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OBJECTIVES Only few studies compared the surgical morbidity and mortality of thoracoscopic segmentectomy versus lobectomy for non-small-cell lung cancer, in particular, by relating the segmental resections with the corresponding anatomical lobes. METHODS We enrolled a total of 7487 patients who underwent VATS lobectomy (7269) or segmentectomy (218) from January 2014 to July 2019. A propensity score matching approach was used to account for potential confounding factors between the 2 groups. After matching, 349 lobectomies and 208 segmentectomies were included in the analysis. We analysed the operative and postoperative outcomes of video-assisted anatomical segmentectomy compared with video-assisted lobectomy and, in details, the results of segmentectomy with its corresponding lobectomy in a large cohort of patients from the Italian VATS Group Registry. RESULTS The overall conversion rate to thoracotomy was not statistically different between the groups (27 patients 8% vs 7 patients 3%, P = 0.1). The lobectomy group had a greater number of resected lymph nodes (median 11 vs 8, P = 0.006). No significant differences were detected in 30-day mortality (1.4%, 5 patients vs 0.9%, 2 patients), overall complications (18%, 62 patients vs 14%, 29 patients) and prolonged air leakage (31 patients, 9% vs 12 patients, 6%) between lobectomy and segmentectomy, respectively. No statistical differences were found regarding the median duration of drainage (3.2 days, P = 1) and the overall median length of hospital stay (6.4 days, P = 0.1) between the 2 groups. In the context of segmentectomy versus corresponding lobectomy, the right upper lobectomy compared with right upper segmentectomy showed a higher number of resected lymph nodes (P = 0.027). No statistical differences were reported in terms of conversion rate and postoperative complication and mortality. CONCLUSIONS Segmentectomy could be considered a safe procedure without significant differences compared to thoracoscopic lobectomy in terms of postoperative morbidity and mortality.

OBJECTIVES This study compares the uniportal with the 3-portal video-assisted thoracic surgery (VATS) by examining the data collected in the Italian VATS Group Database. The primary end point was early postoperative pain; secondary end points were intraoperative and postoperative complications, surgical time, number of dissected lymph nodes and length of stay. METHODS This was an observational, retrospective, cohort, multicentre study on data collected by 49 Italian thoracic units. Inclusion criteria were clinical stage I–II non-small-cell lung cancer, uniportal or 3-portal VATS lobectomy and R0 resection. Exclusion criteria were cT3 disease, previous thoracic malignancy, induction therapy, significant comorbidities and conversion to other techniques. The pain parameter was dichotomized: the numeric rating scale ≤3 described mild pain, whereas the numeric rating scale score >3 described moderate/severe pain. The propensity score-adjusted generalized estimating equation was used to compare the uniportal with 3-portal lobectomy. RESULTS Among 4338 patients enrolled from January 2014 to July 2017, 1980 met the inclusion criteria; 1808 patients underwent 3-portal lobectomy and 172 uniportal surgery. The adjusted generalized estimating equation regression model using the propensity score showed that over time pain decreased in both groups (P CONCLUSIONS Data from the Italian VATS Group Database showed that in clinical practice uniportal lobectomy seems to entail a higher risk of moderate/severe pain on second and third postoperative days.

OBJECTIVESInherent technical aspects of pulmonary lobectomy by video-assisted thoracoscopic surgery (VATS) may limit surgeons’ ability to deal with factors predisposing to complications. We analysed complication rates after VATS lobectomy in a prospectively maintained nationwide registry.METHODSThe registry was queried for all consecutive VATS lobectomy procedures from 49 Italian Thoracic Units. Baseline condition, tumour features, surgical techniques, devices, postoperative care, complications, conversions and the reasons thereof were detailed. Univariable and multivariable regressions were used to assess factors potentially linked to complications.RESULTSFour thousand one hundred and ninety-one VATS lobectomies in 4156 patients (2480 men, 1676 women) were analysed. The median age-adjusted Charlson index of the patients was 4 (interquartile range 3–6). Grade 1 and 2 and Grade 3–5 complications were observed in 20.1% and in 5.8%, respectively. Ninety-day mortality was 0.55%. The overall conversion rate was 9.2% and significantly higher in low-volume centres (CONCLUSIONSVATS lobectomy is a safe procedure even in medically compromised patients. An improved classification system for conversions is proposed and prevention strategies are suggested to reduce conversion rates and possibly complications in less-experienced centres.

Accurate staging of early non-small cell lung cancer is fundamental for selecting the best treatment. The aim of this study was to identify risk factors for nodal upstaging after video-assisted thoracoscopic lobectomy for clinical T1-3N0 tumors.From 2014 to 2017, 3276 thoracoscopic lobectomies were recorded in the prospective database "Italian VATS Group". Linear and multiple logistic regression models were adapted to identify independent predictors of nodal upstaging and factors associated with progression in postoperative N status.Nodal upstaging was found in 417 cases (12.7%), including 206 cases (6.2%) of N1-positive nodes, 81 cases of N2 nodes (2.4%), and 130 cases (4%) of involvement of both N1 + N2 nodes. A total of 241 (7.3%) patients had single-station nodal involvement, whereas 176 (5.3%) had multiple-station involvement. In the final regression model, the tumor grade, histology, pathologic T status, and 12 resected nodes were independent predictors of nodal upstaging.The number of resected lymph nodes seems to predict nodal upstaging better than the type of intraoperative lymph node management. Other preoperative risk factors correspond to those for which the current guidelines of the European Society of Thoracic Surgery recommend more extensive preoperative mediastinal staging.

Background: The expertise curve of video-assisted thoracoscopic surgery (VATS) lobectomies still stirs debate and controversy both because of the number of procedures to carry out and of the evaluation of the learning threshold. The purpose of our study was the examination of the variables related to the learning curve of the video-assisted approach, to establish what may be an expression of the technical maturity of the surgeon. Methods: The National Register for VATS lobectomy built in 2013 was used to collect data from 65 Thoracic Surgery Units. Out of more than 3,700 patients enrolled, only information from Units with ≥100 VATS lobectomies were retrospectively analysed. Unpaired Student’s t-tests, Fisher’s exact tests, Pearson’s χ 2 were applied as needed. Cumulative summative analysis and one-way ANOVA were used to identify the expertise curve of VATS lobectomy. Results: Ten institutions contributed a total of 1,679 patients, who were divided into three uniform groups according to the chronological sequence of surgery. The length of utility incision, the number of dissected lymph nodes and the operative time were not statistically significant (P=0.999, P=0.972 and P=0.307, respectively) among groups. Conversion to thoracotomy and postoperative air leaks occurred in 125 (7.44%) and 109 (6.49%) patients, gradually declined in Group 3 with statistical signi cance (P=0.048 and P=0.00086). Conclusions: The conversion rate and the percentage of air leaks seem to de ne the expertise of VATS lobectomy, being linked to the ability to manage more complicated surgical cases or intraoperative adverse events.

Maria Bonomi,1 Costantino De Filippis,2 Egesta Lopci,3 Letizia Gianoncelli,1 Giovanna Rizzardi,4 Eleonora Cerchiaro,1 Luigi Bortolotti,4 Alessandro Zanello,2 Giovanni Luca Ceresoli1 1Department of Oncology, Thoracic and GU Oncology Unit, 2Department of Radiology, Cliniche Humanitas Gavazzeni, Bergamo, 3Nuclear Medicine Unit, Humanitas Clinical and Research Hospital, Milan, 4Department of Thoracic Surgery, Cliniche Humanitas Gavazzeni, Bergamo, Italy Abstract: Malignant pleural mesothelioma (MPM) is a disease with limited therapeutic options, the management of which is still controversial. Diagnosis is usually made by thoracoscopy, which allows multiple biopsies with histological subtyping and is indicated for staging purposes in surgical candidates. The recommended and recently updated classification for clinical use is the TNM staging system established by the International Mesothelioma Interest Group and the International Association for the Study of Lung Cancer, which is based mainly on surgical and pathological variables, as well as on cross-sectional imaging. Contrast-enhanced computed tomography is the primary imaging procedure. Currently, the most used measurement system for MPM is the modified Response Evaluation Criteria in Solid Tumors (RECIST) method, which is based on unidimensional measurements of tumor thickness perpendicular to the chest wall or mediastinum. Magnetic resonance imaging and functional imaging with 18F-fluoro-2-deoxy-d-glucose positron-emission tomography can provide additional staging information in selected cases, although the usefulness of this method is limited in patients undergoing pleurodesis. Molecular reclassification of MPM and gene expression or miRNA prognostic models have the potential to improve prognostication and patient selection for a proper treatment algorithm; however, they await prospective validation to be introduced in clinical practice. Keywords: malignant pleural mesothelioma, staging, contrast-enhanced computed tomography, magnetic resonance imaging, positron-emission tomography

OBJECTIVES: Inherent technical aspects of pulmonary lobectomy by video-assisted thoracoscopic surgery (VATS) may limit surgeons’ ability to deal with factors predisposing to complications. We analysed complication rates after VATS lobectomy in a prospectively maintained nationwide registry. METHODS: The registry was queried for all consecutive VATS lobectomy procedures from 49 Italian Thoracic Units. Baseline condition, tumour features, surgical techniques, devices, postoperative care, complications, conversions and the reasons thereof were detailed. Univariable and multivariable regressions were used to assess factors potentially linked to complications. RESULTS: Four thousand one hundred and ninety-one VATS lobectomies in 4156 patients (2480 men, 1676 women) were analysed. The median age-adjusted Charlson index of the patients was 4 (interquartile range 3–6). Grade 1 and 2 and Grade 3–5 complications were observed in 20.1% and in 5.8%, respectively. Ninety-day mortality was 0.55%. The overall conversion rate was 9.2% and significantly higher in low-volume centres (

Purpose Video-assisted thoracoscopic surgery (VATS) lobectomy has become an accepted procedure for the treatment of selected cases of lung cancer. The aim of this project was to establish national practical recommendations for the management of patients suitable for VATS lobectomy. Methods The Scientific Committee of the VATS Lobectomy Group (a branch of the Italian Society of Thoracic Surgery) identified the consensus conference as an appropriate tool for a national debate. The consensus conference was organized following indications of the Italian Department of Health: a panel of experts reviewed the literature, the jury board revised the experts’ reports, and the national conference discussed and voted on statements. The strength of recommendation for a statement was classified as weak, fair, or high when the total score ranged between 51% and 67%, 68% and 84%, or 85% and 100%, respectively. Results Eighty-six Italian thoracic surgeons attended the 1st Italian Consensus Conference on VATS lobectomy in Giulianova, Italy, on October 29-30, 2015. Thirty-three topics were discussed: indications, surgical strategy, perioperative management, and training were the main topics. Consensus was reached on 24 statements that were consequently recommended. Conclusions The Italian Consensus Conference is the first attempt to discuss VATS lobectomy-related issues in a national scientific community. Such experience determined an improvement in epistemic knowledge among the Italian thoracic surgeons and could be a suggestion for other national communities.

Floral and extrafloral angiosperms’ nectar is undoubtedly recognized as a valuable energetic alimentary resource for a large variety of animals. Through nectar consumption insects, small mammals, birds, marsupials and reptiles establish more or less specialized interactions with plants. But according to recent studies, nectar mediates interactions that are much more complex than simply alimentary relations. From the more abundant nectar compounds, i.e. sugars and amino acids mainly responsible for its high alimentary value, attention of scientists is moving towards compounds that are not directly connected with its alimentary importance. Among these, secondary compounds appear to have a special role in regulating interaction with other organisms. Although very few is known about their ecological roles in nectar, recently it was proved that secondary compounds may affect the nectar feeders’ behaviour interacting with their neurobiology. We addressed a special focus on one class of secondary compounds: the non-protein amino acids. Their presence in floral nectar has been reported since long time but their ecological function has not been investigated. Data from several phylogenetically unrelated species indicate that they may represent a consistent part of the total amino acid content of floral nectar (25-45%) and generally the more abundant ones are γ-amino butyric acid (GABA) and β-alanine. The study of nectar chemistry in a restricted taxonomic context (i.e. the tribe Lithospermeae of the Boragniaceae family) revealed that GABA concentration is particularly high in species with specialist bee- and bumblebee-pollination whilst β-alanine increases in species pollinated by flies and passerine birds. This result suggested to test the effect of an artificial diet consisting of 20% sucrose solutions enriched with GABA and β-alanine on some species of Apoidea. Results show that some species of insects increase their mobility, flying activity and survival time when fed with the artificial diet and particularly with the solution enriched with GABA. Although we used high concentration of the non-protein amino acid (20-fold higher than the concentration occurring in nectar), these results push us to further consider the role of GABA in increasing the mobility of insects between flowers and their foraging activity and thus their pollination performances.

Dictamnus albus L., commonly known as dittany, is a long-lived perennial herb belonging to the family Rutaceae; its flowers produce abundant pollen and nectar and are visited by several pollinating insects. Observations on insect behaviour while foraging on D. albus flowers showed that medium to large bees have the highest percentage of contacts with receptive stigmas, i.e. they show the highest probability of acting as valuable pollinators. However, this can be proved through the analysis of the pollen present on their body. We separately collected the pollen sparse on insect body (head, thorax and abdomen) and the pollen actively collected in specialized structures (corbiculae, scopae), in order to assess the fidelity of each visitor taxon, determined as the mean percentage of specific (D. albus) pollen. In addition, we performed a more precise analysis of the pollen load of the main pollinators of D. albus: Habropoda tarsata, Bombus spp. and Megachilidae spp.. For these insect taxa we identified pollen grains at the genus or family level, to infer the levels of competition or synergy among co-flowering species, and to obtain additional information on insect feeding habits. Most visitors showed a high fidelity to D. albus in the study area, meaning that it is a good resource of rewards, and the potentially best pollinators of dittany tend to prefer its flowers compared to co-flowering species, indicating a low competition during full blooming. From the insect perspective, different plants may be source of different rewards at a same time. For example, dittany is mainly visited for nectar by most pollinators but other flowering species are visited for pollen or nectar as well. This study allows us to explore the interactions among species in a complex ecological context and to develop specific conservation actions at both the plant and insect levels.

Amino acids are the main nectar components after sugars. In addition to protein amino acids (among which Proline is the main one) non-protein amino acids (eg GABA, β-alanine) are also present and sometimes very abundant, but their contribution to floral attraction to pollinators is not completely clear. Gentiana lutea subsp. Symphyandra is a perennial and generalist plant; in the studied area, bumble bees are the more important and efficient pollinators. Previous analysis have revealed high concentration β- alanine in G. lutea nectar, and field observations indicated an anomalous behaviour in Bombus individuals that collect nectar from this plant, but not in those collecting pollen (Rossi et al., 2014). To investigate the role of nectar amino acids in plant-pollinator relationship, we analyzed nectar preference under laboratory conditions, using experimental micro colonies of B. terrestris fed with artificially produced nectars. Each trial consisted in the preference analysis (by consumption) of 4 different solutions simulating G. lutea nectar, 3 of them enriched with β-alanine or proline or both amino acids. Nectars were paired in the 6 possible comparisons (dual choice feeding test). Solutions were administered by syringes and consumption was checked at regular intervals (24, 48, 72, and 96 hours). Five trial were performed on B. terrestris workers and two on males. The same tests were carried out with honeybee foragers (Apis mellifera L.) for comparison, since previous studies (Bertazzini et al., 2010) showed a preference for nectars added with Proline in honey bee workers. The results of the single paired comparisons, analysed by t test, indicate a preference of B. terrestris workers for nectars enriched with β-alanine. Nevertheless, ANOVA test on average individual consumption gave inconsistent results among the 5 different trials, although nectars enriched with β-alanine and with both amino acids are the most consumed. MANOVA analysis shows that the preference is influenced not only by the presence of amino acids, but also by the colony of origin and the kind of paired choice. On the contrary, in the two tests performed on B. terrestris males a clear preference for the control solution is observed. Among the enriched solutions, however, also males prefer β-alanine. The results of honey bees tests are under processing.

The abundance and composition of pollinator communities may vary in space and time due to several natural factors, with consequences on the efficiency of pollination and on plant fitness; on the other hand, flowering phenology and abundance may act on the preferences and behaviour of an insect community. We present the results of a 4-year study performed in a natural population of Dictamnus albus within the LIFE+ Project “Plant-Pollinator Integrated CONservation approach: a demonstrative proposal” (LIFE09/NAT/IT000212, http://www.pp-icon.eu). We observed insect behaviour during flower visits, recording the collected rewards, the contacts with receptive stigmas, the movements along the raceme and among plants, and also noting flower abundance and phenological stage. The pollinating ability of each visitor taxon was estimated as an index of pollination performance based on the frequency of visits, fidelity to the dittany (i.e., the percentage of Dictamnus pollen on the total pollen load) and pollination efficiency (i.e., the percentage of contacts with receptive stigmas). Our results indicate a slight variation in the composition of visitor guilds among years, and a considerable ecological specialization of the plant-pollinator system: within the spectrum of visitors, only medium-big sized bees (Habropoda tarsata, Xylocopa spp., Bombus spp.) play a significant role as D. albus pollinators. Megachilids (Megachile, Osmia) show an intermediate efficiency, partly due to their smaller body size; however their high frequency of visit contributes to their role as pollinators. On the contrary, small halictid bees only act as pollen or nectar thieves. These results were helpful for the implementation of concrete conservation measures addressed to pollinator safeguard and habitat restoration, such as the setting of specific nesting sites for solitary bees or bumblebee colonies, as well as the selection of nectariferous flowering species for habitat management. Fruit and seed set of control and pollenaugmented flowers highlighted a variation in pollen/pollinator limitation among years, which may be due to Allee effect (i.e., quantitative limitation) or to high inbreeding between close relatives (i.e., qualitative limitation).

Velutina project: Italian research hunting for solution Vespa velutina Lepieltier, 1836 (Hymenoptera: Vespidae) is an invasive predator of honeybees accidentally introduced into Europe from eastern Asia. It was observed for the first time in southwest France in 2004 and in the following years it rapidly spread almost all over the country. In 2013 it was officially reported in Italy, in the region Liguria, near the border with France. In three years it invaded the whole province of Imperia and it was occasionally reported also in the South Western of Piedmont and in one locality in South Eastern Piedmont. The VELUTINA project was funded in 2014 by the Italian Ministry of Agriculture, with the aim of finding effective control methods against the predator. It includes both research and surveillance: adult and nest monitoring; development of methods for nest detection; development of protocols for nest destruction; studies on wasp chemical communication. Adult monitoring was performed in 5 Italian regions - the two where the hornet is already present and the three bordering ones - with the cooperation of Universities, research centres and beekeeping associations. Reports of V. velutina nests were collected from 2014 to 2016 thanks to the activity of the beekeeping association Apiliguria. Between 2014 and 2015 the presence of V. velutina was confirmed in the provinces were it was already present, with a small enlargement of the distribution area, both along the coast and the valleys, with no trespassing to other regions. Only recently, in November 2016, the presence of V. velutina was reported and confirmed by our institution in a locality of Veneto region, very near to the border with Lombardy and Emilia Romagna. At present, nest destruction represents the most effective method to limit the diffusion of the hornet, but it shows limitations and inconveniences. Nests are often difficult to locate and reach, their destruction is costly and risky for the staff and it is not regulated by official approved protocols. Within VELUTINA project some progresses have been made towards the official recognition of the method, thanks to the cooperation with national and regional institutions. After the end of Velutina project, the researchers of the project and the beekeeping associations of the invaded areas joined together in the scientific net Stopvelutina (www.stopvelutina.it), whose aim is to collect information and find new solutions to limit the spread of V. velutina. Beside the continuation of previous researches, a patent pending method was tested in summer 2016 to fight V. velutina adults in front of the apiaries in Liguria. From the first preliminary results the method resulted highly effective and it seems suitable to contrast the predator also in new invaded areas.