Intrathymic growing bronchogenic cyst mimicking thymoma: A case report

Intrathymic bronchogenic cysts are extremely rare lesions, and the differential diagnosis with a banal thymic cyst or a solid tumor can be problematic. Thymic carcinomas arising within thymic cysts have also been reported. We report a case of radical thymectomy for a slowly growing small thymic cyst. The pathological finding revealed a bronchogenic cyst rather than a thymic neoplasm.

Full subcostal subxiphoid robotic-assisted radical thymectomy: preclinical cadaveric study for optimizing patient positioning, table settings, and port configuration

Robotic subxiphoid transthoracic thymectomy showed several surgical advantages. Nevertheless, the intercostal insertion of trocars may lead to nerve injury with enhanced post-operative pain. Moreover, the dissection of peri-diaphragmatic mediastinal fat may result challenging, in particular on left side, where the presence of the heart precludes the optimal visualization. We describe a preclinical cadaveric study of a novel full subcostal robotic-assisted technique to overcome these limitations. A total subcostal robotic-assisted radical thymectomy was evaluated on a cadaver model using the da Vinci Xi system. The exploratory procedure was divided in two steps: (a) dissection of the thymus gland, except the left mediastinal epi-diaphragmatic fat pad; (b) dissection of the left diaphragmatic mediastinal fat pad avoiding heart compression while perfectly visualizing the left phrenic nerve. Five different setups were explored based on camera and trocars insertions, patient's positioning and table's settings. Both the tasks were accomplished using the novel technique. The subxiphoid insertion of the camera and the position of two robotic arms about 8 cm distally on the subcostal made the most part of mediastinal dissection straightforward. Left peri-diaphragmatic fat pad can be better visualized and dissected positioning the camera in the left subcostal port shifting the instruments on the right side. This may permit a better control of the left phrenic nerve reducing heart compression. Full subcostal robotic-assisted thymectomy resulted feasible in cadaveric model. Clinical trial should be performed to confirm the translational use of this novel technique and the speculated advantages in living model.

Molecular Markers for Long-term Survival in Stage IIIA (N2) NSCLC Patients

BACKGROUND

Survival rates among non-small cell lung cancer (NSCLC) stage IIIA (N2) patients are generally low and depend on the treatment.

PATIENTS AND METHODS

We aimed to identify predictive markers for long term survival in responders and non-responders to chemotherapy, analyzing tumour and non-tumour samples by microarray (n=35) and whole exome sequencing (WES, n=25).

RESULTS

WES data showed correlation of overall survival of all patients with rs9905892 in the SLFN12L gene. High frequency of mutations (4/6, 66.7%) was identified in members of SWI/SNF complex in responder patients and in patients that were alive after seven years. Microarray data for immune components showed that VISTA (VSIR) was down-regulated in tumoral tissue.

CONCLUSION

Our research suggests that mutations in SWI/SNF complex associate with long term survival after multimodal treatment, while down-regulation of VISTA might indicate its immunomodulatory role in NSCLC stage III (N2) patients.

Optimal delineation of the clinical target volume for thymomas in the post-resection setting: A multi-center study

BACKGROUND

The definition of the clinical target volume (CTV) for post-operative radiotherapy (PORT) for thymoma is largely unexplored. The aim of this study was to analyze the difference in CTV delineation between radiation oncologists (RTO) and surgeons.

METHODS

This retrospective multi-center study enrolled 31 patients who underwent PORT for a thymoma from five hospitals. Three CTVs were delineated per patient: one CTV by the RTO, one CTV by the surgeon (blinded to the results of the RTO) and a joint CTV after collaboration. Volumes (cm³), Hausdorff distances (HD) and Dice similarity coefficients (DSC) were analyzed.

RESULTS

RTO delineated significantly bigger CTVs than surgeons (mean: 93.9 ± 63.1, versus 57.9 ± 61.3 cm³, p = 0.003). Agreement was poor between RO and surgeons, with a low mean DSC (0.34 ± 0.21) and high mean HD of 4.5 (±2.2) cm. Collaborative delineation resulted in significantly smaller volumes compared to RTO (mean 57.1 ± 58.6 cm³, p < 0.001). A mean volume of 18.9 (±38.1) cm³ was included in joint contours, but missed by RTO. Conversely, a mean volume of 55.7 (±39.9) cm³ was included in RTO's delineations, but not in the joint delineations.

CONCLUSIONS

To the best of our knowledge, this is the first study investigating CTV definition in thymoma. We demonstrated a significant variability between RTO and surgeons. Joint delineation prompted revisions in smaller CTV as well as favoring the surgeons' judgement, suggesting that surgeons provided relevant insight into other risk areas than RTO. We recommend a multidisciplinary approach to PORT for thymomas in clinical practice.

Electromagnetic navigation bronchoscopy localization of lung nodules for thoracoscopic resection

Background

Thoracoscopic localization of small peripheral pulmonary nodules is a concern. Failure can lead to larger parenchymal resection or conversion to thoracotomy. This study evaluates our experience in preoperative electromagnetic navigation bronchoscopy-guided localization of small peripheral lung lesions.

Methods

From January 2017 to March 2020 clinical, radiographic, surgical, and pathological data of patients who underwent electromagnetic navigation bronchoscopy (ENB)-guided methylene blue pleural marking of highly suspected pulmonary lesions before a full thoracoscopic resection were evaluated. Localization was performed for solid or mixed subpleural nodules measuring <10 mm, solid nodules measuring <20 mm located at more than 1 cm from the pleura and any pure ground glass opacity. Successful localization was defined as successful identification and thoracoscopic resection of target lesions.

Results

Forty-eight patients were included: 30 solid nodules (63%), 12 pure GGO (25%) and 6 mixed (13%). The median largest diameter at CT-scan was 11 mm (IQR, 9-14 mm) while the median distance from the pleural surface was 12 mm (IQR, 6-16 mm). The median ENB length was 25 min (19-33 min). Localization procedure was successful in 45 cases (94%). No procedural-related complications were reported.

Conclusions

ENB is a safe and accurate preoperative procedure to localize small lung peripheral lesions. The high successful rate, the absence of related complications, the possibility of performing the procedure in the same operating room with a single general anesthesia, make ENB-guided dye marking an advantageous tool for thoracoscopic pulmonary resection.

Thoracoscopic complex basilar segmentectomies: an analysis of 63 procedures

Background

Thoracoscopic complex basilar segmentectomies are technically demanding and challenging. We review our experience to check whether this complexity can lead to specific surgical issues or increased post-operative morbidity.

Methods

Complex basilar segmentectomies were defined as the anatomical resection of at least one segment composing the basilar pyramid, excluding S⁶. Data of patients who had an intention-to-treat thoracoscopic complex basilar segmentectomy were retrospectively collected from 2007 to 2019: indications, preoperative assessment, clinical features, operative technical aspects and early post-operative outcome.

Results

Sixty-three patients, 26 men (41%) and 37 women (59%) with a median age of 66 years and a median body mass index (BMI) of 26 kg/m2 were included. Interventions performed were mostly S⁹⁺¹⁰ (n=32) and S⁸ (n=12) segmentectomies. Forty-five planned operations (71%) were completed. Extension to a larger resection was necessary in 17 patients (27%) and 4 patients underwent conversion to open surgery (6%). Median operative time was 168 minutes with a median intraoperative bleeding of 30 mL. Complications occurred in 11 patients (17%). There was no mortality. Median length of pleural drainage was 2 days (range, 1–2 days) and median hospital stay 4 days.

Conclusions

The extension rate of complex basilar segmentectomy is higher than that of other sublobar resections but their post-operative morbidity is identical.

Second pulmonary resection for a second primary lung cancer: analysis of morbidity and survival

OBJECTIVES

Evaluating morbidity and survival of patients operated on for a second primary non-small-cell lung cancer (NSCLC).

METHODS

Retrospective collection of data from patients operated on for a second NSCLC between 2009 and 2018.

RESULTS

Fifty-two patients met the inclusion criteria. At the time of second pulmonary resection, the median time between the 2 surgeries was 25 months (5-44.5 months). Patients' median age was 65 years (61-68 years). Median tumour size was 16 mm (10-22 mm). Thoracoscopy was used in 75% of cases. The resection was a pneumonectomy (n = 1), bilobectomy (n = 1), lobectomy (n = 15), segmentectomy (n = 32) or wedge resection (n = 3). The length of stay was 7 days (5-9 days). Mortality was null and morbidity was 36.5%, mainly from grade I-II complications according to the Clavien-Dindo classification. The median follow-up was 28 months (13-50 months). The median overall survival was 67 months (95% confidence interval 60.8-73.1 months). Survival at 5 years and specific survival were 71.1% and 67.7%, respectively.

CONCLUSIONS

A second surgical resection of either synchronous or metachronous NSCLC has a morbidity that is not superior to the morbidity of the first operation. The new tumour is usually diagnosed at an early stage. An anatomical sublobar resection is most likely the best compromise. It might also be considered for the first operation when there is a suspicious synchronous lesion that may require surgery at a later stage.

Platinum Drug Sensitivity Polymorphisms in Stage III Non-small Cell Lung Cancer With Invasion of Mediastinal Lymph Nodes

BACKGROUND/AIM

Patients with stage IIIA (N2) non-small cell lung cancer (NSCLC) with no progression after induction chemotherapy are usually selected for surgery. Nowadays, response to chemotherapy is not predictable. We aimed to identify genomic predictive markers for response to induction chemotherapy in stage IIIA (N2) NSCLC patients.

PATIENTS AND METHODS

Whole-exome sequencing (WES) was performed on samples from 11 patients with no response after induction chemotherapy and 6 patients with documented pathological response, admitted to the Hotel Dieu Hospital, Paris or Allegemeines Krakenhaus University, Vienna.

RESULTS

A higher alternative allele frequency was found on SENP5, rs63736860, rs1602 and NCBP2, rs553783 in the non-responder group, and on RGP1, rs1570248, SLFN12L, rs2304968, rs9905892, and GBA2, rs3833700 in the responder group.

CONCLUSION

These polymorphisms contribute to inter-individual sensibility to chemotherapy response. Interrogation of these genetic variations may have potential applicability when deciding the treatment strategy for patients with stage III NSCLC (N2).

Establishment and Characterization of a Stromal Cell Line Derived From a Patient With Thoracic Endometriosis

Thoracic endometriosis (TE) syndrome is a clinical condition known as an extrapelvic form of endometriosis with the presence of functioning endometrial tissue involving lung parenchyma, pleura, chest wall, or diaphragm. In an effort to obtain an endometriosis ex vivo model, we established the spontaneously growing TH-EM1 cell line from endometriotic implants in lung parenchyma from a woman with TE. Maintained in long-term culture, the cells grew as large mesenchymal-like cells with a doubling time between 5 and 6 days. Treatment with medroxyprogesterone acetate (10^-7 mol/L) inhibited the TH-EM1 cells growth and induced morphological changes to an epithelial-like cells. Strong expression of the nuclear estrogen receptors, progesterone receptors, and erytropoietin receptors were found in both the pulmonary implant and the TH-EM1 cells by immunohistochemical analysis. Consistent immunoreactivity of TH-EM1 cells for CD9, CD13, CD73, CD90, CD105, and CD157 was revealed by flow cytometry. Likewise, the embryonic markers, SRY-box 2 (SOX-2) and the Nanog molecules, were detected in 76% and 52% of the cells, while fetal hemoglobin and a-globin were detected in 76% and 65% of TH-EM1 cells, respectively. By RHG banding, normal metaphases were observed, while the microarray chromosomal analysis showed gains of DNA sequences located on the segments 8p23.1, 11p15.5, and 12p11.23. The described in vitro cellular model can serve as a useful tool to study the pathogenesis of endometriosis and to improve the knowledge of molecular mechanisms controlling the endometriotic cell dissemination potential.

Resection of Bronchogenic Cysts in Symptomatic Versus Asymptomatic Patients: An Outcome Analysis

BACKGROUND

The natural evolution of bronchogenic cysts (BCs) is unpredictable. Although most surgeons agree that symptomatic BCs should be resected, questions remain regarding the optimal management of asymptomatic mediastinal cysts. We present a case series of BCs to compare patients who underwent preventive operation with those who underwent surgical procedure after symptom onset.

METHODS

This 15-year multicenter retrospective study included 114 patients (32 children and 82 adults). Data on clinical history, pathology, mean hospital stay, intraoperative and postoperative complications, and associated intraoperative procedures were analyzed separately for symptomatic and asymptomatic patients.

RESULTS

A total of 53 asymptomatic patients (46.5%) were compared with 61 symptomatic patients (53.5%). There were significantly more adults in the symptomatic group than in the asymptomatic group (48 vs 34 patients, P < .05). A thoracoscopic approach was used in 88 patients (77%), with 7 conversions to thoracotomy (9%), all in symptomatic patients. There were significantly more additional procedures (20% vs 4%, P = .01) and more intraoperative complications (20% vs 4%, P = .01) in symptomatic patients, but postoperative complications between symptomatic and asymptomatic patients were similar. The postoperative length of stay was significantly longer in symptomatic patients (5.71 days vs 4 days, P < .001). Pathologic examination found significantly more inflammatory reactions in symptomatic patients.

CONCLUSION

Early surgical management of BCs may be recommended to prevent symptomatic complications, which are unpredictable and whose management is more complicated in advanced BCs. Surgery can be performed with a thoracoscopic approach, which is easier and safer when the cyst is small and uncomplicated.

Oncological results of full thoracoscopic major pulmonary resections for clinical Stage I non-small-cell lung cancer

OBJECTIVES

The full thoracoscopic approach to major pulmonary resections is considered challenging and controversial as it might compromise oncological outcomes. The aim of this work was to analyse the results of a full thoracoscopic technique in terms of nodal upstaging and survival in patients with non-small-cell lung carcinoma (NSCLC).

METHODS

All patients who underwent a full thoracoscopic major pulmonary resection for NSCLC between 2007 and August 2016 were analysed from an 'intent-to-treat' prospective database. Overall survival and disease-free survival were estimated using the Kaplan-Meier curves and comparisons in survival using the log-rank test.

RESULTS

A total of 648 patients met the inclusion criteria, of whom 621 patients had clinical Stage I and 27 had higher stages (16 oligometastatic patients were excluded from the analysis, 11 cT3 or cT4). The mean follow-up was 34.5 months. There were 40 conversions to thoracotomy (6.3%). Thirty-day or in-hospital mortality was 0.95%. Complications occurred in 29.3% of patients. On pathological examination, 22.5% of clinical Stage I patients were upstaged. Nodal upstaging to N1 or N2 was observed in 15.8% of clinical Stage I patients. Five-year overall survival of the whole cohort was 75% and was significantly different between clinical Stages IA (76%) and IB (70.9%). For tumours <2 cm, no significant difference in overall survival was found for the segmentectomy group compared to the lobectomy group: 74% versus 78.9% (P = 0.634).

CONCLUSIONS

Long-term survival is not compromised by a full thoracoscopic approach. Our results compared favourably with those of video-assisted techniques.

Robotic Resection of a Left Brachiocephalic Vein Aneurysm Mimicking Thymoma

A 70-year-old man was scheduled for the robotic resection of a 21×16 × 30 mm thymic nodule incidentally detected by a computed tomography scan (CT) for thoracic trauma after a domestic accident. Positron emission tomography (PET) scan confirmed a low [18F]-FDG uptake (SUVmax = 1,9). During the surgery, the mass showed to be a saccular aneurysm of the left brachiocephalic vein (LBCV). A complete tangential resection of the aneurysm, with the use of EndoGIA stapler (Covidien® Endo GIA™) at its origin, was performed. The patient's recovery was uneventful, and postoperative CT with contrast administration confirmed the patency of the vein.

Establishment and Characterization of a Stromal Cell Line Derived From a Patient With Thoracic Endometriosis

Thoracic endometriosis (TE) syndrome is a clinical condition known as an extrapelvic form of endometriosis with the presence of functioning endometrial tissue involving lung parenchyma, pleura, chest wall, or diaphragm. In an effort to obtain an endometriosis ex vivo model, we established the spontaneously growing TH-EM1 cell line from endometriotic implants in lung parenchyma from a woman with TE. Maintained in long-term culture, the cells grew as large mesenchymal-like cells with a doubling time between 5 and 6 days. Treatment with medroxyprogesterone acetate (10-7 mol/L) inhibited the TH-EM1 cells growth and induced morphological changes to an epithelial-like cells. Strong expression of the nuclear estrogen receptors, progesterone receptors, and erytropoietin receptors were found in both the pulmonary implant and the TH-EM1 cells by immunohistochemical analysis. Consistent immunoreactivity of TH-EM1 cells for CD9, CD13, CD73, CD90, CD105, and CD157 was revealed by flow cytometry. Likewise, the embryonic markers, SRY-box 2 (SOX-2) and the Nanog molecules, were detected in 76% and 52% of the cells, while fetal hemoglobin and α-globin were detected in 76% and 65% of TH-EM1 cells, respectively. By RHG banding, normal metaphases were observed, while the microarray chromosomal analysis showed gains of DNA sequences located on the segments 8p23.1, 11p15.5, and 12p11.23. The described in vitro cellular model can serve as a useful tool to study the pathogenesis of endometriosis and to improve the knowledge of molecular mechanisms controlling the endometriotic cell dissemination potential.

Intrarectal Foreign Body Detected at CT Scanner Investigating an Abdominal Syndrome

The field of general surgery offers many different pathologies, cases, and situations for which the general surgeons should be competent in diagnosis as well as treatment and management, including operative intervention. Most situations are complicated by delayed admission to the hospital due to the embarrassment of patient and inability to obtain satisfactory anamnesis. This article reviews the use of computed tomography as a problem-solving tool in the identification, localization, and presurgical planning for extracting the rectal foreign object.

[Pulmonary intralobar sequestration in adults: Evolution of surgical treatment]

BACKGROUND

Until now, the traditional procedure to treat intralobar pulmonary sequestration (ILS) in adults has been a lobectomy performed by open thoracotomy. We have reviewed our data to observe if the surgical management of these lesions has evolved over the last years.

METHODS

We retrospectively reviewed the records of the patients who were operated for an ILS either by posterolateral thoracotomy (PLT group), or by thoracoscopy (TS group) between 2000 and 2016.

RESULTS

Eighteen patients were operated for a SIL during this period. Prior to 2011, all resections were performed by thoracotomy (n=6) and after 2011 the surgical approach was either a thoracotomy (n=5) or a thoracoscopy (n=7). There was one conversion because of dense pleural adhesions and this patient was integrated in the PLT group for further analysis. ILS were more frequently encountered on the left side (n=12, 66.6 %) than on the right one (n=6, 33.3 %) and exclusively in the lower lobes. All patients of the PLT group underwent a lobectomy. In the TS group, 5 patients underwent a sublobar resection (2 segmentectomiesS⁹⁺¹⁰, 1 basilar segmentectomy and 2 atypical resections). There was no mortality. In the PLT group, 5 patients (45 %) had complications versus one patient (14 %) in the TS group. The mean hospital stay was 7.4 days in the PLT group versus 5.4 days in the TS group.

CONCLUSIONS

These data confirm that ILS can be safely treated by a sublobar resection that should be performed, whenever possible, thoracoscopically.

Planning and marking for thoracoscopic anatomical segmentectomies

Although sublobar resection (SLR) for treating non-small cell lung carcinoma (NSCLC) is still controversial, thoracoscopic segmentectomy is rising. Performing it by closed chest surgery is complex as it means confirming the location of the lesion, identifying vascular and bronchial structures, preserving venous drainage of adjacent segments, severing the intersegmental plane and ensuring an oncological safety margin with no manual palpation and different landmarks. Accurate planning is mandatory. We discuss in this article the interest of 3D reconstruction and mapping technics to enhance safety and reliability of these procedures.

Adult pulmonary intralobar sequestrations: changes in the surgical management

Background

Until now, the traditional procedure to treat intralobar pulmonary sequestration (ILS) in adults has been a lobectomy performed by open chest surgery. We have reviewed our data to determine whether the surgical management of these lesions has evolved over the last years.

Methods

We retrospectively reviewed the records of patients who were operated on for an ILS by either posterolateral thoracotomy (PLT group), or by thoracoscopy (TS group) between 2000 and 2016.

Results

Eighteen patients were operated on for a ILS during this period. Before 2011, all resections were performed by thoracotomy (n=6) and after 2011 the approach was either a thoracotomy (n=5) or a thoracoscopy (n=7). There was one conversion because of dense pleural adhesions and this patient was integrated in the PLT group for further analysis. ILS presented more frequently on the left side (n=12, 66.7%) than on the right one (n=6, 33.3%) and exclusively in the lower lobes. All the PLT group patients underwent a lobectomy. In the TS group, five patients underwent a sublobar resection (2 segmentectomies S9+10, 1 basilar segmentectomy and 2 atypical resections). There was no mortality. In the PLT group, 5 patients (45%) had complications versus one patient (14%) in the TS group. The mean hospital stay was 7.4 days in the PLT group versus 5.4 days in the TS group.

Conclusions

These data confirm that ILS can be safely treated by a sublobar resection that should be performed, whenever possible, without opening the chest.

Congenital bronchial atresia in adults: thoracoscopic resection

Congenital bronchial atresia (CBA) is a rare congenital malformation consisting in an interruption of a lobar or-more frequently-of a segmental bronchus. It leads to mucus impaction and hyperinflation of the obstructed lung segment. It causes infectious complications and, in the long term, destruction of the adjacent lung parenchyma. Thus, a surgical resection is usually indicated, even in asymptomatic patients.

Technical means to improve image quality during thoracoscopic procedures

Although high definition imaging systems are now available in the operating room (OR), the displayed image quality during video-assisted procedures is often poor. This is due to several factors such as inappropriate angle of vision, instable endoscope, lens soiling and fogging. The aim of this article is to provide information about some technical and technological means that make it possible to keep a perfect picture all along a thoracoscopic procedure.

Unplanned Procedures During Thoracoscopic Segmentectomies

BACKGROUND

Thoracoscopic sublobar resections (TSLRs) are gaining popularity, but are challenging. However, despite technical difficulties, the reported rate of adverse events, complications, and unplanned procedures is low. To understand this paradox, we have studied our series of TSLRs.

METHODS

We reviewed our prospective and intention-to-treat database on videothoracoscopic anatomical resections and extracted all planned thoracoscopic segmentectomies from January 2007 to July 2016. Intraoperative and postoperative data were analyzed. Unplanned procedures were defined as a conversion into thoracotomy or an unplanned additional pulmonary resection.

RESULTS

During the study period 284 thoracoscopic anatomical segmentectomies were performed in 280 patients. There were 124 men and 156 women with a mean age of 64 years (range, 18 to 86 years). Indication for segmentectomy was a proven or suspected non-small cell lung carcinoma in 184 patients, suspected metastasis in 51 patients, and benign lesion in 49 patients. In total, 23 patients had an unplanned procedure (8%). There were 10 unplanned thoracotomies (9 conversions and 1 reoperation; 3.1%) mainly for vascular injuries, and 15 unplanned additional resections (5.1%) distributed among oncological reasons (n = 7), per operative technical issues (n = 6) and postoperative adverse events (lingular ischemia, n = 2). Considering only the 235 patients operated on for cancer, the unplanned additional pulmonary resection rate for an oncological reason was 3%.

CONCLUSIONS

Although lower than for thoracoscopic lobectomies, the rate of unplanned procedure during TSLRs is of concern. It could most likely be reduced by technical refinements, such as a better preoperative planning.

Thoracoscopic anatomic segmentectomies for lung cancer: technical aspects

Although the interest for thoracoscopic sublobar resections (TSLR) is rising, its use for treating non-small cell lung carcinoma (NSCLC) is still controversial because publications dealing with survival and recurrence rate provide contradictory results. If applied to the resection of lung cancer, thoracoscopic segmentectomies must be performed according to oncological criteria. The aim of this technical paper is to give some technical details on thoracoscopic segmentectomies for the treatment of malignancies. Our experience is based on 235 thoracoscopic anatomical segmentectomies performed in 232 patients for a malignant lesion between January 2007 and July 2016. Indication for segmentectomy was a proven or suspected NSCLC in 184 and suspected metastasis in 51 patients. Intraoperative and postoperative data were recorded in a prospective manner. There were eight conversions into a posterolateral thoracotomy (3.4%) and seven unplanned additional pulmonary resections for an oncological reason (3%). We discuss some technical refinements that could minimize these adverse events and make thoracoscopic segmentectomy a safe and reliable procedure.

Gene-expression Profiling in Non-small Cell Lung Cancer with Invasion of Mediastinal Lymph Nodes for Prognosis Evaluation

BACKGROUND/AIM

The aim of the study was to determine the pathways and expression profile of the genes that might predict response to neoadjuvant chemotherapy in patients with stage IIIA non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

We evaluated, by microarray, the gene-expression profile of tumoral mediastinal lymph node samples surgically removed from 27 patients with stage IIIA NSCLC before neoadjuvant chemotherapy treatment. Depending on the response to the induction treatment, the patients were divided in two groups: group A: patients whose disease evolved, stabilized or who had minor response to chemotherapy, and group B: patients whose disease stabilized or had major response to chemotherapy.

RESULTS

The microarray experiments identified 1,127 genes with a modified expression in the tumoral tissue compared to normal tissue with p≤0.05 and 44 genes with p≤0.01. The identified up-regulated genes between tumoral versus normal tissue included collagen, type I, alpha 1 (COL1A1), inhibin beta A (INHBA) and thioredoxin interacting protein (TXNIP). Pathways identified with a false-discovery rate of <0.005 included: cytokine pathways, focal adhesion or extracellular matrix receptor interaction.

CONCLUSION

Our approach identified important characteristics of NSCLC and pointed-out molecular differences between sub-groups of patients based on their response to therapy.

[Cystic mediastinal schwannoma appended to the vagus nerve]

INTRODUCTION

Schwannomas are a form of rare tumor, arising from neural tissue and representing 2 % of mediastinal tumors. They are usually located in the posterior mediastinum, most often in the paravertebral gutters and typically appended to intercostal nerves.

CASE REPORTS

We report two cases of unusual mediastinal schwannomas, appended to the vagus nerve. The schwannoma was located in the subcarinal region in the first case and in the right para-tracheal region in the second case. The lesions were thought to be bronchogenic cysts preoperatively in both cases because of a cystic appearance on preoperative CT scan and endobronchial ultrasonography. A surgical approach was adopted to remove the tumors. Video-assisted thoracoscopy was used in one case and robotic-assisted surgery in the second case, without any complication, allowing for complete resection and to establish a certain pathological diagnosis.

CONCLUSION

Despite this location and cystic presentation being unusual, schwannoma should be considered as a possible cause of cystic lesions in the mediastinum. Minimally invasive surgery allows for complete resection and definitive pathological diagnosis.

Totally thoracoscopic pulmonary anatomic segmentectomies: technical considerations

BACKGROUND

While video-assisted thoracic surgery (VATS) lobectomies are being increasingly accepted, VATS segmentectomies are still considered as technically challenging. With the renewed interest for sublobar resection in the management of early stage lung carcinomas, the thoracoscopic approach may have a major role in a near future. We report our technique and results.

PATIENTS AND METHODS

Totally thoracoscopic anatomic segmentectomiy, i.e., using only endoscopic instrumentation and video-display without utility incision, was attempted on 117 patients (51 males and 66 females), aged 18 to 81 years (mean: 62 years). The indication was a clinical N0 non-small cell lung carcinoma in 69 cases, a solitary metastasis in 17 cases and a benign lesion in 31 cases. The following segmentectomies were performed: right apicosuperior [26] right superior [10], right basilar [18], lingula sparing left upper lobectomy [15], left apicosuperior [11], lingula [7], left superior [14], left basilar [13] and subsegmental resection [3]. Segmentectomy was associated with a radical lymphadenectomy in 69 cases.

RESULTS

There were 5 conversions to thoracotomy. The mean operative time was 181±52 minutes, the mean intraoperative blood loss was 77±81 cc. There were 12 postoperative complications (11.7%). The median postoperative stay was 5.5±2.2 days. Out of the 69 patients operated on for a cN0 lung carcinoma, 6 were finally upstaged.

CONCLUSIONS

Totally thoracoscopic anatomic pulmonary segmentectomies are feasible and have a low complication rate.

Predictive factors for complications of anatomical pulmonary segmentectomies

OBJECTIVES

The role of anatomical pulmonary segmentectomy is increasing, but there are few data about its complication rate. We have analysed the postoperative morbidity, mortality and risk factors in a consecutive series of 228 segmentectomies performed in our department.

METHODS

Between January 2007 and December 2011, 221 patients underwent 228 segmentectomies. There were 99 women (45%) and 122 men (55%). The mean age was 61 years (range 18-86 years). The mean forced expiratory volume in 1 s (FEV1) was 87%, and 30 patients had an FEV1 of ≤60%. Fifty-seven patients had a previous history of pulmonary resection. Indications for segmentectomy were: primary lung cancer (111 cases), metastases (71 cases), benign non-infectious (25 cases) and benign infectious diseases (21 cases). The approach was a posterolateral thoracotomy (Group PLT) in 146 patients (64%) and a thoracoscopy (Group TS) in 82 (36%). The two groups were homogenous in terms of age, gender, indications of surgery and type of segmentectomy.

RESULTS

The mortality rate at 3 months was 1.3% (3 patients). The overall complication rate was 34%. Ten patients were reoperated for the following reasons: haemothorax (4 cases), ischaemia of the remaining segment (3 cases), active bleeding (1 case), prolonged air leak (1 case) and dehiscence of thoracotomy (1 case). The average duration of drainage was 5 days (range 1-34 days) and the average length of stay was 9 days (range 3-126 days). On univariate analysis, FEV1, male gender and thoracotomy were statistically significant risk factors for complications. On multivariate analysis, the same three predictive factors of complications independently of age were found statistically significant: preoperative FEV1 < 60% [odds ratio (OR) = 5.9, 95% CI (2.5-13.7), P < 0.001] male gender [OR = 2.04, 95% CI (1.2-3.6), P < 0.013] and thoracotomy [OR = 2.14, 95% CI (1.33-3.46), P = 0.001].

CONCLUSIONS

Pulmonary anatomical segmentectomies have an acceptable morbidity rate. Postoperative complications are more likely to develop in male gender patients, with FEV1 ≤ 60% and operated by open surgery.

[Thoracic surgery for lung cancer]

There are two main types of lung cancer. The reference treatment for small cell lung cancer is chemotherapy combined or not with radiotherapy. Generally multimodal, the treatment for non-small cell cancer combines surgery, chemotherapy and radiotherapy. A major procedure for patients, surgery is a stage in their fight against the cancer.

Which patients should be operated on after induction chemotherapy for N2 non-small cell lung cancer? Analysis of a 7-year experience in 175 patients

OBJECTIVE

The role of surgery in patients with N2 non-small cell lung cancer is debated. The aim of this study was to evaluate the results of surgical resection after induction chemotherapy.

METHODS

We retrospectively reviewed the cases of patients with N2 non-small cell lung cancer who underwent neoadjuvant chemotherapy followed by resection between 2001 and 2007. They all had tumors deemed resectable.

RESULTS

One hundred seventy-five patients entered the study. Most of them received 2 or 3 cycles of chemotherapy (81%), in all cases platinum-based regimens. Chemotherapy response rate was 62%. Operations included 96 lobectomies/bilobectomies and 79 pneumonectomies. Complete resection rate was 94%, and perioperative mortality was 4.5%. A pathologic mediastinal downstaging was found in 39% of patients. Overall median survival time and 5-year survival were 34.7 months and 30%, respectively. Survival was affected by clinical response (median survival time 51 months and 5-year survival 42% for responders versus 19 months and 10% for nonresponders) and by nodal downstaging (51 months and 45% versus 25% and 22%). In the group of responders, nondownstaged patients showed satisfying survival (median survival time 30 months, 5-year survival 30%). In the group of nonresponders, survival was unsatisfactory when a lobectomy was performed (median survival time 20 months, 5-year survival 13%) and poor in case of pneumonectomy (15 months and 6%). Multivariate analysis found 4 factors significantly affecting survival: clinical response, nodal downstaging, number of chemotherapy cycles, and histopathologic response.

CONCLUSIONS

Surgery after chemotherapy could be effective for selected patients with N2 non-small cell lung cancer. Survival for responders is satisfactory, even in case of persistent N2 disease. Prognosis for nonresponders is disappointing.

[Anesthesia for experimental surgery in swine]

New surgical techniques cannot be safely and widely performed in human subjects unless they are first applied to large animal models. Experimental model using swine as surgical practice subject is one of the most reliable and widely practiced, taking into consideration the similarity between human and swine anatomy. Based on our large experience (around 100 pigs) we hereby present important aspects of handling and anesthesia procedures for pigs. Our goal is to share our experience with young surgical and anesthesia investigators who are planning investigations using pig as an experimental animal.

[Thoracoscopic splanchnicectomy--a method of pain palliation in non-resectable pancreatic cancer and chronic pancreatitis]

Severe upper abdominal pain is a dominant and distressing feature in advanced pancreatic cancer and in chronic pancreatitis. A way of palliation needs to be practiced in the non-resectable pancreatic cancer in order to control the pain. Between the many methods of palliation the thoracoscopic splanchnicectomy seems to be the best due its simplicity, no risk to the patient and the good results. In the Center of General Surgery and Liver Transplantation from Fundeni Clinical Institute we have practiced 50 thoracoscopic splanchnicectomies in a number of 49 patients during a period of 3 years. The morbidity was 2% and the mortality 0. We noticed a significant improvement in the pain score, the quality of sleep and the overall quality of life and consecutively a quick social reintegration of these patients. The quality of life is greatly improved (with a significant reduction of the pain score in 92% of the cases) after this minimally invasive procedure, a fact the qualifies this procedure as the technique of choice in these patients.

[Our experience regarding a series of adrenal surgical diseases]

AIMS

The problems of positive and differential clinic-pathologic diagnosis, the optimal therapeutic decision and importance of surgery in a series of patients with adrenal gland (AG) diseases was studied.

MATERIAL AND METHODS

Between 1987-1999, 91 patients (pts.) with adrenal diseases were operated on. Sex ratio was 63 f/28 m and the medium age 42.3 years (extremes 14 and respectively 75 years old). The lesions were localized in medullar, cortical and in the both components of AG. 1) The cortical determinations were represented by 40 (44%) pts. with: a) Cushing's syndrome 37 pts. histologically grouped: 24 pts. (63%/37) with benign, diffuse hyperplasia of cortico-adrenal glands; 4 pts. with cortical benign adenoma; 7 adenocarcinoma; 2 with borderline lesions. b) Conn syndrome--3 pts. 2) Medullary lesions (Phaeochromocytoma)--30 pts. (33%/91) with following microscopically lesions: 22 typical phaeochromocytoma; 3 benign adenoma; 5 carcinoma and 1 medullo-adrenal paraganglioma. One patient have had bilateral medullo-adrenal lesions: left carcinoma and right benign adenoma). 3) Non functioning tumors (Incidentaloma)--21 pts. (23%/91) (17 malignant and 5 benign). The distribution of the whole group of 91 pts. was: 62 with benign lesions (diffuse hyperplasia or tumors), 26 malignant tumors, 1 both of them and 2 borderline lesions. The diagnosis was the result of clinically, biochemical-hormonal tests and imagery examinations (computed tomography especially) with postoperative pathological confirmation. The surgery applied was:--bilateral adrenalectomy 16 pts.;--right adrenalectomy 20 pts.;--left 26 pts. (two through laparoscopic approach);--tumor exeresis 26 and--3 biopsy of the tumors. The dimensions of the operatory specimens were: < 10 cm--67 pts.; 10-20 cm--16 pts.; > 20 cm--2 pts.; undetermined 6 pts. For malignant lesions the main parameters (in various associations) were: neighborhood invasion--18 pts.; distant metastasis--5; metastatic lymphnodes--13; the microscopic grading (G1-1; G2-9; G3-7 pts.). Three cases imposed iterative interventions for a recurring adenoma of the cortically AG or for restant tissue in Cushing's syndrome. There were necessary 28 supplementary operative (partially or totally) organs exeresis. All pts. with malignant lesions were postoperative treated with chemio- or/and radiotherapy.

RESULTS

Postoperative morbidity: 18 (20%) pts.; depending of the surgery 8 pts., secondary of the patient general status 12. General postoperative mortality 4 (4.8%) pts. determined by severe cardio-vascular complications.

CONCLUSIONS

1--The surgical diseases of adrenal glands are difficult to diagnose and are based primarily on the clinical information's and confirmed by the hormonal and imagery examinations (errors are possible). 2--Operatory indications, especially for hyperplasic bilateral forms in Cushing's syndrome (one step or two steps surgery) must be very well documented and carefully established. 3--There are cases which impose recurrent operations. 4--A correct operative indication and technical surgery procedure are followed by good results. 5--The laparoscopic approach of the surgical lesions of the AG is a good alternative for the open surgical approach with the condition of a very correct indication. 6--Postoperative, the malignant lesions must be mandatory submitted to the adjuvant treatment.

[Pyogenic liver abscess]

The objective of this study was to investigate and report changes in presentation, management and outcome of patients with pyogenic liver abscess (PLA). Between 01.01.1995-31.12.1999, 27 patients with PLA were treated in the General Surgical Service of the Fundeni Clinical Hospital. The incidence of cryptogenic abscesses was dominant (55.5%). The symptoms and the biological status are frequently nonspecific. The CT scan and echographic examination sensibility in the diagnosis of the PLA was 89.5% and 78.3%. The aerobe germs are most involved. All patients received antibiotic treatment in preoperative as in postoperative period. The surgical treatment was performed in 24 patients: in 9 patients (33.3%), the abscess was surgically evacuated and drained and in 15 patients (55.5%), a liver resection was performed. Percutaneous catheter drainage under CT or echo-guidance was performed in three patients (11.1%). The clinical evolution was good in 21 patients (77.7%). There was four complications (14.8%) and two death (7.4%). Although with a better prognostic, the PLA remains an important pathology.

[Insulinomas--nesidioblastomas. Clinical experience]

Between 1980 and 1996, 16 patients (10 women) with pathologically confirmed insulinomas were operated on; they represents a median of 0.9 per year and 1.1 per cent from the total of pancreatic tumors. Median age was 47.2 (+/- 22.8) years old (range 23-68). Insulinomas occurred with following frequency in: head--2 patients, body and tail--11 patients and diffuse forms (nesidioblastomas)--3 patients. The specific clinical forms only with tumoral syndrome (without hypoglycemic manifestations) and one was an intraoperative discovery. In the case of the four patients two presented with splenic-portal hypertension +/- upper digestive haemorrhages and the other two only tumoral syndrome. The surgical approach was: the midline (ten), uni- or bilateral subcostal (five), and other incisions one. There were performed tumor exeresis through: enucleation (three), segmentary pancreatectomies (two), spleno-left-pancreatectomies (nine) and the extension of an anterior pancreatectomy (one). In one case biopsy alone was done. The tumors were not intraoperatively identified in three cases (blind left spleno-pancreatectomies). The malignancy index was 4/16 (25 per cent). Postoperative mortality rate was 12.5 per cent (two patients: one acute necrotizing pancreatitis and one pulmonary embolism).