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http://hdl.handle.net/20.500.11768/96442

Bronchopleural fistula (BPF) is a well recognized and potentially fatal complication of major thoracic surgery and several strategies regarding its prevention and subsequent management have been described. An immediate BPF occurring intraoperatively after bronchial closure is a rare event and is usually treated by bronchial stump reamputation and/or hand-suture reinforcement by mattress suture, or myoplasty. We report a simple and successful technique, using azygous vein flaps, to repair an intraoperative BPF associated to a small bronchial dehiscence occurred after a right pneumonectomy in a 70-year-old diabetic man receiving induction chemotherapy treatment.

The aim of this study was to evaluate the safety of continuous nonabsorbable (3/0 polypropylene) sutures for sleeve lobectomy, and the influence of induction chemotherapy on postoperative outcome in patients with lung malignancies.A review of a prospective database of a single surgeon identified 41 consecutive patients who underwent sleeve lobectomy from May 1998 to July 2003. Bronchial reconstruction was done placing two 3/0 polypropylene sutures at the far side of the cartilaginous wall and subsequently fixed. Afterwards, two running sutures were performed in order to obtain a telescopic anastomosis.Twenty-four patients (59%) underwent induction chemotherapy. There were 31 right upper, 3 left lower ''reverse'', and 7 left upper sleeve lobectomies with radical lymph node dissection. Eight patients underwent reconstruction of the pulmonary artery. There were 34 non-small cell lung cancers, 3 limited small cell lung cancers, 1 neuroendocrine large cell carcinoma, and 3 bronchial carcinoid tumors. N2, N1, and N0 diseases were found in 13, 12 and 16 patients, respectively. Post-operative morbidity and mortality were 14.5% (n=6) and 4.8% (n=2) (1 patient, 4%, after induction chemotherapy). The rate of postoperative anastomotic complications was 2.4% (n=1). Late bronchial stenosis developed in 3 cases, but all were successfully medically treated. Twenty-nine patients are still alive, 27 without evidence of disease. The overall 2-year probability of survival (Kaplan-Meier) was 59%. Induction chemotherapy did not influence postoperative morbidity/mortality (chi2 test: P=0.64/P=0.56).Continuous nonabsorbable suture for sleeve lobectomy is quick and technical easy to perform, with low postoperative morbidity/mortality; induction chemotherapy does not influence postoperative outcome in these patients.

The authors report their experience on the use of urapidil in 31 patients, submitted to neurosurgical procedures. Urapidil, administered both in the inductive (0.7-1 mg/kg) and in preoperative phases (0.6-0.8 mg/kg/h), produced a MAP decrease of about 25% without significant variations in cardiac frequency or of other monitored parameters.

The role of fluorodeoxyglucose positron emission tomography (FDG-PET) as an additional investigation to computer tomography for pulmonary carcinoid tumors remains controversial. The aim of this study was to assess the role of FDG-PET for the diagnosis and staging of pulmonary carcinoid tumors.We performed a retrospective mono-institutional analysis of data from 97 patients with pathologically confirmed pulmonary carcinoid tumor who had been operated on between July 1998 and April 2009 and had had a preoperative FDG-PET scan performed.Sixty-five (67%) of the 97 tumors were typical (TC) and 32 (33%) atypical (AC) carcinoid tumors. Overall FDG-PET sensitivity was 67% being lower for TC (60%) than for AC (81%) (P=0.04). FDG-PET negative tumors were smaller than FDG-PET positive tumors, with a respective median size of 15 and 17 mm (P=0.02). Median SUVmax for FDG-PET-positive tumors was 4.0 (2.8-5.1) with no difference between TC and AC tumors. Median Ki-67 expression was respectively 4.7% and 3.1% for FDG-PET positive and FDG-PET negative tumors (P=0.05). During a median follow-up of 49 months (interquartile range 30-63 months), 9 patients (4TC, 5AC) developed recurrent disease. Neither SUVmax nor Ki-67 expression resulted associated with disease-free survival.With an overall sensitivity of 67%, FDG-PET has shown to be useful in the preoperative work-up of patients with suspect lung carcinoid tumors. In particular it could have a role in larger tumors. These results warrant a prospective evaluation of FDG-PET in the staging of lung carcinoid tumor.

We report a case of a 62-year-old man affected by Pancoast's tumor who developed pneumocephalus 17 days after right upper lobectomy with en bloc resection of the first three ribs and C8-D1 branches of the brachial plexus. The patient complained of aphasia, disorientation and sphincterial release. A chest and brain-CT scan showed a right apical pneumothorax associated with a massive pneumocephalus of the ventricles and of the subarachnoidal spaces. A pneumoperitoneum was also seen. The patient was treated using pleural drainages, Trendelenburg's position and antibiotic therapy. Clinical and radiological remission was achieved after 12 days of additional hospital stay.

Solitary fibrous tumors of the pleura (SFTP) are rare mesenchymal neoplasms usually originating from the visceral pleura, but sometimes found in other sites like the orbit, dura, paranasal sinus, upper respiratory tract, thyroid, sublingual gland, lung, periosteum, cauda equina, ovary, scrotum and testicular tunica vaginalis. Solitary fibrous tumor of the kidney is extremely rare with fewer than 15 reported cases in modern English literature. To the best of our knowledge, this report describes the first known case of synchronous SFTP in the left parietal pleura and left kidney. The SFTP of the pleura, widely compressing and displacing the left lower lung lobe, was resected via left thoracotomy, whereas the renal SFTP, diagnosed by echo-guided histological biopsy, was closely monitored by computed tomography scan and ultrasound. After a one-year follow-up no recurrence was detected in the left hemithorax and the renal lesion remained stable.

Introduction: Breast cancer is the leading cause of cancer death among women in the industrialized countries. The incidence of local recurrences after mastectomy and breast-conserving therapy varies between 5% and 40% depending on risk factors and primary therapy. Methods: From April 1999 to April 2011, 40 patients underwent chest wall resection and reconstruction for locally recurrent breast carcinoma with chest wall invasion. The main goal of surgery was local disease control to palliate clinical symptoms. Results: Local radical resection was achieved in 26 patients (65%). One, 2 and 5 year overall survival rates were 94.4%, 82.0% and 68.5%; 1, 2 and 5 year disease-free survival rates were 94.4%, 73.6% and 45.5% respectively.Univariate analysis indicated age (p = 0.002) and synchronous distant metastases (p = 0.020) as factors having a negative impact on overall survival; multivariate analysis disclosed age (p = 0.052) and synchronous metastases (p = 0.059) as factors with a slight negative impact on overall survival. Older age was associated with improved overall survival.Univariate analysis indicated synchronous distant metastases (p = 0.029) and the need of post resectional additional treatments (p = 0.022) as factors adversely conditioning disease-free survival or time to progression; multivariate analysis disclosed the need of post resectional additional treatments (p = 0.036) as the only factor adversely conditioning disease-free survival or time to progression. Conclusions: Chest wall resection and reconstruction for locally recurrent breast cancer is a feasible and safe procedure providing adequate local disease control and an excellent palliation of very disabling symptoms in a selected group of patients.

Objective Tracheal sleeve pneumonectomy is a challenge in lung cancer management and in achieving long-term oncological results. In November 2018, we started a prospective study on the role of extracorporeal membrane oxygenation (ECMO) in tracheal sleeve pneumonectomy. We aim to present our preliminary results. Methods From November 2018 to November 2019, six patients (three men and three women; median age: 61 years) were eligible for tracheal sleeve pneumonectomy for lung cancer employing the veno-venous ECMO during tracheobronchial anastomosis. Results Only in one patient, an intrapericardial pneumonectomy without ECMO support was performed, but cannulas were maintained during surgery. The median length of surgery was 201 minutes (range: 162–292 minutes), and the average duration of the apneic phase was 38 minutes (range: 31–45 minutes). No complications correlated to the positioning of the cannulas were recorded. There was only one major postoperative complication (hemothorax). At the time of follow-up, all patients were alive; one patient alive with bone metastasis was being treated with radiotherapy. Conclusion ECMO-assisted oncological surgery was rarely described, and its advantages include hemodynamic stability with low bleeding complications and a clean operating field. As suggested by our preliminary data, ECMO-assisted could be a useful alternative strategy in select lung cancer patients.

OBJECTIVES A few studies have already demonstrated survival benefits for local treatment in solitary metastatic non-small-cell lung cancer (NSCLC). The aim of this study is to retrospectively investigate the role of surgery in patients with oligometastatic (OM) NSCLC. METHODS Between January 1998 and December 2018, 57 patients with OM stage IV NSCLC (1 or 2) underwent a multidisciplinary approach including lung cancer surgery, local treatment of the distant metastasis (DM) and systemic medical treatments. RESULTS All patients had DM synchronous to lung cancer. Fifty-one (90%) patients had a single DM whereas 6 (11%) patients had 2 DMs. Forty-eight (84%) patients underwent induction chemotherapy. We performed 47 (82%) lobectomies, 4 (7%) segmentectomies and 6 (11%) pneumonectomies. Pathological lymph node involvement was evident in 28 (49%) patients. Adjuvant chemotherapy was administered in 20 (35%) patients. Forty-six (81%) patients had local treatment of the DM before lung resection, and 11 (19%) patients had after lung resection; 6 (11%) patients had both treatments. The median overall survival (OS) was 30 months, with the 2-, 3- and 5-year OS of 57%, 50% and 30%, respectively. OS was significantly related to lymph node involvement (P = 0.04), size of the primary tumour (P CONCLUSIONS Multidisciplinary approach is the gold standard in OM patients. Patients with no lymph node involvement are the best candidates, with an acceptable OS. Thus, patients with OM-NSCLC should not be excluded from surgery as a matter of principle.

INTRODUCTION: Robotic-assisted surgery has become the first choice for several conditions since its introduction in clinical practice in 2000. However, the U.S. Food and Drug Administration has recently raised a warning against the use of robotic surgical approaches for the cure and prevention of cancer following the publication of two studies focused on endometrial cancer. We conducted an internal audit to retrospectively analyze our experience to assess the safety and feasibility of robotic-assisted surgery compared to open surgery. METHODS: We selected a 5-year period to guarantee at least 2 years of follow-up (2011-2016) and identified 1139 patients who underwent lobectomy for non-small-cell lung cancer (NSCLC) in our division. The primary data set analyzed included 544 early-stage clinical N0 patients (348 open and 196 robotic surgeries). We compared 131 patients of each group individually matched, with demographic and clinical characteristics almost identical. RESULTS: No difference was observed between the cohorts, either in terms of recurrence-free survival (hazard ratio: 1.09; p = 0.55) or overall survival (hazard ratio: 0.86; p = 0.36). The 5-year recurrence of disease risk and overall survival were 24.9% and 83.2%, respectively, in the open group and 24.6% and 86.1%, respectively, in the robotic group. CONCLUSIONS: These data underline that robotic-assisted lobectomy for early NSCLC is a safe and feasible technique with adequate long-term and progression-free survival compared to open surgery.

Background: Advanced treatment options for non-small cell lung cancer (NSCLC) consist of immunotherapy, chemotherapy, or a combination of both. Decisions surrounding NSCLC can be considered as preference-sensitive because multiple treatments exist that vary in terms of mode of administration, treatment schedules, and benefit–risk profiles. As part of the IMI PREFER project, we developed a protocol for an online preference survey for NSCLC patients exploring differences in preferences according to patient characteristics (preference heterogeneity). Moreover, this study will evaluate and compare the use of two different preference elicitation methods, the discrete choice experiment (DCE) and the swing weighting (SW) task. Finally, the study explores how demographic (i.e., age, gender, and educational level) and clinical (i.e., cancer stage and line of treatment) information, health literacy, health locus of control, and quality of life may influence or explain patient preferences and the usefulness of a digital interactive tool in providing information on preference elicitation tasks according to patients.Methods: An online survey will be implemented with the aim to recruit 510 NSCLC patients in Belgium and Italy. Participants will be randomized 50:50 to first receive either the DCE or the SW. The survey will also collect information on participants' disease-related status, health locus of control, health literacy, quality of life, and perception of the educational tool.Discussion: This protocol outlines methodological and practical steps to quantitatively elicit and study patient preferences for NSCLC treatment alternatives. Results from this study will increase the understanding of which treatment aspects are most valued by NSCLC patients to inform decision-making in drug development, regulatory approval, and reimbursement. Methodologically, the comparison between the DCE and the SW task will be valuable to gain information on how these preference methods perform against each other in eliciting patient preferences. Overall, this protocol may assist researchers, drug developers, and decision-makers in designing quantitative patient preferences into decision-making along the medical product life cycle.

Objective Since data from large retrospective observational studies and cancer registries became available, suggesting a benefit for patients undergoing surgery, the role of surgery in the treatment of small cell lung cancer (SCLC) needs to be reconsidered. The aim of this study was to evaluate outcomes and results of patients with SCLC undergoing intent-to-treat surgery. Material and methods We retrospectively analyzed 324 patients (1998–2018) with a diagnosis of SCLC referred to our Institution. 65 patients underwent surgical resection with curative intent. Kaplan-Meier and Cox regression analyses were used to compare overall survival (OS) for all patients. Results Among the patients, 39 (60.0 %) patients had surgery upfront, whereas 24 (36.9 %) had surgery after chemotherapy (CT) alone, and 2 (3.1 %) after CT plus radiotherapy (RT). Twenty-nine (44.6 %) patients were stage I or had a complete response to induction treatment, 21 (32.3 %) had stage II, and 15 (23.1 %) stage III. Forty-four (67.7 %) patients underwent adjuvant treatment: 21 (32.3 %) had CT, 31 (47.7 %) RT, and 7 (10.8 %) both. Prophylactic cranial irradiation was administered in 15 patients (23.1 %). The median OS after initial diagnosis at 1, 5, 10 years was 1, 5, 10 years was 81.4 %, 41.4 % and 25.4 % respectively. Among patients who underwent surgical resection with curative intent, those with clinical stage I had a longer survival (5-year OS 62.9 %) p Conclusion patients with stage I SCLC could be considered the best candidates for surgery, in a multidisciplinary setting. Instead, considering their worse survival, those with stage II and III should be carefully selected for the surgical approach, and alternative therapy should be considered.

Excisional biopsy of non-palpable rib tumors still represents a challenge for thoracic surgeons: in fact primary or metastatic tumors originating from a rib can be difficult to localize topographically at the time of excisional biopsy, thus potentially resulting in inappropriately placed skin incisions, incomplete tumor excision or even in wrong rib or segment resection (1).

Objectives While the best approach to malignant pleural mesothelioma has yet to be demonstrated, surgery remains the mainstay of treatment. We analysed a group of candidates for trimodality treatment, aiming to identify prognostic factors guiding patient selection. Methods Between 2003 and 2015, 83 (31.6%) of the 283 patients with malignant pleural mesothelioma were considered for trimodality treatment to perform induction chemotherapy, extrapleural pneumonectomy and adjuvant radiotherapy. All patients underwent cisplatin-based chemotherapy. Radiotherapy was administered at a mean dose of 50.4 Gy. Results Thirty-six patients (43.4%) had 3 cycles of chemotherapy, whereas 21 (25.3%) had more than 3. Progression to chemotherapy was observed in 10.9% (9 of 83) of patients, partial response in 30.1% (25 of 83) and stable disease in 59% (49 of 83). Sixty-three patients underwent extrapleural pneumonectomy. Fifty-five patients (87.3%) had epithelial tumour. Forty-two patients (66.7%) were in pathological Stage 3. Major complications after extrapleural pneumonectomy were observed in 28 patients (44.4%), whereas 30-day postoperative mortality was 11.1% (7/63). Radiotherapy was not administered in 24 patients (38.1%) due to major complications after surgery or patient intolerance. Two patients (3.2%) died within 90 days after the end of radiotherapy. The trimodality treatment was completed in 37 (44.6%) patients. Median overall survival was 35.6 months, with 1- and 3-year overall survival of 82% and 48% for patients who completed the trimodality treatment compared with 32% and 14% for patients who did not undergo radiotherapy. Conclusions Only 45% of patients completed the planned trimodality treatment, and morbidity/mortality remained high. Nonetheless, the patients who completed treatment showed good loco-regional disease control and better overall survival.

Objective: To validate previously identified associations between radiological features and clinical features with Epidermal Growth Factor Receptor (EGER)/Kirsten RAt Sarcoma (KRAS) alterations in an independent group of patients with Non-Small Cell Lung Cancer (NSCLC).Material and methods: A total of 122 patients with NSCLC tested for EGFR/KRAS alterations were included. Clinical and radiological features were recorded.Univariate analysis were performed to look at the associations of the studied features with EGFR/KRAS alterations. Previously calculated composite model parameters for each gene alteration prediction were applied to this validation cohort. ROC (Receiver Operating Characteristic) curves were drawn using the previously validated composite models, and also for each significant individual characteristic of the previous training cohort model. The Area Under the ROC Curve (AUC) with 95% Confidence Intervals (CI) was calculated and compared between the full models.Results: At univariate analysis, EGFR + confirmed an association with an internal air bronchogram, pleural retraction, emphysema and lack of smoking; KRAS + with round shape, emphysema and smoking. The AUC (95%CI) in the new cohort was confirmed to be high for EGFR + prediction, with a value of: 0.82 (0.69-0.95) vs. 0.82 in the previous cohort, whereas it was smaller for KRAS + prediction, with a value of 0.60 (0.48-0.72) vs. 0.67 in the previous cohort. Looking at single features in the new cohort, we found that the AUC for the models including only smoking was similar to that of the full model (including radiological and clinical features) for both gene alterations.Conclusions: Although this study validated the significant association of clinical and radiological features with EGFR/KRAS alterations, models based on these composite features are not superior to smoking history alone to predict the mutations.

Background and Objective. EBUS-TBNA has revolutionized the diagnostic approach to thoracic diseases from a surgical to minimally invasive procedure. In non small-cell lung cancer (NCSLC) patients, EBUS-TBNA is able to dictate the consecutive therapy both for early and advanced stages, providing pathological diagnosis, mediastinal staging, and even adequate specimens for molecular analysis. This study reports on the ability of EBUS-TBNA to make different diagnoses and dictates the consecutive therapy in a large cohort of patients presenting different thoracic diseases. Methods. All procedures performed from January 2012 to September 2016 were reviewed. Five groups of patients were created according to the main indications for the procedure. Group 1: lung cancer staging; Group 2: pathological diagnosis in advanced stage lung cancer; Group 3: lymphadenopathy in previous malignancies; Group 4: pulmonary lesions; Group 5: unknown origin lymphadenopathy. In each group, the diagnostic yield of the procedure was analysed. Non malignant diagnosis at EBUS-TBNA was confirmed by a surgical procedure or clinical and radiological follow-up. Results. 1891 patients were included in the analysis. Sensitivity, negative predictive value, and diagnostic accuracy in each group were 90.7%, 79.4%, and 93.1% in Group 1; 98.5%, 50%, and 98.5% in Group 2; 92.4%, 85.1%, and 94.7% in Group 3; 90.9%, 51.0%, and 91.7% in Group 4; and 25%, 83.3%, and 84.2% in Group 5. Overall sensitivity, negative predictive value, and accuracy were 91.7%, 78.5%, and 93.6%, respectively. Conclusions. EBUS-TBNA is the best approach for invasive mediastinal investigation, confirming its strategic role and high accuracy in thoracic oncology.

Background The role of extended pulmonary resection for lung metastases is still unclear, and little information is available in the literature. This study was performed to analyze the outcomes and prognostic factors of patients who underwent extended resections for pulmonary metastases. Methods From 1998 to 2013, 1027 patients underwent lung metastasectomy procedures. Twenty-nine patients had extended pulmonary resections: three resections of the chest wall, one azygos, one diaphragm, four vascular resections/reconstructions, six sleeve resections, and 14 pneumonectomies. Results Extended resection was performed for metastatic disease mainly from epithelial (62.1%) and sarcomatous (20.7%) tumors. Complete resection was obtained in all patients. Thirty-day operative morbidity and mortality rates were 38% (11 of 29) and 0%, respectively. Only one patient had a major complication due to a bronchopleural fistula. Mean hospital stay was 6.3 days. After a median follow-up of 27 months, 16 patients (55%) had died. At univariate analysis, survival was determined by primary tumor histology ( p = 0.03); the number of metastases, nodal status, disease-free interval or extension of surgery (pneumonectomy vs. lobar resection) were not related to survival probably due to the low number of patients. Overall survival after a complete extended metastasectomy was 66% at 2 years, 42% at 5 years, and 36% at 10 years. Conclusions Extended resections performed during pulmonary metastasectomies are associated with low mortality and morbidity rates and an acceptable long-term survival when performed in selected patients susceptible to complete resection.

Lung cancer is the leading cause of death for neoplasm. Lung cancer mortality is frequently associated with late diagnosis, therefore an early diagnosis is a key factor to significantly improve overall survival in high risk populations of asymptomatic patients. Conventional cancer screenings (low-dose computed tomography or chest x-ray) today offer early detection but are invasive and expensive. Previously these studies evaluated the solid and topographic cancer structure and morphology. Today the concept of tumor has been remodelled, being defined as a disease that has its own genetic, biological and metabolic identity; it is on this new awareness that we should base new screening methods. Recent research has shown great reliability of new tests such as exhaled breath analysis, serum biomarkers and urine analysis in early diagnosis of lung cancer. Analysis of new biomarkers associated with the high specificity of these new screening methods, which are non-invasive, safe, inexpensive and simple to perform, could allow a non-invasive approach to determine a big change in the early diagnosis of cancer and its survival rate. Furthermore, these new techniques put the patient at the core of a non-invasive diagnostic process and ensure a better quality of life during medical diagnosis. In this article, we want to analyze the possible benefits of these new and promising methods, suggesting a possible combination between them to ensure, as soon as possible, an early and effective diagnosis of lung cancer with a special focus on the patient, in a new era of personalized medicine.

http://hdl.handle.net/20.500.11768/96623 Background. Robotic lobectomy with radical lymph node dissection is a new frontier of minimally invasive thoracic surgery. Series of sublobar anatomic resection for primary initial lung cancers or for metastasis using video-assisted thoracic surgery have been reported but no cases have been so far reported using the robot-assisted approach. We present the technique and surgical outcome of our initial experience. Methods. Clinical data of patients undergoing robotic lung anatomic segmentectomy were retrospectively reviewed. All cases were done using the DaVinci System. A 3- or 4-incision strategy with a 3-cm utility incision in the anterior fourth or fifth intercostal space was performed. Individual ligation and division of the hilar structures was performed using Hem-o-Lok (Teleflex Medical, Research Triangle Park, NC) or endoscopic staplers. The parenchyma was transected with endovascular staplers introduced by the bedside assistant mainly through the utility incision. Systematic mediastinal lymph node dissection or sampling was performed. Results. From 2008 to 2010, 17 patients underwent a robot-assisted lung anatomic segmentectomy in two centers. There were 10 women and 7 men with a mean age of 68.2 years (range, 32 to 82). Mean duration of surgery was 189 minutes. There were no major intraoperative complications. Conversion to open procedure was never required. Postoperative morbidity rate was 17.6% with pneumonia in 1 case and prolonged air leaks in 2 patients. Median postoperative stay was 5 days (range, 2 to 14), and postoperative mortality was 0%. Final pathology was non-small cell lung cancer in 8 patient, typical carcinoids in 2, and lung metastases in 7. Conclusions. Robotic anatomic lung segmentectomy is feasible and safe procedure. Robotic system, by improving ergonomic, surgeon view and precise movements, may make minimally invasive segmentectomy easier to adopt and perform. (Ann Thorac Surg 2012;94:929-34) (C) 2012 by The Society of Thoracic Surgeons

Objective Pneumonectomy is not always sufficient for the radical resection of cancer. In the present study, pneumonectomy may be associated with an extended resection of mediastinal or parietal structures. The postoperative risk and the oncologic benefits of such an extended procedure have not been sufficiently demonstrated. Methods We have defined "extended" pneumonectomy (EP) as the removal of the entire lung, associated with one or more of the following structures: superior vena cava, tracheal carina, left atrium, aorta, chest wall, or diaphragm. Our clinical database was retrospectively reviewed to identify patients who underwent EP to assess their postoperative morbidity, mortality, and long-term survival. Results Between 1998 and 2005, 47 EPs were performed. The "extended" procedure included left atrium resection in 15 patients, combined SVC and carinal resection in 9 patients, aortic resection in 8 patients (in 3 patients with prosthetic replacement), chest wall or diaphragmatic resection in 6 patients, SVC resection in 4 patients, and carinal resection in 4 patients. A partial esophageal muscular resection was performed in 1 patient. Overall 60-day mortality was 8.5%. Major postoperative complications occurred in 8 patients (17%). The 2- and 5-year survival rates for the overall population were 42% and 22.8%, respectively. Interestingly, long-term survivors were recorded only in the group of patients who received induction treatment. Conclusions Extended pneumonectomy is a feasible procedure with an acceptable risk factor. To improve the selection of patients, all candidates should undergo preoperative mediastinoscopy and induction chemotherapy. In patients with positive response to chemotherapy or stable disease, extended pneumonectomy may afford a radical resection in more than 80% of cases and may result in a permanent cure in some instances.

Background: Extended resections (ER) for lung cancer may improve survival in selected patients. However, analysis on large series is still lacking. We reviewed our experience to identify prognostic factors useful for patient selection. Methods: Between 1998 and 2010, 167 patients with involvement of one or more mediastinal organs underwent operations with the intent to perform ER. At thoracotomy, 42 patients (25%) were considered unresectable (explorative thoracotomy [ET]), and 125 (75%) underwent ER. The types of ER were superior vena cava in 43 patients (34.4%), carina in 33 (26.4%), combined with superior vena cava in 18 (14.4%), with the left atrium in 35 (28%), and with the aorta in 14 (11.2%). We excluded Pancoast tumors and vertebral resections. The minimum follow-up was 6 months. Kaplan-Meier method and log-rank test were used for statistical analysis of survival. Results: There were 136 men (81.4%), with mean age of 63 years (range, 36 to 81 years). Of the 167 patients, induction chemotherapy was administered in 119 (71.3%), including 34 ET patients (81%) and 85 ER patients (68%). Complete resection was achieved in 106 patients (84.8%). The overall 5-year survival was 23% (27% in ER and 13% in ET, p = 0.41). Overall 30-day mortality was 4.8% and morbidity was 34.1%. Factors affecting survival were complete resection (p < 0.01), pStage 0-I-II disease (p < 0.0007), and age younger than 60 years (p < 0.01). Conclusions: ER for lung cancer invading mediastinal organs could improve long-term survival (46% at 5-years in pN0). The best surgical candidates are young patients without lymph nodes involvement who undergo radical resection. Multimodality treatment is suggested in case of mediastinal lymph node involvement. © 2013 by The Society of Thoracic Surgeons.

http://hdl.handle.net/20.500.11768/96435

A 38-year-old Caucasian woman was admitted to hospital complaining of recent-onset acute night dyspnoea. A chest radiograph disclosed a bulky cystic lesion in the middle-lower field of the left lung (Figure 1), and a computed tomography scan confirmed the presence of a 91 50 98-mm multiseptated giant cystic mass arising in the lingula and compressing the adjacent pulmonary parenchyma (Figure 2). The patient’s clinical history was unremarkable apart from autoimmune hyperthyroidism under medical treatment for 4 years. The patient underwent left muscle sparing thoracotomy with resection of the entire unopened lesion and no lung tissue sacrifice. Grossly, the tumor consisted of a multiseptated giant cystic mass with gaseous content and scant liquid material (Figure 3). Histologically, it featured a typical alveolar adenoma with dual cell composition of type II pneumocytes and elongated septal mesenchymal cells, but with unusual formation of giant cystic spaces (Figures 4A, B). The immunohistochemical profile—positivity for thyroid transcription factor-1 (Figure 4C), negativity for myogenin, surfactant and cytokeratins in pneumocytes, and negativity for desmin in mesenchymal cells—was consistent with alveolar adenoma. The proliferative activity as assessed by Ki-67 immunostaining was unremarkable in both cell types (Figure 4D). The nonrandom occurrence of specific genetic alterations in alveolar adenoma in relation to its neoplastic nature, albeit benign, inasmuch as recurrence has never been recorded.1–4 Most patients are middle aged to elderly and asymptomatic, with a slight female predominance. Most tumors are found by chance, whereas the occurrence of severe tumorrelated symptoms, as described in our case, is exceptional. Conservative surgery is the best treatment and no further therapy is required.2

http://hdl.handle.net/20.500.11768/96473 Background: Prolonged air leak after pulmonary lobectomy is a common time- and cost-consuming complication. Its prevention may significantly reduce hospitalization length and costs offering patients a standard uneventful postoperative course. The aim of the present study is to identify predictors of prolonged postoperative air leak and to stratify preoperative risk factors. Methods: From July 2004 to December 2007 241 consecutive standard lobectomies were performed with curative intent for lung cancer. After excluding patients not fulfilling the inclusion criterion, 58 patients were enrolled in the "prolonged air leak" group and 63 patients were enrolled in the "standard outcome" group. Results: Total lung capacity (p = 0.0038) and percentage emphysema (p = 0.0050) calculated by computed tomography were both significantly related to prolonged postoperative air leak; the values of 4773 cc and 0.4% showed the highest predictive value in terms of sensitivity (84.5% and 75.9% respectively). Multivariate logistic regression disclosed that male sex (p = 0.0006), right side of operation (p = 0.0010) and age (p = 0.0082) were significantly related to prolonged postoperative air leak. Preoperative chemotherapy (p = 0.0940) did not affect air leak status. Conclusions: Computed tomography quantification of emphysema is the best predictor of prolonged air leak. Age, male sex and right side lobectomy are correlated to this complication. Preoperative chemotherapy is not an additional risk factor. (C) 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Introduction Indications and results of salvage surgery in mediastinal tumors are still unclear. This study analyzes a single-center experience to assess its mortality, morbidity, and long-term results. Methods Mediastinal salvage surgery (MSS) was defined as surgical resection of persistent or recurrent primary mediastinal tumors after previous local treatments with curative intent or exclusive chemotherapy in case of bulky tumors. Clinical data of patients undergoing MSS between 1998 and 2005 were analyzed. Overall and disease-specific long-term survival was calculated. Results Twenty-one patients (15 men and 6 women, mean age 41 years) underwent MSS. Eleven patients suffered from thymic tumors (eight thymomas, three thymic carcinoma) whereas 10 patients suffered from nonthymic tumors (one lung adenocarcinoma + thymoma, two mediastinal monophasic sinovial sarcoma, one mediastinal neuroendocrine tumor, one mediastinal teratoblastoma, one mediastinal disgerminoma, one Hodgkin's lymphoma, one mediastinal atypic carcinoid, two medullary thyroid carcinoma). MSS required extended vascular resection in 10 cases and cardiopulmonary bypass in one case. Median operation time was 215 minutes (range 140–720). One postoperative death and four major complications were recorded (overall mortality 4.7%, morbidity 19.0%). With a median follow-up of 30.6 months, overall 1-, 3-, and 5-year Kaplan-Meier survival was 89.7, 71.2, and 56.6%, respectively. Thymic neoplasms had a better prognosis (1-, 3-, and 5-year survival was 100, 87.5, 87.5%, respectively) when compared with others (1-, 3-, and 5-year survival was 77.8, 53.3, 26.7%, respectively—logrank p = 0.0128). Conclusions MSS can offer a chance of curative treatment in selected patients with an acceptable morbidity and mortality. Thymic tumors obtain the best results in term of long-term survival.

http://hdl.handle.net/20.500.11768/96592

Objective The impact of lymph node involvement in lung metastasectomy from extrapulmonary malignancies is uncertain. We assessed the prognostic value of lymph node status in lung metastasectomy and the prevalence of unexpected mediastinal lymph node involvement after lymph node sampling or dissection. Methods From May 1998 to October 2005, 388 patients underwent 430 pulmonary metastasectomies with curative intent. The clinical records of all patients who underwent radical lymph node dissection or sampling were reviewed retrospectively. Survival was evaluated using the Kaplan–Meier method and comparison of survival curves by log–rank test. Results A total of 124 patients (61 men, mean age 59 years) underwent 139 pulmonary metastasectomies (56 wedge resections, 30 segmentectomies, 49 lobectomies, and 4 pneumonectomies with radical lymph node dissection [88] or sampling [51]). Means of 9.4 lymph nodes and 2 lung metastases per intervention were removed. The median disease-free interval from primary treatment to lung metastasectomy was 49 months. Lymph node involvement was present in 25 patients (20%), in 10 (8%) at N1 stations (hilar or peribronchial) and in 15 (12%) at N2 stations (mediastinal), and in 7 (12.5%) after atypical resection and in 19 (23%) after typical resection. In 15 patients (12%) (60% of N+ patients), lymph node involvement was unexpected. Estimated overall 5-year survival was 46%: It was 60% for subjects with no lymph node metastasis and 17% and 0% for those with N1 and N2 disease, respectively ( P = .01). Conclusions Lymph node involvement heavily affects prognosis after pulmonary metastasectomies. In most patients, lymph node involvement was not revealed by preoperative workup.

Background. The oncologic value of superior vena cava (SVC) resection for lung and mediastinal malignancies remains controversial. In this context, we have reviewed our experience in the treatment of locally advanced lung and mediastinal tumor invading the SVC system, analyzing postoperative outcome and long-term oncologic results. Methods. The clinical data of patients who underwent SVC resection were retrospectively analyzed to assess postoperative mortality, and overall and procedure-specific morbidity. Overall survival was calculated for mediastinal and lung tumor groups. Results. From 1998 to 2004, 70 consecutive patients (52 with lung cancer and 18 with mediastinal tumors) underwent SVC system resection. There were 25 replacements (36%) of the SVC system by prosthesis, whereas the remaining underwent partial resection. Major postoperative morbidity and mortality rates in lung cancer patients were 23% and 7.7%, respectively (50% and 5.6% in mediastinal tumors). In the lung cancer group, 5-year survival probability was 31%, and it was affected by mediastinal nodal status (5-year survival in N0‐N1 patients 52%, 21% in N2 patients, 0 in N3 patients). Median survival for mediastinal tumors was 49 months. Conclusions. In conclusion, SVC resection may achieve permanent cure in patients who would have been defined as inoperable 10 years ago. In the case of mediastinal tumors, the need for SVC resection alone should not be considered a contraindication for surgery when prosthetic replacement is feasible. In the case of lung tumors, infiltration of SVC can achieve satisfactory long-term results after neoadjuvant chemotherapy, only when pathologic N2 disease is excluded by preoperative mediastinoscopy.

2006;131:490-491 J Thorac Cardiovasc Surg Gasparri, Francesco Petrella, Alessandro Borri, Giuseppe Pelosi and Marco Venturino Lorenzo Spaggiari, Domenico Galetta, Giulia Veronesi, Francesco Leo, Roberto prosthesis: Preliminary results Superior vena cava replacement for lung cancer using a heterologous (bovine) http://jtcs.ctsnetjournals.org/cgi/content/full/131/2/490 located on the World Wide Web at: The online version of this article, along with updated information and services, is

Summary Occasionally, breast cancer relapses in the subclavicular region. In patients with failed multimodal treatment, or in those who develop an isolated recurrence, surgical resection may be useful to remove all macroscopically evident diseases. However, the procedure may be technically demanding and there are no published data regarding its benefits. The aim of the present study was to evaluate the feasibility and safety of subclavicular resection in breast cancer and provide indications as to whether it can contribute to disease control. We used a transpectoral approach to surgically remove isolated breast cancer recurrence in the subclavicular region in seven consecutive patients presenting over 2 years; in the eighth case a transmanubrial approach was necessary. We found that the surgical approach proposed is feasible and safe, with a 75% rate of complete resection; however, the series was characterised by a high rate of local and distant relapse. We conclude that the technique may be useful, in selected cases, for palliation only.

A 66-year-old nonsmoker woman had a chest computed tomography (CT) during oncological follow-up of bilateral breast cancers. The CT scan disclosed a partially-solid 17-mm nodule in the right upper lobe, a 17-mm retrosternal left mammary chain lymph node, and a 20-mm left subclavicular lymph node. Seventeen years earlier, she had been submitted to left Patey mastectomy for lobular infiltrating carcinoma (pT1c pN1b1 R0—stage IIA according to the 1987 Union Internationale Contre le Cancer classification) and, 10 months later, underwent redo breast resection for tubular ductal carcinoma (pT1c pN0G1 R0—stage I according to the1987 Union Internationale Contre le Cancer classification). The patient received bilateral breast prosthesis implantation. Seven years earlier, the patient underwent median sternotomy for mitral mechanical valve implantation, and 3 years earlier, she required breast prosthesis replacement due to prosthesis damage. Her current evaluation included a positron emission tomography (PET), which showed pathologic [18F]-fluorodeoxyglucose uptake with a maximal standardized uptake values of 4.8, 3.5, and 3.2 in the lung lesion, retrosternal lymph node, and subclavicular node, respectively (Figures 1A–C). CT-guided biopsy and bronchoalveolar lavage of the right upper lobe were nondiagnostic. She did not have an positron emission tomography because of claustrophobia. The patient underwent right axillary muscle-sparing thoracotomy and wedge resection of the right upper pulmonary nodule: frozen section disclosed adenocarcinoma, probably primary non-small cell lung cancer. Right upper lobectomy and lymphadenectomy were performed. Retrosternal dissection and mediastinal adhesiolysis (due to previous median sternotomy) allowed biopsy of the lymph node of the left internal mammary chain. Frozen section disclosed a foreign body inflammatory reaction. Subsequent biopsy of the left subclavicular lymph node revealed breast metastatic carcinoma. Definitive histology confirmed primary pT1 pN0 G1 TTF1 positive acinar adenocarcinoma of the lung (stage IA), subclavicular estrogen receptor positive breast cancer recurrence, and mediastinal silicon-induced lymphadenitis. On the one hand, clinical staging by CT and PET/CT scan in our patient suggested a diagnosis of primary lung cancer with contralateral mediastinal and subclavicular lymph node involvement (stage III B—cN3 disease) and thus not amenable to surgical exploration. An alternative explanation was nodal recurrence by breast cancer and pulmonary metastasis. Although it was known that the patient had had prosthesis rupture, the hypothesis of a foreign body reaction lymphadenitis was not entertained preoperatively mainly because of the coexisting pulmonary lesion. In addition, similar [18F]-FDG uptake values in the three different lesions (standardized uptake values of 4.8, 3.5, and 3.2) led us to consider only one disease rather than three different conditions, as was the case. Another misleading factor was the relatively recent median sternotomy that may have accounted for [18F]-FDG uptake by the internal mammary lymph node. The exceptional nature of the present case lies in the misleading concomitance of three unrelated clinical events with similar CT and PET features. Although synchronous or metachronous lung and breast cancers have been described, as well as silicon-induced lymphadenitis in patients with prosthetic augmentation mammoplasty,1 to our knowledge synchronous primary lung cancer, breast cancer recurrence, and mediastinal silicon-induced lymphadenitis have never been described in the same patient. Although rare, multiple synchronous oncologic and nononcologic diseases need to be considered during follow-up in patients treated for breast cancer to offer them the best therapeutic approach.

A 67-year-old man with a history of alcoholic hepatitis was admitted for hemoptysis. Preoperative chest computed tomography (CT) scan was acquired before (Figure 1) and after injection of iodinated contrast medium (Figure 2). Axial images and multiplanar reconstructions (Figure 3) disclosed a solid lesion of the right upper lobe containing a round enhancing area. The suspicion of an intralesional aneurysm excluded percutaneous CT-guided lung biopsy. Bronchoscopy was performed without any evidence of intraluminal lesions; bronchoalveolar lavage was positive for neoplastic cells and negative for mycobacterium tuberculosis. Positron emission tomography scan was focally positive on the right upper lobe. The patient was submitted to intrapericardial right upper lobectomy because of a close adhesion of the lesion to the superior vena cava wall; no superior vena cava resection was required to complete lobectomy. Postoperative histologic examination showed an epidermoid carcinoma without nodal involvement. Pulmonary artery aneurysm is a rare vascular anomaly, frequently associated with congenital heart disease: patent ductus arteriosus followed by ventricular and septal atrial defects are the most common associated congenital anomalies.1,2 Behcet’s disease, generalized vasculitis, infections, and trauma are other clinical conditions often involved in the etiopathogenesis of pulmonary artery aneurysm. In our patient, the acquisition of CT preand postcontrast images demonstrated a round well-circumscribed area within the malignant lesion, whose contrast enhancement was comparable with the aorta, thus confirming its vascular origin. These findings were very important in the subsequent management of the patient: a percutaneous CT-guided lung biopsy was skipped, as it was considered a procedure at high risk of bleeding, and the diagnosis of malignancy was confirmed by bronchoalveolar lavage.

http://hdl.handle.net/20.500.11768/96643

http://hdl.handle.net/20.500.11768/96475