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OBJECTIVES Total thymectomy in addition to medical treatment is an accepted standard therapy for myasthenia gravis (MG). Patients with severe generalized MG present life-threatening events, poor prognosis and higher risk of postoperative myasthenic crisis. The aim of our study is to investigate neurological and surgical results in patients with Myasthenia Gravis Foundation of America (MGFA) class IV and V MG following thymectomy. METHODS Data on 76 MG patients with preoperative MGFA classes IV and V who underwent thymectomy were retrospectively collected. Primary end points included short-term surgical outcomes and long-term neurological results including the achievement of complete stable remission and any improvement as defined by MGFA Post-Intervention Status criteria. RESULTS There were 27 (35.5%) males and 49 (64.5%) females; 53 (69.7%) were classified as MGFA class IV and 23 (30.3%) as class V. Thymectomy was performed through sternotomy in 25 (32.9%) patients, Video-assisted thoracic surgery (VATS) in 5 (6.6%) and Robot-assisted thoracic surgery (RATS) in 46 (60.5%). The median operative time was 120 (interquartile range: 95; 148) min. In-hospital mortality was observed in 1 (1.3%) patient and postoperative complications in 14 (18.4%) patients. The median postoperative hospital stay was 4 (interquartile range: 3; 6) days. Pathological examination revealed 31 (40.8%) thymic hyperplasia/other benign and 45 (59.2%) thymomas. Cumulative complete stable remission and improvement probabilities were 20.6% and 83.7% at 5 years and 66.9% and 97.6% at 10 years, respectively. A significant improvement rate was found in patients with age at the time of thymectomy of ≤50 years (P = 0.0236), MGFA class V (P = 0.0154) and acetylcholine receptor antibodies positivity (P = 0.0152). CONCLUSIONS Thymectomy in patients with severe MG yields good perioperative outcomes and satisfactory long-term neurological improvement, especially for patients younger than 50 years, with MGFA class V and anti-AChR+ MG.

OBJECTIVES Lung metastases from gynaecological tract cancers are rare, and prognostic factors are still undefined. The goal of this study was to analyse prognostic factors for survival in this group of patients. METHODS Data of patients with lung metastases from gynaecological tract cancers who underwent surgical resections from 1 January 2005 to 31 May 2019 were reviewed retrospectively. All patients were treated surgically if the primitive tumour was under control and the lung was the only organ involved. Clinical and pathological data associated with metastatic patterns and previous treatment types were correlated with overall survival (OS) and disease-free survival using Kaplan–Meier curves, whereas the log-rank test was used to assess differences between subgroups. RESULTS The analysis was conducted on 55 patients. OS was 65% at 5 years. With univariable analysis, age >45 years (P = 0.022) and the absence of pleural infiltration (P = 0.001) were determined to be favourable prognostic factors. The 5-year OS was 69.9% versus 53.3% in patients with pleural involvement. Multivariable analysis confirmed the absence of pleural infiltration as a favourable independent prognostic factor; the hazard ratio was 0.06; the 95% confidence interval was 0.00–0.23 (P = 0.011). At univariable analysis, the absence of pleural infiltration was determined to be a favourable prognostic factor (P = 0.034) for disease-free survival. The numbers and dimensions of the metastases did not influence survival in these patients. In uterine cancers of endometrial or cervical origin, the presence of pleural infiltration (P = 0.001), lymph node involvement (P = 0.001) and young age (P = 0.044) were considered unfavourable prognostic factors for OS. CONCLUSIONS Surgical treatment in technically resectable gynaecological tract metastases may represent an important option. Pleural infiltration and lymph node metastases seem to be adverse prognostic factors.

OBJECTIVES 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 (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.

Thymectomy plays an important role in patients with myasthenia gravis (MG). This study aimed to explore predictors of postoperative myasthenic crisis (POMC) after thymectomy and to define a predictive score of respiratory failure.The clinical data of 177 patients with MG undergoing thymectomy from January 1995 to December 2011 were retrospectively reviewed. The following factors were analysed in relation to the occurrence of myasthenic crisis: gender, age, body mass index (BMI), anti-acetylcholine receptor-antibody level, bulbar symptoms, comorbidities, duration of symptoms, Osserman-stage, Myasthenia Gravis Foundation of America (MGFA) stage, history of myasthenic crisis, use of immoglobulins or plasmapheresis, kind of therapy, spirometric and blood gas parameters, histology, kind of surgery, non-myasthenic complications and duration of intubation.Twenty-two patients experienced postoperative respiratory failure after thymectomy. Univariate analysis revealed a correlation with age60 years (odds ratio (OR) = 1.79, 95% confidence interval (CI) = 1.04-6.78; P = 0.040); Osserman-stage (IIB- OR = 5.16, 95% CI = 1.10-24.18; P = 0.037, III-IV- OR = 8.75, 95% CI = 1.53-50.05; P = 0.015); bulbar symptoms (OR = 7.42, 95% CI = 1.67-32.84; P = 0.008); BMI28 (OR = 3.99, 95% CI = 1.58-10.03; P = 0.003); preoperative plasmapheresis (OR = 2.97, 95% CI = 1.18-14.04; P = 0.021); duration of symptoms2 years (OR = 4.00, 95% CI = 1.09-14.762; P = 0.036); extended surgery (OR = 2.52, 95% CI = 1.02-6.22; P = 0.045); lung (OR = 4.05, 95% CI = 1.44-11.42; P = 0.008), pericardial (OR = 3.78, 95% CI = 1.45-9.82; P = 0.006) or pleural resection (OR = 3.23, 95% CI = 1.30-8.03; P = 0.012); Vital Capacity %80% (OR = 0.20, 95% CI = 0.05-0.82; P = 0.025) and PaCO240 mmHg (OR = 3.76, 95% CI = 1.12-12.68; P = 0.032). Multivariate logistic regression analysis showed that Osserman-stage (IIB- OR = 5.69, 95% CI = 1.09-29.69; P = 0.039 (III-IV- OR = 11.33, 95% CI = 1.67-76.72; P = 0.013), BMI28 (OR = 3.65, 95% CI = 1.10-12.15; P = 0.035), history of myasthenic crisis (OR = 24.10, 95% CI = 2.34-248.04; P = 0.007), duration of symptoms2 years (OR = 5.94, 95% CI = 1.12-31.48; P = 0.036) and lung resection (OR = 8.48, 95% CI = 2.18-32.97; P = 0.002) independently predict POMC. Excluding history of preoperative myasthenic crisis (statistically associated with Osserman-stage), we built a scoring system according to the OR of Osserman-stage (I-IIA, IIB, III-IV), BMI (28, ≥ 28), duration of symptoms (1, 1-2,2 years) and association with a pulmonary resection. This model helped in creating four classes with increasing risk of respiratory failure (Group I, 6%; Group II, 10%; Group III, 25%; Group IV, 50%).Our model facilitates the stratification of patient risk and prediction of the occurrence of POMC. Moreover, it could help to guide the anaesthesiologist's decision on the duration of intubation. Further studies based on larger series are needed to confirm these preliminary data.

OBJECTIVES: The outcome of locally advanced non-small-cell lung cancer (NSCLC) patients with pathological complete response (pCR) —pT0N0 —after induction chemoradiotherapy (IT) followed by surgery has, to date, only rarely been investigated. The long-term results in this highly selected subset of patients were evaluated and reported here to identify any predictive factors associated with prognosis. METHODS: From January 1992 to December 2009, 195 consecutive locally advanced (T1–T4/N0–2/M0) NSCLC patients underwent IT, and after clinical restaging, 137 were operated upon with radical intent. Among these, 37 (19% of the overall and 27% of the surgical cohort) showed a pCR status and were included in this retrospective analysis. Survival rates and prognostic factors were analysed by the Kaplan–Meier, the log-rank and Cox regression analyses. RESULTS: The mean age and male/female ratio were 61.9 ± 9.8 years and 33/4, respectively. Before starting IT, the clinical staging was IIb in 2 (5%) patients, IIIa in 20 (54%) and IIIb in 15 (41%). Morbidity and 30-day mortality rates were 27 and 3%, respectively. The overall 3- and 5-year long-term survivals (LTSs) and disease-free survival (DFS) were 67 and 64% and 68 and 71%, respectively. Overall, 17 patients (46%) experienced a recurrence, occurring more frequently in a distant site (32%) than locally (19%). The analysis of the 5year LTS suggests that (i) the initial single N2 station involvement (P= 0.010); (ii) the resection to a lesser extent than pneumonectomy (P= 0.005) and (iii) the adjuvant therapy (P= 0.005) are all positive prognostic factors. In particular, a 5-year hazard ratio of 8.21 (95% confidence interval 2.16–31.16, P= 0.002) was estimated by Cox regression analysis for subjects who did not undergo adjuvant therapy vs those who did. CONCLUSIONS: After induction radiochemotherapy followed by surgery in locally advanced NSCLC, a pCR is achieved in a remarkable proportion of cases (27% in our experience). In such patients, a rewarding LTS (64% at 5 years) could be expected, especially when a single N2 station is involved at diagnosis or when an adjuvant treatment is administered. Nevertheless, recurrences after surgery are quite common (46%) and this evidence deserves further investigations and deeper analysis.

Objective: Radical surgery is the cornerstone of treatment for thymic tumors, but a complete surgical resection in stage III is not always achievable; and recurrence of disease is not rare. We reviewed the results of four centers with large experience in multimodality treatment of stage III thymic tumors. Methods: Between 1980 and 2009, 249 patients (137 males: 112 females; median age 50 years) with stage III thymic tumors underwent surgery. Myasthenia gravis (MG) was present in 110 (44.2%) patients. A total of 94 (37.7%) patients received induction chemotherapy and 205 (82.7%) had adjuvant treatments. Results:Thirty-day mortality was 0.8%. A total of 203 (81.6%) had R0, 26 (10.4%) R1 and 20 (8%) R2 resection. World Health Organization (WHO) histotype was: A in 2.4%, AB in 15.3%, B1 in 16.5%, B2 in 31.3%, B3 in 22.1%, and thymic carcinoma in 12.4%. The R0 rate was lower in patients who received induction chemotherapy (p = 0.04), in B1—B2-thymic carcinoma histotypes (p = 0.05), and in patients without MG (p = 0.04). Overall 10-year survival rate was 64%; tumor-related and disease-free survival were 76% and 74%, respectively. At univariate analysis, R2 resection (p < 0.0001), recurrence of disease (p < 0.0001), absence of MG (p = 0.0009), thymic carcinoma (p = 0.002), age more than 50 years (p = 0.01), and vascular invasion (p < 0.0001) were predictors of poor survival. At multivariate analysis, type of resection (p < 0.0001), vascular involvement (p = 0.007), and recurrent disease (p < 0.0001) were independent predictors of prognosis. During follow-up, 43 (21.2%)patients developedrecurrence. Patients with recurrence, who underwent redo surgery (n = 24), showed a similar survival to patients without recurrence. Conclusions: Multimodality treatment of stage III thymic tumors achieved good survival. Radical surgery, even at recurrence, seems to be the most important prognostic factor. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Objective: The clinical outcome of 180 non-thymomatous myasthenia gravis (MG) consecutive cases surgically treated is reported herein. The original surgical access, consisting of a video-assisted infra-mammary cosmetic incision and median sternotomy, has originally been designed and described by our group. Methods: The in-hospital patients’ charts and the outpatients’ clinic follow-up information of the 180 cases have been extensivelyreviewed.In additionto the strictly surgicalbenchmarkreferral,data on therate of cure of the MG (completestableremission— CSR; pharmacological remission — PR) as indicated by the Myasthenia Gravis Foundation of America (MGFA) have been analysed as recorded at the 12 months after surgery checkpoint. Cosmetic outcome was evaluated as well. Results: Female to male ratio was 156 (86.7%):24 (13.3%). Mean age: 29.1 10.9 years. Preoperative MGFA score: stage I: 4 patients (2.2%); IIa: 57 (31.7%); IIb: 32 (17.8%); IIIa: 41 (23.3%); IIIb: 42 (23.3%); IVa: 2 (1.1%); V: 2 (1.1%). Median operative time was 110 min (70—130 min) and median postoperative hospital stay was 4 days (3—10 days). Postoperative mortality was nil and morbidity occurred in seven patients (3.8%). Final pathology was consistent with: 146 hyperplastic thymus (81.1%); 28 involuted thymus (15.6%) and 6 normal thymus (3.3%). Ectopic thymic tissue was found in 68% of the patients. Mean follow-up was 62.9 34.6 months. A CSR was obtained in 55%; PR in 18.3%; improvement in 39.9%, unchanged in 3.5%, worse in 1.1% and died in 0.5%. Kaplan— Meier estimates of CSR were 34.1% and 75.8% at 5 and 10 years, respectively. The preoperative therapy was the only parameter significantly associated with Kaplan—Meier CSR rates (univariate analysis — p < 0.001). Remarkably, 171 (95%) patients judged their cosmetic results to be excellent or very good.Conclusions:Thymectomy in MG patients via video-assisted infra-mammary cosmetic incision and median sternotomyhas shown to be a useful surgical approach as demonstrated by the good functional and very good aesthetic results, associated with a very low morbidity and no mortality. Patients with preoperative mono-therapy have higher CSR rates. CSRs are durable, as the CSR rate improves with extended follow-up. # 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Objectives: To evaluate the effectiveness of radiological assessment (high-resolution CT (HRCT), helical CT (HCT) scan) of lung metastases and to verify if a complete manual exploration by thoracotomy is necessary. Materials and methods: From 1/96 to 1/00, 166 consecutive patients presenting with lung metastases were treated. Preoperative CT scan (HRCT in 78 patients, group A; HCT in 88 patients, group B) to assess the number, size and location of the lesions (slice thickness 5 mm; reconstruction interval 3–5 mm) was always performed. All patients underwent axillary thoracotomy (staged when lesions were bilateral); accurate palpation of the lung parenchyma was always performed to identify any undetected lesion. Non-metastatic lesions were excluded. Results: We performed 356 wedge resections in 161 patients (113 monolateral, 70.2%; 48 bilateral, 29.8%) and five lobectomies. In group A, primary neoplasm was epithelial in 44 patients, sarcoma in 26 and germ cell in eight, and in group B, epithelial in 61 patients, sarcoma in 20 and germ cell in seven. Three hundred and sixtyone histologically proven metastases were resected (188 in group A and 173 in group B). HRCT correctly identified 142/188 lesions (sensitivity 75%); HCT revealed 142/173 metastases (sensitivity 82.1%). Sensitivity for lesions less than 6 mm in maximum diameter was 48% (30/58 false negative) in group A and 61.5% (20/52 false negative) in group B. Conclusions: The sensitivity of HCT exceeds that of HRCT. However, complete manual exploration by thoracotomy remains the procedure of choice for patients undergoing pulmonary metastasectomy, because of limitation in preoperative radiological assessment of lung lesions smaller than 6 mm. q 2002 Elsevier Science B.V. All rights reserved.

Solitary fibrous tumor (SFT) of the esophagus has been very rarely reported in literature. Herein, we report a case of a successful surgically treated malignant solitaryfibroustumor of the esophagus. A 36-year-old womanwas admittedat our hospital with an erroneousultrasound-based diagnosis of cervico-mediastinal goiter. Surprisingly, the preoperative diagnostic work-up, including a computed tomographic chest scan, endoscopy, and endoscopic ultrasonography, revealed a pedunculated intraluminal mass in the esophagus. The tumor was radically removed through left antero—lateral cervicotomy. Pathologic and immunohistochemical examination was concludedfor a malignant SFT, a rare variant not previously described in relation to the esophagus. The patient underwent adjuvant radiotherapy and is alive with no signs of tumor recurrence 32 months after surgery. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Objective: The prognosis of non-small cell lung cancer (NSCLC) with brain metastasis is very poor, with median survival rate below 6 months, even if treated with palliative radio and/or chemotherapy. To assess the effectiveness of surgical treatment for this kind of patients we reviewed our experience. Methods: From January 1989 to October 1999, 30 patients (26 males and four females; mean age: 58.7 years) with NSCLC and single brain metastasis underwent surgical treatment of both primary lung cancer and secondary cerebral lesion. Patients (pts) were divided into two major groups. In group 1 (G1) 20 pts (18 males and two females) presented a synchronous brain metastasis. In group 2 (G2) 10 pts (eight males and two females) presented a metachronous brain metastasis during the follow-up period (range 3‐24 months since the primary tumor). Patients selected in G1 had T1‐2, N0‐1 clinical staging, good ‘performance status’ (ECOG:0‐1; Karnofsky index .70%), age , 75 years. Craniotomy has always been the first approach. In G2 also patients with locally advanced tumors (T3 and/or N2) were included. Whole brain radiotherapy and/or chemotherapy was the post-operative choice treatment. Results: Histologic findings have shown: adenocarcinoma in 17 cases (12 in G1; five in G2), squamous cell carcinoma in 10 cases (six in G1; four in G2), large cell carcinoma in 2 (one in G1; one in G2) and large cell neuroendocrine carcinoma in one (G1). Survival analysis (Kaplan‐Meier method) has shown an overall value of 80% at 1 year (95% in G1; 50% in G2), 41% at 2 years (47% in G1; 30% in G2) and 17% at 3 years (14% in G1; 20% in G2). Overall median survival is 23 months (23 in G1; 11 in G2); mean survival 27.8 months (30.3 months in G1; 22.8 months in G2). According to univariate analysis prognosis is definitively better in N0 tumors compared to N1‐2 tumors and in adenocarcinoma cases compared to other histotypes (P , 0:05). Conclusions: We can conclude that combined surgical therapy is, nowadays, the choice treatment for this kind of patients, even though restricted to selected cases. The knowledge of prognostic factors may optimize indications for surgery. q 2001 Elsevier Science B.V. All rights reserved.

Objective: This is an analysis of a randomized controlled clinical trial planned to evaluate the effects of adjuvant radiotherapy (AR) on the local recurrence rate in patients with non-small cell lung cancer (NSCLC) with pathological stage (pStage) Ia (pT1N0) and Ib (pT2N0). The effects of AR on the long-term survival have also been marginally evaluated. Materials and methods: This clinical trial was planned with the hypothesis that AR on pStage Ia and Ib, R0 NSCLCs was effective on local recurrence rate. From July 1989 through March 1997, 104 patients with NSCLC who presented with pStage Ia and Ib have been observed and treated and entered the study. Male/female ratio was 91:13; the mean age was 62 years (range 41‐75 years). All patients underwent major pulmonary resection and homolateral standard hilar and mediastinal lymph node dissection. pStage was T1N0 in 29 and T2N0 in 75 cases. Patients have been randomized ‘by chance’ into two groups (G1 and G2). G1 received radiotherapy, G2 did not receive any adjuvant treatment. Fifty-two patients entered G1 and 52 entered G2. Results: Post-operative mortality was nil. Seven patients have been excluded from the study (four in G1 and three in G2), due to incomplete follow-up data. We do not report any radiotherapy-related complication or deterioration of lung function. The treatment effect on the local recurrence rate demonstrated a clearly significant protective effect of the AR. No statistically significant difference was found from the comparison of the 5-year survival rate of the treated (83%) versus untreated (70%) patients. No detrimental effect of the radiotherapy has been assessed. Conclusions: AR in the treatment of pStage Ia and Ib NSCLC has been well tolerated and had a significant relative effect on the local recurrence rate but did not significantly modify overall survival even if a positive trend in the group of treated patients is reported. q 2000 Elsevier Science B.V. All rights reserved.

Objective: In recent years many authors have been focused on N2 non-small cell lung cancer patients to determine whether the rate of resectability and long term survival can be improved by a combined preoperative treatment, with significant results. Following these experiences, we planned an induction therapy trial to assess the impact on downstaging, resectability and survival of concurrent radio-chemotherapy on N2 non-small cell lung cancer patients. Methods: Between January 1990 and August 1995, 82 N2 non-small cell lung cancer patients (44 IIIA and 38 IIIB) received preoperative chemo-radiotherapy with a single cycle of Carboplatin (90 mg/m 2 per day for days 1-4), concurrent with radiotherapy (daily radiation dose of 180 cGray for a total of 5040). After surgery, all patients received multi-drug chemotherapy with Carboplatin 300 mg/m 2 per day on day 1 and VP-16 100 mg/m 2 per day on days 1, 2 and 3, for a total of 6 monthly cycles. Patients with unresectable tumors underwent to this multi-drug chemotherapy, directly. Results: Two patients were excluded from the study. When the remaining 80 patients had a 'clinical' re-staging, 41 (51.3%) showed a major response, 36 (45%) had minimal or none response, and 3 (3.7%) had progression of disease. Forty-one patients were judged to be resectable, 11 staged IIIB, and 30 IIIA; 2 patients of the IIIB group refused surgery. Of the 39 operated cases, 37 were completely resected (resectability rate: 94.8%). We report one perioperative death due to respiratory failure and two major complications. The overall actuarial 5 year survival is 24.5%. Downstaging was observed in 22 patients (56.4%), with three patients (7.7%) having no evidence of tumor in the specimen, 16 (41%) having sterilization of all lymph nodes, and three (7.7%) having sterilization of mediastinal nodes but positive N1 nodes. The 5-year actuarial survival is 53% for patients who had complete resection and 0% for patients with no resection (P= 0.0000). Conclusions: The following conclusions are possible: preoperative radiotherapy and chemotherapy with Carboplatin is well tolerated by patients, does not increase postoperative complications and produces an high rate of response. There is an high resection rate for patients who respond to the therapy. Patients with major response who undergo complete surgical resection had statistically significant improved survival compared with patients whose disease was not resected.

Primary pulmonary meningioma is an uncommon, usually benign, soft tissue tumour which has rarely been reported. We report an additional case of primary pulmonary meningioma occurring in an asymptomatic 56-year-old man whose diagnosis was only established after resection. The features of this lesion together with a review of the previous literature are described.

From 1980 to 1990, 31 patients were treated surgically in our department for esophageal diverticula: 12 Zenker's diverticula (ZD); 11 mid-thoracic diverticula (MTD); 8 epiphrenic diverticula (ED). Cricopharyngeal dysfunction was detectable in 8 of 12 ZD patients (66.6%). Cricopharyngeal myotomy with diverticulectomy was performed in all cases. There were no deaths. Relief of dysphagia was obtained in all cases. No recurrences of dysphagia or diverticulum were observed at a mean follow-up of 3 years. A motility disorder was observed in 10 of 11 MTD (90.9%). An extended esophageal myotomy with diverticulectomy was performed in 3 cases, an extended myotomy alone in 3 cases, a diverticulectomy alone in 5 cases; an anti-reflux procedure was added in 6 cases. One patient died on the 7th postoperative day. All remaining patients were free of symptoms at a mean follow-up of 3.2 years. A motor dysfunction was detected in all 8 ED patients (100%). No diverticulectomy was performed. Six patients underwent Heller-Dor myotomy and 2 underwent Nissen fundoplication. There were no deaths. Relief of symptoms was obtained in all patients, at a mean follow-up of 3.1 years. Myotomy with diverticulectomy represents the treatment of choice in ZD. As regards MTD and ED, the treatment of the underlying motor disorder is the main therapeutic goal, whereas diverticulectomy is reserved to selected patients.

Objective: We describe our experience with the staged axillary thoracotomy (SAT), for the treatment of bilateral lung metastases. Materials and Methods: Between January 1995 and June 1998, 75 lung metastasectomies were carried out in our institution, 49 (65%) monolateral, and 26 (35%) bilateral. In the latter group of patients we adopted a staged axillary thoracotomy. Results: All wedge resections and two lobectomies (1 LUL and 1 RLL) were performed through this approach. Resection has been complete in all patients. Histology was epithelial in 15 (57%), sarcoma in nine (35%) and germ cell in two (8%). Two to three metastases have been resected in 10 patients (38%); four to 10 in 12 patients (46%) and over 10 in four patients (15%). The radiological pre-operative assessment was accurate in 15 patients (57%), underestimated in nine (35%) and overestimated in two (8%). The average interval between the two procedures has been 24 ^ 6 days. The average operation duration time was 50 min (range 36‐67). We do not report any post-operative death or major complication. The average hospitalization was 3.2 days (range 2‐6) for each single procedure and 6.2 days (range 4‐10) for both procedures. Conclusion: This technique is adequate, fast and safe and did not affect the shoulder girdle motion at all providing an excellent cosmetic outcome. The operative trauma is limited and a minor post-operative pain is present. A shortening of the interval between the two operations is allowed. q 1999 Elsevier Science B.V. All rights reserved.

We describe the technique, the benefits and the drawbacks of an original video-assisted thymectomy (VAT), performed through an inframammary cosmetic incision and median sternotomy in myasthenia gravis (MG) patients. This procedure is clinically valuable and cosmetically satisfactory so as to be very well accepted by patients, especially by young women. We report a review of 71 MG patients treated between 1993 and 1997. A clinical remission was obtained in 48 (80%) out of 60 patients who had been followed for at least 12 months from surgery. Fifty-three of these patients (93%) judged their cosmetic results to be excellent or good.

Let requires anastomoses of renal arteries. (2) T EVAR alone is associated with the risk of emboli, including lipid-laden plaques in the kidneys. (3) In follow-up, contrast-enhanced computed tomography (CT) scans are essential for detecting TEVAR-specific complications (e.g., endoleaks and migration). This requires the use of intravenous contrast agents, which is associated with contrast nephrotoxicity.

respectively. All patients but 2 (treated with chemotherapy) underwent surgi- cal resection with curative intent. At diagnosis, 8 patients (40%) presented with advanced (or locally advanced) disease. The overall median and 5-year survivals were 47 months and 71.5%, respectively. A complete remission of CS was obtained in 14 cases (70%). Four patients (25%) experienced a relapse of disease after radical surgery. Log-rank analysis identified the tumour location (peripheral versus central; P = 0.004), the histology (atypical versus typical carcinoids; P= 0.064), the pTNM-staging (P = 0.020), the number of mitosis (P= 0.001), the ki-67% index (P= 0.001) and the persistence of CS (P= 0.035) as prognostic factors in such cohort of patients. Conclusions: Pulmonary carcinoids causing Cushing's syndrome are character- ized by a high rate of lymph nodal involvement at diagnosis (N2 disease in 30% of patients), a suboptimal prognosis (5-year survival = 71.5%) and a remarkable risk of relapse (25%) even after radical resection. Tumour location (periph- eral location), histology (atypical carcinoids), high number of mitosis, high ki-67% index, advanced p-Stage and the persisting of the CS after surgery cor- relate with a poor prognosis in such patients. Disclosure: No significant relationships.

We read with interest the report from Bobbio et al. on preoperative pulmonary rehabilitation (Pre-PR) in COPD/ non-small cell lung cancer (NSCLC) patients who are candidates for surgery [1]. We have recently published our own experience based on early stage NSCLC patients where surgery could not be considered due to impaired pulmonary function [2]. The eight patients who accepted to enter the study could then be operated (necessary functional criteria for surgery were re-met). Interestingly a degree of functional amelioration was noticed: increases were observed in the FVC, both in terms of volume and percentage of that predicted (+0.44 l and +12.9%, respectively) and less significantly in FEV1. Apart from this, an amelioration of the exercise endurance (6 min walking test) was reported. We would like to invite the authors of [1] to discuss the possible reasons for this difference (no substantial change in function, as expressed by volumes, in their experience vs a significant change in ours) whereas, apart from the differences in the protocol (the length and the ‘inpatient’ condition may have helped situations like suspension of smoking habit/compliance to therapy along with a comprehensive psychological support to foster motivation), we could attest to the fact that only patients with a very impaired function were enrolled in our observation and this fact may have given a certain enhancement to the relative improvement of volumes (potential interpretation bias). Our group has a long lasting interest in pulmonary rehabilitation in NSCLC surgical patients. In fact we have recently published our experience in postoperative pulmonary rehabilitation (Post-PR) whereas most functional parameters among treated (rehabilitated) patients were improved and, on the contrary, global function in the control group (non-rehabilitated patients) was homogeneously decreased [3]. Despite the substantial difference at baseline in functional terms of the two groups (rehabilitated worse, non-rehabilitated better), the comparison of treated vs untreated patients 1 month after the operation did not show significant difference thus demonstrating a clinically significant amelioration in the treated ones. Both the PrePR and the PostPR approaches have proved to benefit NSCLC patients who are candidates for or who have undergone surgery. For this reason we have planned a more comprehensive clinical experimentation to addmore power to our preliminary results within properly controlled prospected trials (weareperfectly aware thatat least in thePrePR setting, recruitment canbequitedifficult).Moreoverwearepursuinga translational approach investigating, on the clinical side, the value of the BODE index [4] as a validated indicator of the effects of PR and, on the opposite side of the translational research loop, the possible validation of some molecular biomarkers (mostly related to oxidative stress) to verify any potential match and value in the monitoring of the effects of PR in COPD and NSCLC surgical patients. As well we would like the authors [1] to briefly comment on these approaches in the light of fostering a comprehensive and constructive discussion towards the full inclusion of PR into the treatment strategy for NSCLC.

Talc pleurodesis for malignant pleural effusion (MPE) is a procedure which, undoubtedly, is useful in the approach to advanced stage cancer patients whose quality of life is severely impaired by this clinical occurrence. In this setting, we really appreciate the report from Stefani and co-workers [1] that, even within the limits of a prospective nonrandomized trial, gives a clear and evidence-based rationale to support talc poudrage for MPE per se and suggests some valuable criteria to support the decision-making process towards the indication for a videothoracoscopic procedure (thoracoscopic talc poudrage—TP) or a bedside one (talc slurry—TS). We now had time to evaluate retrospectively our experience with 317 patients with MPE who, in the period from January 1995 to December 2006, underwent TP. In the same period, 76 patients underwent bedside TS, due to very poor clinical conditions. The comparison of these two groups in terms of efficacy (successful pleurodesis within 90 days from procedure) largely confirms the authors’ conclusion that TP is better than TS (87.5% vs 72.3%, p < 0.01). Unlike the figures reported in [1], the incidence of post-procedural pain was different, but not significantly, in the two groups. Herein we would like to report our results when a single access thoracoscopic procedure is compared with a multiple accesses procedure (two or more). Of the 317 patients, in fact, 187 underwent a single access procedure (group A) in which a 5 mm camera was introduced in the same port (12 mm) along with instruments for suction, pleurolysisbiopsy and poudrage (pneumatically atomized talc — 6 g — through a soft silicone tube); a single chest drain, 28 Fr, was inserted through the same hole. The remaining 130 cases underwent a standard, multiple accesses procedure (group B). Morbidity and mortality (30-day procedure related, nil in both groups) did not differ between the two groups. Analgesic drug administration (elastomeric pump for continuous infusion of 20 mg morphine plus 150 mg ketorolac at 2 ml/h/48 h) was discontinued after 48 h in 81% of the patients in group A and in 61% in group B (p = 0.0001). No statistical differences in terms of procedure efficacy (endpoint: MPE recurrence) were found between the two groups. Our results strongly support the value of TP in the treatment of MPE as reported in [1]. We would really appreciate the authors’ reflection and reaction in considering and discussing a single approach for TP.

We have read with interest the report from Christodoulou and co-workers [1] regarding the video-assisted thoracic surgery (VATS) treatment of spontaneous (non-traumatic) recurrent chylotorax. As a matter of fact, due to the respiratory, nutritional and immunological implications, surgery is indicated whereas any conservative treatment failed in controlling this clinical condition. On the basis of their experience on a series of six treated patients, the Authors do conclude that recurrent or persistent non-traumatic chylothorax may be successfully treated by video-assisted right supradiaphragmatic thoracic duct ligation. We strongly agree with the Authors on their conclusion since we have observed similar evidences in our own experience (adopting the same surgical approach) on 12 cases (10 right sided, 2 left sided) observed and treated in our Institution in the period between January 2001 and December 2005 (in the same period, two cases were treated by an open thoracotomic approach because they were previously submitted elsewhere to video-assisted thoracic duct ligation). Before surgery, all patients had a pleural drainage for almost 2 weeks with a persisting leak >300 ml/ day. Four patients developed chylothorax as a result of thoracic irradiation and four cancer (three lymphoma, one breast cancer). In particular, we report a mean operating time of 92 14 min with no mortality or major perioperative complications. A single chest drain was left in place after operation connected with a very mild continuous aspiration for the first 24 h. The drain was removed 5 1 days after the operation (mean). Patient controlled anaesthesia (PCA) and physiotherapy were adopted in all cases. A