Air leak and intraoperative bleeding in thoracic surgery: a Delphi consensus among the members of Italian society of thoracic surgery

Background

Persistent air leak and the management of intraoperative blood loss are common threats in thoracic surgical practice. The availability of new procedures, technology and materials is constantly evolving topical hemostats and surgical sealants must be added to this toolkit. Topical hemostats and surgical sealants differ according to their chemical nature and physical characteristics, to their origin and mechanism of action, regulatory/registration and vigilance paths. A Delphi consensus was set to highlight the different points of view on the use of topical haemostatic products and sealants among the members of Italian Society of thoracic surgery.

Methods

The board was formed by a group of five Italian experts; in the first phase after a careful review of the scientific literature and two rounds, the board finally generated 16 consensus statements for testing across a wider audience. During the second phase, the statements were collated into a questionnaire, which was electronically sent to a panel of 46 Italian surgeons, experts in the field.

Results

Out of 46 Italian surgeons, 33 (72%) panel members responded to the Delphi questionnaire. All the items reached a positive consensus, with elevated levels of agreement, as demonstrated by the presence of a 100% consensus for nine items. For the remaining 7 statements the minimum level of consent was 88% (29 participants approved the statement and 4 disagreed) and the maximum was 97% (32 participants approved the statement and 1 was in disagreement).

Conclusions

The present Delphi analysis shows that air leak and intraoperative bleeding are clinical problems well known among thoracic surgeons. Nevertheless, the aim of the scientific societies and of the group of experts is to execute the education activities in the surgery community. This Delphi survey suggest the need of wider and updated scientific information about technical and registration characteristics of most recent technologic solutions, such as the of topical hemostats and surgical sealants to provide healthcare and administrative staff with the opportunity to work and interact through a common and shared language and eventually to guarantee minimal requirements of assistance.

Coexpression of ΔNp63/p40 and TTF1 Within Most of the Same Individual Cells Identifies Life-Threatening NSCLC Featuring Squamous and Glandular Biphenotypic Differentiation: Clinicopathologic Correlations

Introduction

Double occurrence of TTF1 and ΔNp63/p40 (henceforth, p40) within the same individual cells is exceedingly rare in lung cancer. Little is known on their biological and clinical implications.

Methods

Two index cases immunoreactive for both p40 and TTF1 and nine tumors selected from The Cancer Genome Atlas (TCGA) according to the mRNA levels of the two relevant genes entered the study.

Results

The two index cases were peripherally located, poorly differentiated, and behaviorally unfavorable carcinomas, which shared widespread p40 and TTF1 decoration within the same individual tumor cells. They also retained SMARCA2 and SMARCA4 expression, while variably stained for p53, cytokeratin 5, and programmed death-ligand 1. A subset of basal cells p40+/TTF1+ could be found in normal distal airways. Biphenotypic glandular and squamous differentiation was unveiled by electron microscopy, along with EGFR, RAD51B, CCND3, or NF1 mutations and IGF1R, MYC, CCND1, or CDK2 copy number variations on next-generation sequencing analysis. The nine tumors from TCGA (0.88% of 1018 tumors) shared the same poor prognosis, clinical presentation, and challenging histology and had activated pathways of enhanced angiogenesis and epithelial-mesenchymal transition. Mutation and copy number variation profiles did not differ from the other TCGA tumors.

Conclusions

Double p40+/TTF1+ lung carcinomas are aggressive and likely underrecognized non-small cell carcinomas, whose origin could reside in double-positive distal airway stem-like basal cells through either de novo-basal-like or differentiating cell mechanisms according to a model of epithelial renewal.

Immunotherapeutic Advances for NSCLC

Immunotherapy with antibodies against PD-1 or PD-L1, either alone or in combination with chemotherapy, has revolutionized treatment paradigms of non-small cell lung cancer (NSCLC) patients without oncogenic driver alterations. These agents, namely immune checkpoint inhibitors (ICIs), have also widely demonstrated a remarkable efficacy in locally advanced as well as in early-stage NSCLC. Assessment of tumor PD-L1 expression by immunohistochemistry has entered into routine clinical practice to select patients for immunotherapy, even though its predictive role has long been debated. Despite improved survival outcomes over standard chemotherapy, treatment with ICIs is associated with initial low response rate, with a significant proportion of patients not responding to these agents. Hence, novel appealing predictive biomarkers, such as those related to tumor cell signaling pathways, metabolism or the tumor microenvironment, have emerged as potentially useful to select those patients most likely to benefit from immunotherapy. Moreover, most patients ultimately develop acquired resistance to ICI treatment over time and novel therapeutic strategies are urgently needed to overcome or delay resistance. Herein, we provide an overview on recent advances in immunotherapy in NSCLC, focusing on updated results from studies on ICIs in different disease settings and at different lines of treatment. We further describe currently emerging predictive biomarkers, beyond PD-L1, to optimize patient selection and novel strategies to improve clinical outcomes.

Stage-specific expression of a Schistosoma mansoni polypeptide similar to the vertebrate regulatory protein stathmin

The ubiquitous vertebrate protein stathmin is expressed and phosphorylated in response to a variety of external and internal signals. Stathmin, in turn, controls cell growth and differentiation through its capacity to regulate microtubule assembly dynamics. This is the first report on the molecular cloning and characterization of a stathmin-like protein (SmSLP) in an invertebrate, the human blood fluke Schistosoma mansoni. SmSLP is first synthesized at high levels in the intermediate molluscan host and completely disappears 48 h after penetration into the mammalian host. The protein is preferentially iodinated in intact immature parasites using the Bolton-Hunter reagent, can be quantitatively extracted in high salt buffers, and remains soluble after boiling. Native SmSLP was partially sequenced, and its complete structure was derived from the cloning and sequencing of its cDNA. The sequence is up to 26% identical to vertebrate stathmin sequences and contains two potential phosphorylation sites. Native SmSLP is indeed phosphorylated because phosphatase digestion shifts its mobility in electrofocusing gels. SmSLP associates with tubulin, as suggested by immune co-precipitation results. In vitro experiments demonstrated that SmSLP inhibits tubulin assembly and causes the depolymerization of preassembled microtubules, thus probably fulfilling regulatory roles in critical steps of schistosome development.

[Bronchial carcinoid tumors. Retrospective analysis of 32 cases]

Thirty-two cases of bronchial carcinoids (rate m/f = 1, average age 50.33 years) had been treated from 1970 to 1993. 62.5% of patients were symptomatic, 6% with specific symptoms. 62.5% of tumors had a central growth. Thirty-one patients underwent surgical treatment, another one a laser Nd:YAG coagulation. The operative mortality and morbidity were respectively 3% and 0%. 84.4% of tumours were typical carcinoid, 11% of those had lymphonodal metastases. Atypical carcinoids were found in 15.6% of patients, 40% had lymphnodal metastases. The global actuarial survival to 1, 5, 10 years were respectively 96, 88 and 84%. Statistically the survival difference between the typical and atypical carcinoid is relevant. The authors underline the preoperative cytologic diagnosis to perform a minimal lung resection in typical bronchial carcinoids.

Antiproliferative effect of lonidamine on a human glioblastoma multiforme cell line

Recent data from phase II trials have shown that lonidamine (LND) is effective in the treatment of tumors of various histogenesis, including gliomas. In the present work, we tested the antiproliferative effect of LND on a human glioblastoma cell line (LI) in different culture conditions. When LI are cultured in their standard conditions, a reduction of cell growth is seen after 3 days of treatment with 10(-4) M LND. It reaches 70% with respect to control after 6 days and is statistically significant. LND is ineffective at the other concentrations tested. In more stringent culture conditions, 10(-4) M LND determines a higher inhibition of cell proliferation both after 3 and 6 days of exposure, while other doses of LND are unable to affect cell growth.

[Behavior of plasma and urinary cAMP after intravenous fructose load]

Increased excretion of uric acid and cAMP has been observed in many pathological conditions in man, but interrelation between behaviour of uric acid and cAMP is not well known. To investigate these aspects of purine metabolism the authors have studied behaviour of plasma and urinary cAMP in 8 subjects after intravenous rapid load of fructose (0.5 g/Kg b.w.) compared with the uric acid one. The results have shown that urinary excretion of cAMP after load of fructose is increased, but levels of plasma cAMP remain unchanged. These data confirm consensual relation between urinary uric acid and cAMP excretion, but the exact mechanism of this relation remains unexplained.

[Unilateral rheumatoid arthritis]

The authors describe a case of left monolateral rheumatoid arthritis of a patient who nine years previously presented ischemic cerebral lesion resulting in right emiparesis. It should be noted that rheumatoid arthritis appears clinically and radiologically monolateral, whereas from a histological viewpoint the lesions are always bilateral. This brings to mind previously advanced hypothesis to explain this rare expression of rheumatoid arthritis. In conclusion the main factor for articular protection is the rest period induced by the stroke.

[Pulmonary aspergillosis. Presentation of an anatomo-clinical case of lobitis]

A case of pulmonary aspergillosis in an elderly, wasted patient is described from the clinical and anatomopathological points of view. The different ways in which pulmonary aspergillosis presents in humans are reviewed and the different factors favouring onset of the disease, which has become commoner in recent years, are considered. Finally, stress is laid on the anatomoclinical aspects of the case which, unlike those typical of aspergillosic pneumonia, also presented cavital zones.