosmolar resistance -21.0%, P = 0.001; hyposmolar resistance -18.0%, P = 0.007) and erythrocyte antioxidant enzymes [superoxide dismutase (SOD) +60.0%, P < 0.001; glutathione peroxidase +39.0%, P = 0.004 and glutathione reductase +24.5%, P = 0.008] were observed after surgery. In the RR group, we did not find any significant improvements in osmotic resistance, although respiratory and functional parameters were significantly improved. Correlation analysis in the surgical group showed that the reduction in residual volume (RV) significantly correlated the normalization of hyperosmotic (P = 0.019) and hyposmotic resistances (P = 0.006), the decrease in the absolute number of reticulocytes (P = 0.037) and increase in SOD (P < 0.001).

CONCLUSIONS

LVRS improved unsaturated fatty acid content, erythrocyte osmotic resistance and levels of erythrocyte antioxidant enzymes compared with RR. Correlations between erythrocyte osmotic resistance and antioxidant intracellular enzymes with RV suggest that reduction in lung hyperinflation with the elimination of inflammatory emphysematous tissue may explain such improvements after surgery.

The impact on quality of life after en-bloc resection for non-small-cell lung cancer involving the chest wall

BACKGROUND

  En-bloc resection for non-small cell lung cancer with chest-wall involvement may achieve a 5-year survival rate higher than 40%, but the impact on postoperative quality of life is not yet known.

METHODS

  Twenty-six patients undergoing en-bloc lung resections were included. Life quality ratings were assessed through a Short-Form 36 questionnaire preoperatively and at six, 12, 18 and 24 month follow-up visits. The degree of dyspnea, pain level, and flow-volume curves were also obtained at the same time periods. Changes occurring over time were analyzed by means of repeated-measure ANOVA.

RESULTS

  As a whole, the Physical Component Summary score declined six months postoperatively (P < 0.0001) and failed to improve thereafter. Patients with preoperative Forced Expiratory Volume in one second (FEV₁ ), <80% predicted (P = 0.029), resected ribs >2 (P = 0.03), and chest wall defect ≥50 cm² (P = 0.007) experienced a greater and lasting impairment. Net postoperative decrease in FVC (P = 0.02; r = 0.48) and dyspnea worsening (P = 0.03; r =-043 at six months, P = 0.05; r =-0.39 at 12 months) were also correlated with the extent of physical deterioration, whereas age (P = 0.92), gender (P = 0.51), type of resection (P = 0.71), and adjuvant therapy (P = 0.68) did not. The Physical Component Summary didn't change significantly in patients with high pain levels (VAS >7). The Mental Component Summary score increased slightly at six months, with no difference in any patients' subgroup.

CONCLUSIONS

  The extent of chest wall resection, preoperative FEV₁ , and postoperative decline in FVC were the main indicators of quality of life impairment after en-bloc resection for lung cancer. The impact upon quality of life should be considered in a cost-to-benefit ratio of planning this surgery in suboptimal candidates.

Randomized comparison of awake nonresectional versus nonawake resectional lung volume reduction surgery

OBJECTIVE

The study objective was to assess in a randomized controlled study (NCT00566839) the comparative results of awake nonresectional or nonawake resectional lung volume reduction surgery.

METHOD

Sixty-three patients were randomly assigned by computer to receive unilateral video-assisted thoracic surgery lung volume reduction surgery by a nonresectional technique performed through epidural anesthesia in 32 awake patients (awake group) or the standard resectional technique performed through general anesthesia in 31 patients (control group). Primary outcomes were hospital stay and changes in forced expiratory volume in 1 second. During follow-up, the need of contralateral treatment because of loss of postoperative benefit was considered a failure event as death.

RESULTS

Intergroup comparisons (awake vs control) showed no difference in gender, age, and body mass index. Hospital stay was shorter in the awake group (6 vs 7.5 days, P = .04) with 21 versus 10 patients discharged within 6 days (P = .01). At 6 months, forced expiratory volume in 1 second improved significantly in both study groups (0.28 vs 0.29 L) with no intergroup difference (P = .79). In both groups, forced expiratory volume in 1 second improvements lasted more than 24 months. At 36 months, freedom from contralateral treatment was 55% versus 50% (P = .5) and survival was 81% versus 87% (P = .5).

CONCLUSIONS

In this randomized study, awake nonresectional lung volume reduction surgery resulted in significantly shorter hospital stay than the nonawake procedure. There were no differences between study groups in physiologic improvements, freedom from contralateral treatment, and survival. We speculate that compared with the nonawake procedure, awake lung volume reduction surgery can offer similar clinical benefit but a faster postoperative recovery.

Awake thoracoscopic bullaplasty

OBJECTIVE

Staple excision of emphysematous bullae through general anesthesia is the standard surgical treatment of bullous emphysema. We have developed a new surgical technique entailing thoracoscopic bullaplasty performed in fully awake patients through sole epidural anesthesia.

METHODS

This prospective nonrandomized trial included 35 patients undergoing awake thoracoscopic bullaplasty between 2002 and 2009. Preoperative work-up included computed tomography with algorithm for quantitative measurement of the bulla volume. Outcome measures included patient's satisfaction with the anesthesia, scored into four grades (1=unsatisfactory; 4=excellent); ratio of arterial oxygen tension to fraction of inspired oxygen (PaO(2)/FiO(2)), and postoperative assessment of standard clinical measures at 6, 12, and 36 months.

RESULTS

There were 29 men and six women with a median age of 60 years. Median volume of the bulla was 688 ml. Awake bullaplasty was successfully completed in 34 patients. Perioperatively, PaO(2)/FiAO(2) decreased significantly (analysis of variance (ANOVA), P<0.0001) though remaining satisfactory (>300 mmHg), whereas PaCO(2) increased intraoperatively (ANOVA, P<0.0001) but returned to baseline values 1h after surgery (P=0.20). There was no mortality; four patients had air leaks longer than 7 days. Mean hospital stay was 4.9 ± 2.2 days. Comparisons between pre- to 6-month changes in outcome measures showed improvements (P<0.0001) in forced expiratory volume in 1s (FEV(1)) (+0.37 l), residual volume (-1.16 l), dyspnea index (-2), and standard 6-min walk test (SMWT) (+71 m). These improvements lasted for up to 36 months and in no patient did operated bullae recur.

CONCLUSION

Our study suggests that awake thoracoscopic bullaplasty was well tolerated and easily performed in the majority of the patients, and significant clinical improvements lasted for up to 36 months.

The role of awake video-assisted thoracoscopic surgery in spontaneous pneumothorax

OBJECTIVE

We assessed in a randomized study the feasibility and efficacy of awake video-assisted thoracoscopic bullectomy with pleural abrasion to treat spontaneous pneumothorax.

METHODS

Between January 2001 and June 2005, a total of 43 patients with primary spontaneous pneumothorax were randomly assigned by computer to undergo video-assisted thoracoscopic bullectomy and pleural abrasion under sole thoracic epidural anesthesia or general anesthesia with single-lung ventilation (control group). Primary outcome measures included technical feasibility and patient satisfaction with anesthesia as scored into 4 grades (from 1, unsatisfactory, to 4, excellent). Secondary outcome measures included global operating room time, assessment of thoracic pain by visual analog pain scale, number of nursing care calls, hospital stay, and recurrences within 12 months.

RESULTS

In the awake group, technical feasibility was scored as excellent, good, and satisfactory in 8, 7, and 6 patients, respectively. Intergroup comparisons (awake versus control) showed that global operating room time (78.0 +/- 20.0 vs 105.0 +/- 15.0 minutes, P < .0001), perioperative visual analog pain scale score (2.0 +/- 3.0 vs 3.5 +/- 2.0, P = .005), nursing care calls (2.0 +/- 1 vs 3.0 +/- 3.0, P = .017), hospital stay (2.0 +/- 1.0 days vs 3.0 +/- 1.0 days, P < .0001), and overall costs (2540 euros +/- 352 euros vs 3550 euros +/- 435 euros, P < .0001) were significantly better in the awake group. In the awake group, 5 patients (23.8%) could be discharged within the first 24 postoperative hours. One patient in the awake group and 2 patients in the control group had recurrences within 12 months (difference not significant).

CONCLUSION

In our study, awake video-assisted thoracoscopic bullectomy with pleural abrasion proved easily feasible and resulted in shorter hospital stays and reduced procedure-related costs while providing equivalent outcome to procedures performed under general anesthesia.

Flexible Videopericardioscopy in cT4 Nonsmall-Cell Lung Cancer With Radiologic Evidence of Proximal Vascular Invasion

BACKGROUND

The purpose of this study was to evaluate feasibility and effectiveness of flexible videopericardioscopy (FVP) in assessing resectability of cT4 nonsmall-cell lung cancer (NSCLC) with radiologic evidence of proximal vascular invasion.

METHODS

Between March 2003 and December 2005, 22 patients with NSCLC deemed unresectable owing to signs of proximal vascular invasion at multislice computed tomography were included in a nonrandomized prospective study entailing FVP performed before curative-intent thoracotomy. Primary outcome measures were technical feasibility (graded from 1 = poor to 3 = excellent) and quality of anatomic visualization (graded as diagnostic or nondiagnostic). Patients with FVP evidence of proximal vascular invasion did not receive thoracotomy and were included in an induction chemoradiotherapy protocol.

RESULTS

Mean operative time was 31 +/- 6 minutes. Technical feasibility ranged from good to excellent in 21 patients. In 1 patient, FVP was not completed owing to intrapericardial adhesions. In 7 patients, FVP disclosed no tumor spread to intrapericardial pulmonary vessels, and radical resection was carried out. The FVP findings were considered not diagnostic because of poor visualization of the right pulmonary artery in 2 patients with bulky hilar tumors. There was no operative mortality and morbidity. Mean hospital stay was 2.9 +/- 1 days for patients who did not undergo thoracotomy and 6.3 +/- 1 days for patients receiving FVP plus resection. Definitive pathologic staging in patients undergoing resection was pT3N1 (n = 2), pT3N0 (n = 2), pT2N0 (n = 3), and pT2N1 (n = 1).

CONCLUSIONS

Flexible videopericardioscopy proved safely feasible and allowed a better assessment of centrally located NSCLC, with radiologic evidence of proximal vascular involvement eventually resulting in increased resectability rate.

Late-Onset Occult Pneumothorax After Lung Volume-Reduction Surgery

BACKGROUND

Lung volume-reduction surgery has proved to be a reliable palliative surgical treatment for patients with severe emphysema. Nonetheless, late complications can arise after lung volume-reduction surgery although this matter has been poorly investigated by previous studies.

METHODS

We report a series of 6 patients undergoing unilateral lung volume-reduction surgery at our institution between October 1995 and December 2004, who were readmitted several months after discharge because of the occurrence of occult pneumothorax mimicking acute respiratory failure.

RESULTS

Occult pneumothorax occurred in 3.3% of the 182 patients treated with lung volume-reduction surgery at our institution. Patients were readmitted after a mean of 94 days (range, 20 to 700 days) from the discharge. Chest roentgenography was unable to detect the occurrence of pneumothorax, which was instead revealed by means of a computed tomographic scan in all patients. The interval between admission and correct diagnosis averaged 22.4 hours. The number of air collections ranged between two and four. Treatment entailed solely blind chest drainage placement in 2 patients and awake video-assisted thoracoscopic surgery in the others, including placement of chest tube under direct vision in 1 patient, repair of lung tears by means of cyanoacrylate glue in 2 and bovine pericardium patch plus cyanoacrylate glue apposition in 1 patient.

CONCLUSIONS

In conclusion, we believe that occult pneumothorax should be kept in mind as one of the possible late complications of lung volume-reduction surgery and should be suspected whenever sudden worsening of dyspnea is noticed even in the presence of an uneventful chest roentgenogram. Awake video-assisted thoracoscopic surgery management can represent an effective option in these instances.

Cisplatin, mitomycin-C, 5-fluorouracil and leucovorin combination chemotherapy (l-FCM) in locally advanced unresectable or metastatic gastric carcinoma: a phase-II study

Despite relevant progress, the impact of chemotherapy on advanced gastric cancer patients' survival is still unsatisfactory. Thus, the key objective of our efforts should be palliation of the symptoms and the maintenance of an adequate quality of life. In this phase-II study, we evaluated toxicity and efficacy of the combination of cisplatin, fluorofolates and mitomycin C. Thirty-one advanced gastric cancer patients received cisplatin (15 mg/m2) and 5-fluorouracil (350 mg/m2), both for 5 consecutive days every 4 weeks; 5-fluorouracil infusion was preceded by a rapid i.v. injection of 100 mg/m2 leucovorin, while mitomycin-C (10 mg/m2) was administered on day 1 of odd cycles. Cycles were repeated every 4 weeks until disease progression. We recorded 16 objective responses (51.6%, 95% confidence interval: 42.63-60.57); furthermore, such a response rate was coupled with a moderate degree of toxicity and an extremely good tolerance. In particular, alopecia, a frequent and distressing side-effect in patients, especially women, in our series occurred only in two patients. This treatment appears to be an active and tolerable therapeutic option for patients with advanced gastric carcinoma.