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Pulmonary metastasectomy (PM) is a well-established treatment that is able to contribute to the cure of oligometastatic cancer. Surgery should adopt the most lung-sparing approach possible to preserve pulmonary function (and, consequently, the quality of life) and to spare the lung for potential additional lung resections. In this framework, laser technology has been introduced in recent decades, but only few experiences combining laser technology with VATS approaches have been reported till now. The main focus of this manuscript is to report our institutional experience in performing lung-sparing laser-assisted PM by uniportal VATS (uniportal laser-assisted VATS: U-LA-VATS). The surgical technique and peri-operative results from our series of patients were herein presented and compared with the pertinent literature. Methods: Between March 2021 and November 2023, among 98 patients who underwent PM, a total of 24 patients (18 men (75%); 6 women (25%); mean age 61.4 years; age range 13–83 years) were treated with laser-assisted PM at our institution. Patients who underwent anatomical resection were excluded for the purpose of the analysis. The U-LA-VATS procedure adopted a modified laser-assisted lung resection technique for performing PM via VATS. Dedicated instruments are used, characterized by a long shape and a curved shape, with distal and proximal articulations. A surgical laser system (Thulium + Diodo OUTPUT 30–10 W, Quanta System S.p.a., Solbiate Olona, Italy) was used, and a 550-μm sterile optical fibre conducted through a specific thoracoscopic handpiece was introduced in the lowest part of the incision. Peri-operative results were analysed in all cohort and compared according to the surgical technique. Moreover, these results were compared with those reported in the literature. Comprehensive research of the literature was conducted on PubMed from 2000 to 2024. A review was performed and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results: In 12 cases (50%), thulium laser-assisted resection was performed using uniportal video-assisted thoracic surgery (VATS), and in the other cases (12, 50%), a (mini)thoracotomy access was adopted. In the thoracotomy group, the mean duration of surgery was 95 ± 57.7 min; meanwhile, it was 73.5 ± 35.5 in the uniportal VATS group. At the univariate analysis, this difference resulted to be statistically significant (p value 0.025). We did not observe intra-operative complications or remarkable malfunction of the laser system. We also did not report major complications after surgery; also the air-leak rate was 8.3% and 0% after thoracotomic and VATS procedures, respectively. Surgical margins were free from disease in all cases. Major and minor post-op complication rates were similar in both groups. The mean hospitalization after surgery was 2.9 ± 0.3 days for the uniportal VATS group and 3.7 ± 0.9 days for the thoracotomy group, this difference being statistically significant at the univariate analysis (p value = 0.015). Conclusions: U-LA-VATS is a safe and effective procedure, able to combine a parenchymal sparing exeresis with a mini-invasive approach. This procedure is associated with a shorter hospital stay compared with PM performed by a thoracotomic approach. Compared with the selected works for the review, our series is the only one describing the use of laser resection combined with a uniportal VATS approach. [ABSTRACT FROM AUTHOR]

Simple Summary: Completion lobectomy (CL) entails the resection of the remaining pulmonary lobe subsequent to wedge resection or segmentectomy. Indications for CL include reoperations for multiple or relapsed lung cancers and metastatic lung tumors, and the prognostic advantage of these procedures has been widely reported. However, ipsilateral surgical treatments, particularly within the same lobe, present challenges due to the development of intrapleural adhesions, rendering reoperation more difficult and time-consuming. VATS has emerged as the gold standard in the surgical treatment of early-stage NSCLC, offering superior postoperative outcomes when compared to thoracotomy. Its efficacy has been well established, even during complex procedures. However, its application in ipsilateral reoperations remains anecdotal, and to the best of our knowledge, no studies have analyzed the safety and efficacy of uniportal-VATS in this setting. This paper aims to evaluate the role of iniportal-VATS in CL long after wedge resection or anatomical segmentectomy in the same lobe. Background: Completion lobectomy (CL) following a prior resection in the same lobe may be complicated by severe pleural or hilar adhesions. The role of uniportal video-assisted thoracoscopic surgery (U-VATS) has never been evaluated in this setting. Methods: Data were collected from two Italian centers. Between 2015 and 2022, 122 patients (60 men and 62 women, median age 67.7 ± 8.913) underwent U-VATS CL at least 4 weeks after previous lung surgery. Results: Twenty-eight (22.9%) patients were affected by chronic obstructive pulmonary disease (COPD) and twenty-five (20.4%) were active smokers. Among the cohort, the initial surgery was performed using U-VATS in 103 (84.4%) patients, triportal-VATS in 8 (6.6%), and thoracotomy in 11 (9.0%). Anatomical segmentectomy was the initial surgery in 46 (37.7%) patients, while hilar lymphadenectomy was performed in 16 (13.1%) cases. CL was performed on 110 (90.2%) patients, segmentectomy on 10 (8.2%), and completion pneumonectomy on 2 (1.6%). Upon reoperation, moderate pleural adhesions were observed in 38 (31.1%) patients, with 2 (1.6%) exhibiting strong adhesions. Moderate hilar adhesions were found in 18 (14.8%) patients and strong adhesions in 11 (9.0%). The median operative time was 203.93 ± 74.4 min. In four (3.3%) patients, PA taping was performed. One patient experienced intraoperative bleeding that did not require conversion to thoracotomy. Conversion to thoracotomy was necessary in three (2.5%) patients. The median postoperative drainage stay and postoperative hospital stay were 5.67 ± 4.44 and 5.52 ± 2.66 days, respectively. Postoperative complications occurred in 34 (27.9%) patients. Thirty-day mortality was null. Histology was the only factor found to negatively influence intraoperative outcomes (p = 0.000). Factors identified as negatively impacting postoperative outcomes at univariate analyses were male sex (p = 0.003), age > 60 years (p = 0.003), COPD (p = 0.014), previous thoracotomy (p = 0.000), previous S2 segmentectomy (p = 0.001), previous S8 segmentectomy (p = 0.008), and interval between operations > 5 weeks (p= 0.005). In multivariate analysis, only COPD confirmed its role as an independent risk factor for postoperative complications (HR: 5.12, 95% CI (1.07–24.50), p = 0.04). Conclusions: U-VATS CL seems feasible and safe after wedge resection and anatomical segmentectomy. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study is to evaluate if the efficacy and safety of chest tube placement are influenced by the level of intercostal space insertion (uniportal VATS vs. biportal VATS) or by the type of drain employed (standard vs. smart coaxial drain). Methods: Data on patients who underwent either uniportal or biportal VATS upper lobectomies with lymphadenectomy were prospectively collected in three European centers. The uniportal VATS group with a 28 Fr standard chest tube (U-VATS standard) was compared with the uniportal VATS group with a 28 Fr smart drain (U-VATS smart), and U-VATS smart was also compared with biportal VATS with a 28 Fr smart drain inserted in the VIII intercostal space (Bi-VATS smart). Results: When comparing the U-VATS standard group with the U-VATS smart, a higher fluid output was recorded in the U-VATS smart (p: 0.004) in the III post-operative day (p.o.) and overall (p: 0.027), with a lower 90-day re-admission in the U-VATS smart (p: 0.04). The Bi-VATS smart group compared to U-VATS smart showed a higher fluid output in the I p.o. (p < 0.001), with no difference in total fluid amount or hospitalization. The Bi-VATS smart recorded a lower incidence (p < 0.001) of residual pleural space or effusion (p: 0.004) at chest X-rays prior to drain removal but a higher level of pain and chronic intercostal neuralgia (p: 0.03). Conclusions: Chest tube insertion through the same incision space in uniportal VATS seems to be safe and effective. Smart drains can improve the fluid output in uniportal VATS, as if the drainage were inserted in a lower space (i.e., biportal VATS), but with less discomfort. [ABSTRACT FROM AUTHOR]

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

Background: Descending necrotizing mediastinitis (DNM) is a severe, life-threatening complication of oropharyngeal infections with cervical necrotizing fasciitis. In this study, we aimed to identify any possible factors that correlate with favorable outcomes. Methods: We retrospectively analyzed our series of 18 patients who underwent surgical treatment for DNM from a cervical abscess. Gender, age, symptoms, etiopathogenesis, comorbidities, time to surgery from diagnosis, degree of diffusion, identified microorganisms, surgical procedure, days in the intensive care unit, need for tracheostomy, complications, and surgical outcomes were reviewed. Results: The main type of surgery was thoracotomy + cervicotomy in eight cases (50.0%), followed by cervicotomy +VATS in four (22.2%). Seven patients (38.9%) had two or more surgeries; a bilateral operation was necessary for four patients. Evaluating the risk factors associated with post-operative complications, age ≥ 60 years (p:0.031), cervicotomy alone as surgical approach (p = 0.040), and the bilateral approach (p = 0.048) resulted in significance in terms of the univariate analysis; age ≥ 60 years (p = 0.04) and cervical approach (p = 0.05) maintained their significance in terms of the multivariate analysis. Conclusions: The low mortality of our series emphasizes the importance of an extensive and immediate surgical drainage of both the neck and the mediastinum. Mediastinal drainage from cervicotomy seems to be a risk factor for post-operative complications. Minimally invasive surgery on the chest cavity, such as with Uniportal-VATS, could be a good approach above all in elderly patients and all those cases where bilateral access is required. [ABSTRACT FROM AUTHOR]

OBJECTIVES Open in new tab Download slide Open in new tab Download slide Overlapping survival curves for N1b (multiple N1 stations), N2a2 (single N2 station + N1 involvement) and N2a1 (skip N2 metastasis) limit the current tumour–node–metastasis (TNM) node (N) subclassification for node involvement. We validated externally the proposed subclassification. METHODS Clinical records from a multicentric database comprising 1036 patients with pulmonary adenocarcinoma (ADC) or squamous cell carcinoma with N1/N2 involvement who underwent, from January 2002 to December 2014, complete lung resections were retrospectively reviewed. Patients were categorized according to the 8th TNM N subclassification proposal. Histological type, number of resected nodes (#RN) and adjuvant therapy (ADJ) were considered limiting factors. RESULTS No difference in the 5-year overall survival (-OS) was noted between N1b and N2a1 (49.6% vs 44.8%, P  = 0.72); instead, the 5-year-OS was significantly improved in patients with squamous cell carcinoma (63% in N1b vs 30.7% in N2a1, P  = 0.04). In patients with ADC, the 5-year-OS was better in those with N2a1 than with N1b (50.6% vs 37.5%, P  = 0.09). When we compared N1b with N2a2, the 5-year-OS was statistically significant (49.6% vs 32.8%, P  = 0.02); considering only patients with squamous cell carcinoma (63% vs 25.8%, P  = 0.003), #RN >10 (63.2% vs 35.3%, P  = 0.05) and without ADJ (56.4% vs 24.5%, P  = 0.02), the 5-year-OS was significantly different. Differences were not significant for ADC, #RN <10 and ADJ. Finally, the 5-year-OS was statistically significant when we compared N2a1 with N2a2 of the total cohort (44.8% vs 32.8%, P  = 0.04), in ADC (5-year-OS 50.6% vs 36.5%, P  = 0.04) and #RN >10 (5-year-OS 49.8% vs 32.1%, P  = 0.03) without ADJ. CONCLUSIONS Histological type, ADJ and #RN are relevant prognostic factors in N + non-small-cell lung cancer. Considering these results, we may better interpret the prognosis prediction limits of the proposed 8th TNM subclassification for the N descriptor. [ABSTRACT FROM AUTHOR]

Purpose. Several meta-analyses have reported data about the diagnostic performance of positron emission tomography or positron emission tomography/computed tomography (PET or PET/CT) with different radiotracers in patients with suspicious lung cancer (LC) or pleural tumours (PT). This review article aims at providing an overview on the recent evidence-based data in this setting. Methods. A comprehensive literature search of meta-analyses published in PubMed/MEDLINE and Cochrane Library database from January 2010 through March 2020 about the diagnostic performance of PET or PET/CT with different radiotracers in patients with suspicious LC or PT was performed. This combination of keywords was used: (A) "PET" OR "positron emission tomography" AND (B) "lung" OR "pulmonary" OR "pleur∗" AND (C) meta-analysis. Only meta-analyses on PET or PET/CT in patients with suspicious LC or PT were selected. Results. We have summarized the diagnostic performance of PET or PET/CT with fluorine-18 fluorodeoxyglucose (18F-FDG) and other radiotracers taking into account 17 meta-analyses. Evidence-based data demonstrated a good diagnostic performance of 18F-FDG PET or PET/CT for the characterization of solitary pulmonary nodules (SPNs) or pleural lesions with overall higher sensitivity than specificity. Evidence-based data do not support the routine use of dual time point (DTP) 18F-FDG PET/CT or fluorine-18 fluorothymidine (18F-FLT) PET/CT in the differential diagnosis of SPNs. Even if 18F-FDG PET/CT has high sensitivity and specificity as a selective screening modality for LC, its role in this setting remains unknown. Conclusions. Evidence-based data about the diagnostic performance of PET/CT with different radiotracers for suspicious LC or PT are increasing, with good diagnostic performance of 18F-FDG PET/CT. More prospective multicenter studies and cost-effectiveness analyses are warranted. [ABSTRACT FROM AUTHOR]

Background Pulmonary sarcomatoid carcinoma (PSC) is a very rare subtype of non-small cell lung cancer (NSCLC). The aim of this study was to clarify the pathologic characteristics and long-term survival after surgical treatment in patients with PSC. Methods From January 2003 to December 2013, we retrospectively reviewed the clinical findings, surgical notes, and pathologic and follow-up data from 148 consecutive patients who underwent curative resection for PSC in 5 institutions. The Kaplan-Meier method, log-rank test, and Cox regression analysis were used. Results Mean age and male to female ratio were 66.6 ± 9.9 years and 120:28, respectively. Surgical resection (pneumonectomy in 8 patients, bilobectomy in 132 patients, and sublobar resection in 8 patients) was complete in 142 cases (96%). At pathologic evaluation, 36 patients (24%) had stage I, 69 patients (47%) had stage II, 33 patients (22%) had stage III, and 10 patients (7%) had stage IV disease. A “biphasic tumor” (PSC with an NSCLC component) was observed in 77 patients (52%). We detected a high rate of vascular emboli in the surgical specimens (overall, 68%; 57% in pathologic stage I tumors), whereas lymphatic emboli were found in 30% of cases (5% of pathologic stage I tumors). Overall median and 5-year long-term survival (LTS) was 19 months and 12.6% (LTS, 16.3% in pathologic stage I), respectively. Distant recurrences frequently occurred after surgical treatment (81%), even in pathologic stage I tumors that underwent R0 resection (62%). Multivariable survival analysis identified R+ resection (hazard ratio [HR],12.3; 95% confidence interval [CI], 3.67–41.28; p < 0.0001), advanced pathologic stage (HR, 5.75; 95% CI, 2.55–12.98; p < 0.0001), and the presence of vascular emboli (HR, 1.67; 95% CI, 1.05–2.67; p = 0.0327) as independent negative prognostic factors. Conclusions PSCs have very aggressive behavior and high metastatic potential even in early stages. R+ resection, pathologic TNM status, and the presence of vascular emboli are independent prognostic factors. [ABSTRACT FROM AUTHOR]

Background To address the question of how much chest-wall ( CW) resections and prosthetic reconstructions influence functional outcome. Methods We retrospectively reviewed 175 patients who underwent surgery for CW tumors. The clinical, histological, surgical, oncological, and functional factors were analyzed. Results We performed: 75 rib resections; 20 sternal resections; 15 combined resections; and 27 lung resections. In 39 cases (22.2%) CW was stabilized with non-rigid prosthesis (Vicryl-mesh: 8 patients; Goretex-mesh: 31 patients). Postoperative complications occurred in 22 cases (12.6%): a correlation with lung resection was evidenced by multivariate analysis ( P = 0.025). Five-year survival for primary and secondary tumors was 50% and 36%, respectively: multivariate analysis ( P = 0.048) showed a worse survival in men only. In the prosthesis subset, pulmonary function tested as percentage of forced expiratory volume in one second (%FEV1) (pre: 87.1 ± 18.9%; post: 82.3 ± 23.0%, P = ns), percentage of forced vital capacity (pre: 94.1 ± 19.3%; post: 82.0 ± 21.6%, P = ns), diffusing capacity of the lungs for carbon monoxide (pre: 15.7 ± 7.4; post: 12.1 ± 4.1, P = ns) and paO2 (pre: 82.6 ± 10.9 mmHg; post: 83.9 ± 7.3 mmHg, P = ns) was slightly modified from pre to postoperative. Interestingly, the decline of FEV1% was lower in the prosthesis-subset (4.1 ± 15.9%) compared with the subgroup who did not undergo prosthetic stabilization (17.5 ± 16.2%), but this difference was not statistically significant ( P = ns). Conclusion Because of the low decrease of lung parameters, CW prosthetic reconstruction could be helpful for avoiding postoperative worsening of functional outcome, mostly in patients with pre-existing pulmonary diseases. [ABSTRACT FROM AUTHOR]

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

The article present a case study of a 79-year-old White male with a 2-month history of central abdominal pain. It mentions an ultrasound revealed an 11 × 7 cm lesion in the segments 5 and 6 of the liver; and also mentions histopathologic examination of the lesion showed identical morphology and immunohistochemical characteristics to the previously resected gastric tumour with the diagnosis of recurrent gastrointestinal stromal tumour (GIST).

Simple Summary: Lung adenocarcinoma is the most common histology in non-small cell lung cancer that has a large variety of histological and also pathological presentations. However, mediastinal lymph node involvement remains one of the most important prognosticators in these patients, and treatment can vary from upfront surgery to induction therapy or definitive radio-chemotherapy. One of the most intriguing issues regards the identification of the most appropriate treatment for a patient and one of the parameters that may indicate upfront surgical resection is the presence of single mediastinal station involvement. Moreover, another interesting argument regards the adjuvant therapy indication for these patients. For these reasons, we investigated the survival outcome of patients who underwent surgical resection for lung adenocarcinoma and single mediastinal station involvement, with the aim to investigate the prognostic factors in this class of patients. Background: Prognostic factors in patients with single mediastinal station (sN2) involvement continues to be a debated issue. Methods: Data on 213 adenocarcinoma patients with sN2 involvement and who had undergone complete anatomical lung resection and lymphadenectomy, were retrospectively reviewed. Clinical and pathological characteristics together with adjuvant therapy (AD) and node (N) status classifications (number of resected nodes (#RN), number of metastatic nodes (#MN), and node ratio (#MN/#RN = NR) were analyzed. Results: Univariable analysis confirmed that age (0.009), #MN (0.009), NR (0.003), #N1 involved stations (p = 0.003), and skip metastases (p = 0.005) were related to overall survival (OS). Multivariable analysis confirmed, as independent prognostic factors, age <66 years and NR with a three-year OS (3YOS) of 78.7% in NR < 10% vs. 46.6% in NR > 10%. In skip metastases, NR (HR 2.734, 95% CI 1.417–5.277, p = 0.003) and pT stage (HR2.136, 95% CI 1.001–4.557, p = 0.050) were confirmed as independent prognostic factors. AD did not influence the OS of patients with singular positive lymph nodes (p = 0.41), while in patients with multiple lymph nodes and AD, a significantly better 3YOS was demonstrated, i.e., 49.1% vs. 30% (p = 0.004). In patients with N2 + N1 involvement, age (p = 0.002) and AD (p = 0.022) were favorable prognostic factors. Conclusions: Adenocarcinoma patients with single N2 station involvement had a favorable outcome in the case of skip metastases and low NR. Adjuvant therapy improves survival with multiple nodal involvement, while its role in single node involvement should be clarified. [ABSTRACT FROM AUTHOR]

Simple Summary: Higher response may be achieved with induction therapy (IT) and better survival results could be expected after complete surgical resection for non-small-cell lung cancer (NSCLC) patients. Thus, locally advanced (LA)-NSCLC patients with pathological complete response (pCR) are optimal candidates to undergo surgery after IT, achieving good to very good long-term survival. Herein, we performed a retrospective analysis on a large cohort of locally advanced NSCLC patients who achieved pCR after IT and surgery, exploring long-term survival and factors affecting prognosis. We observed a rewarding 5-year overall survival (56%) with baseline N2 single-station disease and adjuvant therapy after surgery associated with better prognosis. These findings may be useful to better define the strategy of care in this highly selected subset of NSCLC patients. Background: Outcomes for locally advanced NSCLC with pathological complete response (pCR), i.e., pT0N0 after induction chemoradiotherapy (IT), have been seldom investigated. Herein, long-term results, in this highly selected group of patients, have been evaluated with the aim to identify prognostic predictive factors. Methods: Patients affected by locally advanced NSCLC (cT1-T4/N0-2/M0) who underwent IT, possibly following surgery, from January 1992 to December 2019, were considered for this retrospective analysis. Survival rates and prognostic factors have been studied with Kaplan-Meier analysis, log-rank and Cox regression analysis. Results: Three-hundred and forty-three consecutive patients underwent IT in the considered period. Out of them, 279 were addressed to surgery; among them, pCR has been observed in 62 patients (18% of the total and 22% of the operated patients). In the pCR-group, clinical staging was IIb in 3 (5%) patients, IIIa in 28 (45%) patients and IIIb in 31 (50%). Surgery consisted of (bi)lobectomy in the majority of cases (80.7%), followed by pneumonectomy (19.3%). Adjuvant therapy was administered in 33 (53.2%) patients. Five-year overall survival and disease-free survival have been respectively 56.18% and 48.84%. The relative risk of death, observed with the Cox regression analysis, was 4.4 times higher (95% confidence interval (CI): 1.632–11.695, p = 0.03) for patients with N2 multi-station disease, 2.6 times higher (95% CI: 1.066–6.407, p = 0.036) for patients treated with pneumonectomy and 3 times higher (95% CI: 1.302–6.809, p = 0.01) for patients who did not receive adjuvant therapy. Conclusions: Rewarding long-term results could be expected in locally advanced NSCLC patients with pCR after IT followed by surgery. Baseline N2 single-station disease and adjuvant therapy after surgery seem to be associated with better prognosis, while pneumonectomy is associated with poorer outcomes. [ABSTRACT FROM AUTHOR]

• Patients underwent surgery presented a remarkable long term survival. • MG seems to be a favourable prognostic factor in these patients. • Iterative surgery shows a better survival outcome compared to chemo/radiotherapy. • Surgery for iterative recurrences may be considered if technically feasible. Thymomas are rare neoplasms with a low recurrence rate, which are preferably surgically treated. Iterative thymoma surgery has not been well investigated yet. Study aim is to analyse prognostic factors after iterative recurrence treatment. Clinical, pathological and surgical findings of 155 patients, treated for thymoma recurrence in three high-volume centres from 01/01/1990 to 1/07/2017, were retrospectively reviewed. Recurrence patterns/treatment types (surgery or chemotherapy, radiotherapy or combined) were correlated to overall (OS) and disease free survival (DFS). Myasthenia Gravis was present in 135 (87%) patients. Surgery was performed in 135/155 (87%) patients with 109 (80.7%) complete resections. Sixty (55%)patients experienced a second recurrence surgically treated in 31/60 (52%) cases with 18 (58%) complete resections. Eleven (61%) patients experienced a third recurrence and nine underwent complete resection. Myastenia Gravis (HR: 0.45; 95% CI: 0.20-0.98, p = 0.046), DFS after the initial thymectomy >36 months (HR: 0.9; 95% CI: 0.96-0.99, p = 0.006) and complete second recurrence resection (HR: 1.45; 95% CI 2.07–10.01, p = 0.010) resulted as independent favorable prognostic survival factor. Despite patient selection bias, rewarding long-term survivals was predictable after iterative thymoma surgery (5 and 10 years survival of 79.6% and 64.6%) while a poor prognosis was observed after CT/RT (5 and 10 years OS of 56.7% and 21.5%), Masaoka stage and DFS > 36 months were risk factor for iterative recurrences. Myasthenia Gravis and long DFS after thymectomy are favorable survival factors for multiple thymoma recurrences. Iterative surgical treatment is a viable therapeutic option associated to long-term survival if technically and clinically feasible. [ABSTRACT FROM AUTHOR]

Background: Till now there are very few reports about surgical results of Uniportal-VATS esophagectomy and no one about long-term outcomes. This study is the first comparing surgical and oncological outcomes of Uniportal-VATS with open McKeown esophagectomy, with the largest reported series and longest oncological follow-up., Methods: The prospectively collected clinical, surgical and oncological data of 75 patients, undergone McKeown esophagectomy at our Thoracic Surgery Department, from January 2012 to August 2022, were retrospectively analyzed. Nineteen patients underwent esophagectomy by thoracotomy and reconstruction according to McKeown technique while 56 by Uniportal-VATS approach. Gastric tubulization was performed totally laparoscopic or through a mini-laparatomic access and cervical anastomosis was made according to Orringer's technique., Results: The mean operative thoracic time was similar in both accesses (102.34 ± 15.21 min in Uniportal-VATS vs. 115.56 ± 23.12 min in open, p : 0.646), with a comparable number of mediastinal nodes retrieved (Uniportal-VATS:13.40 ± 8.12 vs. open:15.00 ± 6.86, p : 0.275). No case needed conversion from VATS to open. The learning curve in Uniportal-VATS was completed after 34 cases, while the Mastery was reached after 40. Both approaches were comparable in terms of minor post-operative complications (like pneumonia, lung atelectasis, anemization, atrial fibrillation, anastomotic-leak, left vocal cord palsy, chylothorax), while the number of re-operation for major complications (bleeding or mediastinitis) was higher in open group (21.0% vs. 3.6%, p : 0.04). Both techniques were also effective in terms of surgical radicality and local recurrence but VATS approach allowed a significantly lower chest tube length (11.89 ± 9.55 vs. 25.82 ± 24.37 days, p : 0.003) and post-operative stay (15.63 ± 11.69 vs. 25.53 ± 23.33, p : 0.018). The 30-day mortality for complications related to surgery was higher in open group ( p : 0.002). The 2-, 5- and 8-year survival of the whole series was 72%, 50% and 33%, respectively. Combined 2- and 5-year OS in Uniportal-VATS group was 76% and 47% vs. 62% and 62% in open group, respectively (Log-rank, p : 0.286; Breslow-Wilcoxon: p : 0.036). No difference in DFS was recorded between the two approaches (5 year-DFS in Uniportal-VATS: 86% vs. 72%, p : 0.298). At multivariate analysis, only pathological stage independently affected OS ( p : 0.02), not the surgical approach ( p : 0.276)., Conclusions: Uniportal-VATS seems to be a safe, feasible and effective technique for performing McKeown esophagectomy, with equivalent surgical and long-term oncological results to standard thoracotomy, but with a faster and unharmed recovery, and a quite short learning curve., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Nachira, Congedo, Calabrese, Tabacco, Petracca Ciavarella, Meacci, Vita, Punzo, Lococo, Raveglia, Chiappetta, Porziella, Guttadauro, Cioffi and Margaritora.)

Background: Robot-assisted thymectomy (RAT) has rapidly emerged as the preferred approach over open trans-sternal or video-assisted thoracoscopy for the surgical treatment of thymomas and non-thymomatous myasthenia gravis (MG). The aim of this study was to describe and discuss the learning curve (LC) of a single surgeon performing 113 consecutive RATs., Methods: A single-center retrospective analysis of prospectively collected clinical data was performed on all patients who had been operated on by the same surgeon in an RAT setting between October 2013 and February 2020. The cumulative sum (CUSUM) analysis of the operative time was used to define the completion of the learning curve (CLC) in RAT. The CLC was separately calculated for myasthenic patients, non-myasthenic patients, and docking time., Results: In myasthenic patients, the CLC cut-off was found in 19 patients. Considering the CLC cut-off of 19 patients, the mean operative time in phase 1 (first 19 cases) was 229.79 ± 93.40 min, while it was 167.35 ± 41.63 min in phase 2 (last 51 cases), p ≪ 0.001 . In non-myasthenic patients, the CLC cut-off was found in 16 cases. The mean operative time in phase 1 (first 16 cases) was 277.44 ± 90.50 min, while it was 169.63 ± 61.10 min in phase 2 (last 27 cases), p  = 0.016. The LC for docking time was reached at 46 cases, recording a significant reduction of time after the first phase (28.09 ± 5.37 min vs. 19.75 ± 5.51 min, p ≪ 0.001 ). The intraoperative and 30-day mortality were null in all phases of the LC in both myasthenic and non-myasthenic patients. There were no differences between the two phases of the LC in terms of blood loss, duration of postoperative drainage, and postoperative stay in both myasthenic and non-myasthenic groups. However, significantly higher hospital readmission at 30 days post surgery was recorded for myasthenic patients operated on during the first phase of the LC (2 cases vs. 0, p  = 0.02)., Conclusions: According to our data, LC in RAT seems to be steep, and RAT confirms to be safe even before reaching CLC., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Meacci, Nachira, Congedo, Petracca-Ciavarella, Vita, Porziella, Chiappetta, Lococo, Tabacco, Triumbari and Margaritora.)

Colorectal cancer (CRC) is one of the most common causes of death from cancer. Lung seeding occurs in approximately 10% of patients surgically treated for primary CRC with radical intent: the lung is the most common site of metastases after the liver. While surgical treatment of liver metastases is widely accepted to affect long-term outcomes, more controversial and not standardized is the therapy for CRC patients developing lung metastases. Experience suggests the potential curative role of pulmonary metastasectomy, especially in oligometastatic disease. However, the optimal strategy of care and the definition of prognostic factors after treatment still need to be defined. This review focused on the uncommon scenario of single pulmonary metastases from CRC. We explored pertinent literature and provide an overview of the epidemiology, clinical characteristics and imaging of single pulmonary metastases from CRC. Additionally, we identified the best available evidence for overall management. In particular, we analyzed the role and results of locoregional approaches (surgery, radiotherapy or ablative procedures) and their integration with systemic therapy., Competing Interests: Conflict-of-interest statement: No conflict-of-interest to declare., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Although the feasibility and safety of Uniportal-Video-Assisted thoracic surgery (U-VATS) has been proven, its surgical effectiveness is still debated. The aim of this study is to assess the equivalence of the U-VATS approach compared with an open technique in terms of surgical (nodal-upstaging, complications, and post-operative results) and short-term survival outcomes., Methods: The clinical data of patients undergoing lobectomy for NSCLC at our center, from January 2014 to December 2019, were analyzed retrospectively. All patients undergoing open or U-VATS lobectomy with lymphadenectomy for early-stage lung cancer (cT1-T3N0, stages IA-IIB) were included in the study. Only 230 patients satisfied the inclusion criteria. Group bias was reduced through 1:1 propensity score matching, which resulted in 46 patients in each group (open surgery and U-VATS)., Results: The intra- and post-operative mortality were null in both groups. There was no difference in the post-operative complications ( p : 1.00) between U-VATS and open lobectomy. There was also no recorded difference in the pathological nodal up-staging [11 (23.9%) after thoracotomy vs. 8 (17.4%) after U-VATS, p : 0.440). The chest tube duration was longer in the open group ( p : 0.025), with a higher post-operative pain ( p: 0.001). Additionally, the 3-year overall survival (OS) was 78% after U-VATS lobectomy vs. 74% after open lobectomy ( p : 0.204), while 3-year disease-specific survival (DSS) was 97 vs. 89% ( p : 0.371), respectively. The 3-year disease-free survival (DFS) was 62% in the U-VATS group and 66% in the thoracotomy group, respectively ( p : 0.917)., Conclusions: Uniportal-VATS lobectomy for the treatment of early-stage lung cancer seems to be a safe and effective technique with similar surgical and short-term survival outcomes as open surgery, but with lower post-operative pain and shorter in-hospital stay., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Nachira, Congedo, Tabacco, Sassorossi, Calabrese, Ismail, Vita, Petracca-Ciavarella, Margaritora and Meacci.)

Surgical scientific literature contains relatively little information regarding the surgical outcomes of anatomic sublobar resections performed with the uniportal video-assisted thoracoscopic surgery (U-VATS) technique. This paper attempts to evaluate the role of U-VATS segmentectomies in the landscape of a minimally invasive approach to the treatment of early stage non small cell lung cancer (NSCLC)., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd.2020.01.12). The series “Early Stage Lung Cancer: Sublobar Resections are a Choice?” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare., (2020 Journal of Thoracic Disease. All rights reserved.)

Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: Uniportal video-assisted thoracoscopic (U-VATS) lobectomy has been becoming the technique of choice in an increasing number of centers. The aim of our study was to review our experience, evaluating the learning curve of U-VATS for lung lobectomy and outcomes., Methods: The prospectively collected clinical data of 43 consecutive patients, undergone U-VATS lobectomy from June 2016 to September 2017, were reviewed. The cumulative sum analysis was applied for defining the completion of learning curve (CLC), evaluating the relationship between operative time and the consecutive number of operations., Results: The mean operative time of Uniportal VATS lobectomy was 179.93±43.41 min. According to the cumulative sum analysis, the CLC was reached after 25 patients. Using the cut-off of 25 patients, the whole populations was divided in group A (first 25 patients of the experience) and group B (the last 18 patients). The mean operative time in group B was significantly shorter than in group A (164.00±24.46 vs. 191.40±50.45 min, respectively, P=0.04). There were no differences in demographic characteristics, number of removed lymph nodes, chest tube duration, and hospital stay among the two groups. The number of conversions was higher in group A (4 vs. 0; P=0.07), as the number of major complications, like reoperations for bleeding (2 vs. 0; P=0.22). There was no postoperative 30-day-related death., Conclusions: U-VATS lobectomy seems to be a quite safe and feasible procedure, with a steep learning curve and low complication rate, if performed by experienced surgeons after proper training., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: Multiportal thoracoscopic approach is already a well standardized procedure for minimally invasive esophagectomy (MIE); conversely very few reports have been published about uniportal video-assisted thoracic surgery (VATS) technique till now. We present our preliminary experience with uniportal VATS esophagectomy, evaluating short-term outcomes as perioperative mortality, complications, oncological radicality, postoperative pain and cosmetic results., Methods: From December 2016 to November 2017, the prospectively collected clinical data of 12 patients, who underwent uniportal VATS esophagectomy and reconstruction with a stomach conduit, according to McKeown technique, were reviewed and outcomes evaluated., Results: The mean age of population was 60.67±8.61 years. Ten (83.3%) patients were males. The main histological type was a squamous cell carcinoma in six patients (50%). No patient had a local recurrence. After 4.33±3.31 months 10 patients (83.3%) were alive with no evidence of disease; 2 (16.7%) patients died of other causes. Two (16.7%) patients developed an anastomotic leak (treated conservatively) and one (8.3%) patient a chylothorax (which required a surgical treatment). The mean operative time of uniportal VATS esophagectomy was 104.67±20.66 min. Mean number of thoracic nodes removed was 10.44±3.94. Post-operative hospitalization was 15.73±14.29 days (median of 9 days). The mean level of pain was 1.92±0.90 in first postoperative day with a duration of 2.25±1.54 days. Cosmetic result was 2.42±0.79 on a 3-point scale., Conclusions: Uniportal VATS esophagectomy seems to be a safe, feasible and effective alternative to multiportal VATS in terms of operative time, postoperative mortality, hospital stay and oncological outcomes. Less postoperative pain and better cosmetic results seem to be some advantages in favor of Uniportal VATS, however further studies with longer follow-up are claimed., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: The acceptance of uniportal video-assisted thoracic surgery (U-VATS) for thoracic procedures has been growing worldwide. This study reports one of the widest Italian U-VATS experiences., Methods: The prospectively collected data of 237 patients underwent a U-VATS procedure, between May 2016 and September 2017, were retrospectively reviewed. A wide range of procedures, like major and minor lung resections, esophageal surgery, pleural and mediastinal one, was performed. The main aim of the study was evaluating general outcomes in terms of safety and effectiveness, and analyzing short-term results of U-VATS approach., Results: The mean age of population was 59.93±16.03 years. In 208 cases (85.3%) a U-VATS lung resection was performed, in 10 cases (4.1%) an esophagectomy or an esophageal diverticulectomy, in 15 (6.1%) a mediastinal procedure and in 11 (4.5%) a toilette for pleural empyema or removal of pleural lesions. The chest tube duration was 4.24±3.73 days and the postoperative hospital stay was 4.62±4.59 days. The intraoperative and thirty-day mortality were null. Mean level of pain in I postoperative day was 2.30±1.26 on VAS scale and the mean duration was of 1.54±1.21 days. In 93% of cases there was a resolution of pain after chest tube removal. Furthermore, the average level of cosmetic satisfaction was 2.73±0.49 (measured on a 0-3 scale)., Conclusions: According to our experience, U-VATS seems to be a safe and practicable mini-invasive technique, above all for surgeons who already have thoracoscopy experience or made proper training attending multilevel courses, hands-on conferences and wet-labs., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: The efficacy of video-assisted thoracic surgery (VATS) in the treatment of pleural empyema has recently been proven. Till today, very few works evaluated the role of uniportal-VATS (U-VATS) approach in the treatment of pleural empyema even if it currently represents the most innovative and less invasive thoracoscopic approach. We report our experience with U-VATS in the treatment of pleural empyema., Methods: A retrospective bicentric analysis of 35 consecutive patients who underwent surgical treatment of stage II and stage III pleural empyema was performed, from January 2015 to May 2017., Results: The mean age of patients was 57.26±18.29 years and 54.3% of them were males. In 85.7% of the cases, empyema was related to a complicated parapneumonic effusion; in only 5 cases it was a post-surgical consequence. All patients were treated with broad-spectrum antibiotics and subsequent target therapy for 14.62±21.76 days prior to operation and 23 patients needed the placement of a chest tube. Twenty patients (57.1%) presented with stage III, 11 patients (31.4%) stage II and 4 patients (11.4%) stage I empyema. Complete debridement and decortication were obtained in all patients through U-VATS approach and no conversion or further access was needed for any reason. No major complication was recorded. Only 2 cases of trapped lung were not responsive to surgical treatment. At a mean follow-up of 247.42±306.29 days, 33 patients (94.3%) were alive with no recurrence, 2 patients died for causes unrelated to the operation., Conclusions: According to our experience, we consider U-VATS as an adequate procedure in the treatment of "stages II and III" empyemas when the necessary surgical expertise has been achieved. Indeed, U-VATS permits an easier performance and complete debridement and decortication, with a very low risk for conversion and excellent postoperative outcomes in terms of less pain, fast recovery and cosmetic results., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

In the era of lung cancer screening and early detection of lung lesions, pulmonary segmentectomy has gained wide acceptance between thoracic community reducing the need of lobectomy for diagnostic purpose and treatment in case of centrally located benign, multiple or undetermined lesions. In rigorously selected patients with stage I non-small cell lung cancer (NSCLC), segmentectomies seem to offer similar survival outcomes rather than lobectomies, but associated with a better conservation of lung function. However, segmentectomy is a more challenging procedure to be performed compared to lobectomy, especially by video-assisted thoracic surgery (VATS). Many difficulties could arise during video-assisted segmentectomy, making the procedure more demanding and stressful. Following the introduction of the near infrared (NIR)/indocyanine imaging system on standard endoscopic module, we decided to adopt peripheral intravenous injection of indocyanine green (ICG) to identify intersegmental plain during uniportal VATS lung segmentectomy. Our technique herein is widely illustrated., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.