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Seven years after left hemicolectomy and radical lymph nodal dissection followed by adjuvant chemotherapy for colorectal cancer (histotype, adenocarcinoma; stage, pT3N2M0; grading, G2), a slight increase in carcinoembryonic antigen levels (6.2 ng/mL; range, 0-5 ng/mL) was detected in a 79-year-old man. He was a heavy smoker with history of an interstitial fibrotic lung disease with associated areas of emphysema.

Non-small cell lung cancer is the most common type of lung cancer. Surgery is proven to be the most effective treatment in early stages, despite its potential impact on quality of life. Pulmonary rehabilitation, either before or after surgery, is associated with reduced morbidity related symptoms and improved exercise capacity, lung function and quality of life. We describe the study protocol for the open-label randomized controlled trial we are conducting on patients affected by primary lung cancer (stages I-II) eligible for surgical treatment. The control group receives standard care consisting in one educational session before surgery and early inpatient postoperative physiotherapy. The treatment group receives, in addition to standard care, intensive rehabilitation involving 14 preoperative sessions (6 outpatient and 8 home-based) and 39 postoperative sessions (15 outpatient and 24 home-based) with aerobic, resistance and respiratory training, as well as scar massage and group bodyweight exercise training. Assessments are performed at baseline, the day before surgery and one month and six months after surgery. The main outcome is the long-term exercise capacity measured with the Six-Minute Walk Test; short-term exercise capacity, lung function, postoperative morbidity, length of hospital stay, quality of life (Short Form 12), mood disturbances (Hospital Anxiety and Depression Scale) and pain (Numeric Rating Scale) are also recorded and analysed. Patient compliance and treatment-related side effects are also collected. Statistical analyses will be performed according to the intention-to-treat approach. T-test for independent samples will be used for continuous variables after assessment of normality of distribution. Chi-square test will be used for categorical variables. Expecting a 10% dropout rate, assuming α of 5% and power of 80%, we planned to enrol 140 patients to demonstrate a statistically significant difference of 25 m at Six-Minute Walk Test. Pulmonary Resection and Intensive Rehabilitation study (PuReAIR) will contribute significantly in investigating the effects of perioperative rehabilitation on exercise capacity, symptoms, lung function and long-term outcomes in surgically treated lung cancer patients. This study protocol will facilitate interpretation of future results and wide application of evidence-based practice. ClinicalTrials.gov Registry n. NCT02405273 [31.03.2015].

Epidermal growth factor receptor (EGFR) is implicated in tumor development and is highly expressed in many human tumors. EGFR overexpression has been observed in both premalignant lesions and in malignant lung tumors, as well as in 40–80% of patients with non-small cell lung cancer (NSCLC). EGFR is a 170-kDa transmembrane glycoprotein with an extracellular ligand-binding domain and a cytoplasmic domain with intrinsic tyrosine kinase activity. Soluble forms of EGFR (sEGFR) containing the extracellular domain have been described both in conditioned media from EGFR overexpressing cells as well as in peripheral blood. However, very little is known regarding the molecular function and the biochemical properties of these circulating EGFR isoforms. This study investigates the expression of sEGFR in lung cancer cultured cells and NSCLC patients with the aim of identifying clinically relevant isoforms specifically produced by tumor cells. Proteomic approaches including OFFGEL electrophoresis and Western blotting analysis were used to assess the sEGFR expression pattern in primary lung tumor samples, normal counterparts and matched plasma. We discover that the isoelectric points of sEGFR isoforms in NSCLC biopsy tissue differ from those of the isoforms present in healthy tissue and detected in the plasma of all subjects. These results demonstrate, for the first time, the existence of sEGFR isoforms specifically produced by NSCLC tumor cells which could represent a new potential biomarker for diagnosis and therapy of lung tumors. However, our observations indicate that more highly sensitive and specific quantitative assays are needed in order to reliably detect the tumor-associated sEGFR isoforms in plasma samples.

Although sporadically reported after dental examination, subcutaneous emphysema may be erroneously confused with an allergic, or anaphylactic, reaction. We herein report a case of a 57-year-old Caucasian woman who came to our attention after restorative treatment for a carious mandibular right second primary molar. During dental examination, an air driven hand-piece was used to restore occlusal caries. Suddenly, swallowing and breathing difficulties and a facial swelling involving the neck and, partially, the face occurred. She was urgently transported to the Emergency Department with the suspicious of allergic reaction. Clinical examination revealed palpable crepitus at the level of the head, neck and pre-sternal region but no inflammation, trismus or fluid collection was detected. A Chest X-ray first and a computed tomography scan later showed air in the deeper regions from the peri-mandibular and retro-mandibular spaces to the sub-maxillary and latero-cervical area along the vascular sulcus and retropharyngeal space descending into the mediastinal space. So, the patient was admitted for respiratory monitoring and started intravenous administration of largespectrum antibiotics and analgesics. Her hospital course was unremarkable and 5 days later she was discharged after regression of symptoms and complete radiological resolution. Three months after discharge, the patient was clinically free of recurrence.Dental care, Pneumomediastinum, Restorative dentistry.Una donna di 57 anni si sottoponeva ad trattamento odontoiatrico per una carie del secondo molare superiore di destra. Durante la visita odontoiatrica veniva utilizzato uno strumento ad aria compressa, secondo lo standard di cura. Improvvisamente, la paziente accusava deglutizione e difficoltà respiratorie ed un notevole gonfiore del viso che coinvolgeva il collo e parzialmente il volto. La paziente veniva pertanto trasportata d’urgenza al Pronto Soccorso con il sospetto di reazione allergica. L’esame clinico rivelava un crepitio palpabile a livello dei tessuti sottocutanei del volto, del collo e della regione pre- sternale senza però rilevare nessun segno di infiammazione, trisma o raccolta di liquidi. Una radiografia del torace prima ed una tomografia computerizzata successivamente confermavano la presenza d’aria nei tessuti molli delle regioni profonde dagli spazi peri-mandibolare e retro-mandibolari e nella zona sub-mascellare e latero –cervicale estendendosi lungo il solco vascolare e nello spazio retrofaringeo discendente fino a livello del mediastino. La paziente veniva quindi sottoposta ad osservazione clinica e monitoraggio respiratorio, e si cominciava la somministrazione endovenosa di antibiotici ad ampio spettro ed analgesici. Il successivo decorso ospedaliero risultava regolare e la paziente veniva dimessa in 5° giornata di ricovero dopo miglioramento del quadro clinico e radiologico. Tre mesi dopo la dimissione, la paziente risultava in buone condizioni cliniche in assenza di recidiva. Come risulta nel caso sopra riportato, l’enfisema sottocutaneo e lo pneumomediastino, sebbene raramente possono essere legati ad alcune manovre odontoiatriche che utilizzano sistemi ad immissione di aria ad alta pressione. Nonostante l’esordio acuto ed la sintomatologia spesso allarmante (al punto da poter essere erroneamente scambiata per una reazione allergica), si tratta di una condizione benigna e sostanzialmente ad auto-risoluzione pur necessitando di un breve periodo di osservazione clinica e profilassi antibiotica.

Background Large cell neuroendocrine carcinoma is a recently recognized histologic entity whose clinical features and optimal treatment have not yet been well defined and are still being assessed. We report our retrospective assessment of cases of large cell neuroendocrine carcinoma observed from 1989 to 1999 in terms of survival. Methods Cases of large cell neuroendocrine carcinoma diagnosed between 1989 and 1999 were reassessed retrospectively according to the World Health Organization classification. The clinical outcome and pathologic features of all cases are described. Survival rates of patients with large cell neuroendocrine carcinoma are compared with those patients with small cell lung cancer treated in the same period. Results Patients were 41 men and 7 women with an average age of 63.7 years. Twenty-nine patients (60.4%) had pathologic stage I disease, 11 patients (22.9%) had pathologic stage II disease, and 7 patients (14.6%) had pathologic stage IIIA disease. One patient (2.1%) had pathologic stage IIIB disease. No patient underwent induction chemotherapy. Two patients underwent adjuvant chemotherapy and 2 underwent mediastinal radiotherapy for N2. No death was reported in the perioperative period. The median follow-up was 5 years. The actuarial survival for the entire group was 60.4% at 1 year, 27.5% at 3 years, and 21.2% at 5 years. The actuarial survival of accurately staged, stage I patients at 5 years was 27%. Conclusions The findings suggest that treating large cell neuroendocrine carcinoma by means of applying treatment for nonsmall cell lung cancer leads to a prognosis that is worse than that for nonsmall cell lung cancer, even in terms of low pathologic stages.

Herein we describe a rare case of neuroglial heterotopia (ectopic mature cerebral tissue) incidentally detected by F-FDG PET/CT. A 52-year-old female patient underwent F-FDG PET/CT for metabolic characterization of a left pulmonary nodule. F-FDG PET/CT revealed increased radiopharmaceutical uptake corresponding to the pulmonary nodule pathologically described as adenocarcinoma. Furthermore, an area of increased F-FDG uptake corresponding to a lesion in the left nasal cavity was detected. Endoscopic biopsy of the nasal lesion showed the presence of ectopic mature cerebral tissue suggesting the presence of neuroglial heterotopia.

Pulmonary neuroendocrine tumors (pNETs) arise from bronchial mucosal cells known as enterochromaffin cells which are part of the diffuse neuroendocrine system. The pathological spectrum of pNETs ranges from low-/intermediate-grade neoplasms such as bronchial carcinoids (BCs), also known as typical or atypical carcinoids, to high-grade neoplasms as large-cell neuroendocrine carcinoma and small-cell lung cancer. The tumor biology of pNETs still represents a matter of open debate. The distinct features among the different pNETs include not only their pathologic characteristics but also their clinical behavior, epidemiology, treatment, and prognosis. In this sense, a correct pathological identification in the preoperative setting is a key element for planning the best strategy of care in pNETs and especially in BCs. Controversial results have been reported on the diagnostic accuracy of fluorine-18-fluorodeoxyglucose positron emission tomography or positron emission tomography/computed tomography (F-18-FDG PET or PET/CT) in BCs. On the other hand, there is increasing evidence supporting the use of PET with somatostatin analogues (DOTA-TOC, DOTA-NOC, or DOTA-TATE) labeled with gallium-68 (Ga-68) in pNETs. Herein, we review the pertinent literature aiming to better define the current state of art of PET/CT in the detection and histological differentiation of pNETs with special emphasis on BCs.

Thymolipoma, a rare benign neoplasm of the anterior mediastinum, is often asymptomatic and as a result it can become quite large before it is diagnosed. CT is the most accurate diagnostic technique to identify the adipose tissue, but it often cannot make a differential diagnosis differentiating it from other anterior mediastinal masses; transthoracic biopsy also reveals the presence of fatty tissue, but a definitive diagnosis can only be achieved by means of surgical excision, which is also curative. We describe the case of a young woman who presented with a fatty neoplasm of the anterior mediastinum. The mass was removed using single-stage bilateral sequential videothoracoscopy. The histopathological diagnosis was thymolipoma.

Solitary fibrous tumor of the pleura (SFTP) is an uncommon entity, generally with an indolent behavior. Nevertheless, some malignant forms have been rarely reported. These, often have an aggressive biological behavior with pathological findings of invasiveness. The preoperative diagnosis and evaluation of the grade of malignancy are extremely challenging. Herein we report a case of a 64-year-old man who presented with a left giant intra-thoracic mass imaged with fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG/PET-CT) and sampled via fine-needle aspiration biopsy (FNAB). Imaging and FNAB findings showed suspicion of a benign form of SFTP. Surgical radical resection of the giant mass was performed. The definitive histological diagnosis showed a malignant SFTP. Based on this report, we take the opportunity to briefly discuss the insidious pitfalls concerning the radiological and (18)F-FDG/PET-CT features as well as cyto/histological findings in the pre-operative diagnostic work-up examination of this rare entity.

Background Thymoma is a T cell neoplasm arising from the thymic epithelium that due to its immunological role, frequently undercover derangements of immunity such a tumors and autoimmune diseases. Methods Herein, we report, to the best of our knowledge, the first description of an association between thymoma and adult onset Still disease (AOSD) in a 47-year-old man. The first one was occasionally detected 4 years later the diagnosis of AOSD, and surgically removed via right lateral thoracotomy. Histology confirmed an encapsulated thymic tumor (type AB sec. WHO-classification). Results The AOSD was particularly resistant to the therapy, requiring a combination of immunosuppressant followed by anti-IL1R, that was the only steroids-sparing treatment capable to induce and maintain the remission. The differential diagnosis was particularly challenging because of the severe myasthenic-like symptoms that, with normal laboratory tests, were initially misinterpreted as fibromyalgia. The pathogenic link of this association could be a thymus escape of autoreactive T lymphocytes causing autoimmunity. Conclusion Clinicians should be always include the possibility of a thymoma in the differential diagnosis of an unusual new onset of weakness and normal laboratories data, in particular once autoimmune disease is present in the medical history.

A 38-year-old non-smoker female with unremarkable history presented with an insidious onset of dry cough. Computed tomography revealed two solid round pulmonary lesions, curiously symmetrically located in the middle lobe and in the lingular segment, respectively (Fig. 1). Trans-bronchial needle biopsy was limited by a profuse bleeding and the diagnosis was inconclusive. The radiological differential diagnosis consisted of non-neoplastic disease, synchronous/multifocal bronchial carcinoids and pulmonary metastases from unknown neoplasm.

Background: The management of a solitary pulmonary nodule is the subject of debate and minimally invasive diagnostic approaches have low sensitivity for small peripheral nodules. We discuss the role of video-assisted thoracoscopic surgery (VATS) in the management of solitary pulmonary nodules (SPNs) ?1 cm performed with a preoperatory computed tomography-guided wire localization. Methods: Thirty-five selected patients underwent VATS resection for SPN, with localization by guide wire before surgery. Results: Seven patients, after VATS exploration, underwent thoracotomy because of pleuropulmonary adhesions, depth or dimensions. Histological diagnosis was obtained in all procedures; there was no postoperative morbility or morbidity. Conclusion: Preoperative computed tomography hook-wire localization is a suitable strategy for peripheral nodules ?1 cm in diameter.

The lengthening of life expectancy has led to more surgical procedures in elderly patients. The aim of this work was to determine whether age >70 years is a risk factor for pneumonectomy. All cases of pneumonectomy from January 1999 to December 2006 were retrospectively reviewed. The 40 patients aged > 70 years were compared with a group of 70 patients aged 40-68 years matched for sex, physical status, respiratory function, side of pneumonectomy, and pathologic stage. Postoperatively, significantly more older patients had atrial fibrillation (24% vs. 5.6%). There was a low incidence of respiratory complications in both groups, and reduced respiratory function did not increase respiratory morbidity. Thirty-day mortality was not significantly different (2.5% in older vs. 1.4% in younger patients), but long-term mortality rates evaluated at December 31, 2007 were 50% for those aged

Objectives The presence of circulating DNA in plasma of patients with malignant neoplasm has been a known fact for over 30 years. Since then, the concentration of free circulating plasma DNA has been studied as well as the genetic alterations and epigenetic alterations of tumour DNA of patients that suffer from various types of tumours. The analysis of circulating plasma DNA may be a useful marker to get an early diagnosis on malignant neoplasms. This study has been specifically designed to validate the quantification of circulating DNA in order to design a test useful for the early identification of non-small cell lung cancer patients and the monitoring of lung cancer progression. A second aim of this work is the sensibility and specificity evaluation of such method for future applications. Methods The quantity of plasma DNA was determined using quantitative Real-Time PCR with amplification of the human telomerase reverse transcriptase (hTERT) gene in 151 patients that suffer from lung cancer and 79 healthy controls. The performance of the test was evaluated with a ROC curve. The relationship between the DNA concentration and main demographic, clinical and pathological variables was examined with logistic regression models as well as multiple linear regression models. Results The concentration of circulating plasma DNA was about four times higher in patients with lung cancer with respect to the controls (12.8 vs 2.9 ng/mL). The area under the ROC curve was 0.79 (95% CI, 0.710–0.83). The concentration of circulating DNA proved to be an important risk factor for the presence of the illness and a prognostic index in the follow-up. Conclusions The use of quantitative Real-Time PCR revealed that higher values of circulating DNA can be found in patients with lung neoplasm compared to the healthy controls. This could have practical implications such as the use in screening programs and a possible prognostic significance in the follow-up.

The various techniques used to perform biopsies of mediastinal masses--mediastinoscopy, mediastinotomy, extended cervical mediastinoscopy, and assisted video-thoracoscopy--have already been amply described. In this study the authors give particular attention to ultrasonically guided percutaneous biopsy. Between January 1998 and July 2001 42 patients underwent anterior mediastinal core needle biopsy with ultrasonic guidance. An accurate diagnosis was made for all the patients, with a sensitivity and specificity of 100%. Two cases of pneumothorax were seen, with pleural drainage and a 5-day hospitalization necessary in one of the cases. The remaining 40 patients were treated as outpatients and were discharged within 4 h of the procedure. Ultrasonically guided percutaneous core-needle biopsy is a safe procedure for the diagnosis of the anterior mediastinal masses.

A 63-year-old woman was referred for evaluation of a mass in the lower lobe of the right lung. The patient, a nonsmoker, in 1989 underwent a bilateral ovariohysterectomy for synchronous enometrioid adenocarcinoma of the uterus and ovary (stage I uterus, stage IA FIGO ovary). The postoperative follow-up (10 years) was uneventful. Recently, due to a right chest pain, the patient underwent a chest roentgenogram demonstrating a mass of the right lower lobe. A subsequent computed tomography of the chest showed a 40 32 mm pulmonary mass of the right lower lobe (Fig 1) in which was also present a 40 mm pure ground glass opacity (Fig 2). Positron emission tomography showed increased fluorodeoxyglucose uptake in the posterolateral portion of the right lower lobe corresponding to the pulmonary mass; hilar and mediastinal activity was normal. Bronchoscopy, lobar bronchial washing, and brushing were negative. Tumor markers (CA-125, NSE, CYFRA, CEA) were negative. A transthoracic biopsy of the mass suggested a metastatic endometrioid adenocarcinoma. The patient underwent a right thoracotomy, with a biopsy of the consolidation area of the lung corresponding to the pure ground glass opacity. Because an intraoperative frozen section suggested a primary bronchioloalveolar adenocarcinoma, a right lower lobectomy with systematic mediastinal limphadenectomy was performed. Final pathologic evaluation of the specimens revealed a metastatic endometrioid adenocarcinoma (Fig 3A), immunoreactive for estrogen (Fig 3B) and progesterone receptors and negative for TTF-1, corresponding to the mass, and a primary

Background Penetrating chest injuries account for 1–13% of thoracic trauma hospital admissions and most of these are managed with a conservative approach. Nevertheless, 18–30% of cases managed only with tube thoracostomy have residual clotted blood, considered the major risk factor for the development of fibrothorax and empyema. In addition, 4–23% of chest injury patients present persistent pneumothorax and 15–59% present an injury to the diaphragm, which is missed in 30% of cases. In order to make a correct diagnosis, reduce the number of missed injuries, chronic sequelae and late mortality we propose performing surgical exploration of all patients with a penetrating injury of the pleural cavity. Methods 1270 patients who sustained thoracic trauma were admitted to our hospital between 1994 and 2004. Of these, 16 patients had penetrating injuries: thirteen were surgically explored by means of Video Assisted Thoracic Surgery (VATS), and 3 with thoracotomy due to hemodynamic instability or suspected lesion of the heart or great vessels. Results In the 13 patients who underwent VATS, 5 injuries to the diaphragm, 3 lesions to an intercostal artery, and 1 lesion to the diaphragmatic artery were detected. In 12 of these patients a laceration of the pulmonary parenchyma was also present. A conversion to thoracotomy was necessary due to a broad laceration of the diaphragm and due to hemostasis of an intercostal artery. In all but one case, which was later converted, diagnostic imaging missed the diagnosis of laceration of the diaphragm. There was no intra- or postoperative mortality, and average hospital stay was five days. Conclusion VATS is a safe and effective way to diagnose and manage penetrating thoracic injuries, and its extensive use leads to a reduction in the number of missed, potentially fatal lesions as well as in chronic sequelae.

A 79-year-old asymptomatic woman underwent arthrodesiswith a double K-wire insertion for a posttraumatic invet-erate right glenohumeral dislocation. After removal of thefirst K-wire, chest X-ray showed intrathoracic migration ofthe foreign body, and the CT scan confirmed the pulmonarypenetration of the device within the right upper lobe withintraparenchymal surrounding hematoma (Fig. 1).Although the vital parameters were substantially within therange, the patient underwent urgent surgery. A combinedapproach was attempted: the K-wire was mobilized fromthe glenoid cavity to resect the distal hook and, at the sametime, a right lateral thoracotomy was performed to removesafely the device deeply slipped into the lung and suture theparenchyma (Fig. 2). The postoperative course wasuneventful, and the patient was discharged on the eighthpostoperative day.Improper uses or positioning of K-wires are widelydescribed in the literature and may expose patients toinsidious but potentially life-threatening complications [1];therefore, regular radiological follow-up may be advisablein patients with foreign body at risk of dislodgement intovital structures.

The present international system for staging lung cancer classifies multiple pulmonary nodules present in one pulmonary lobe or in distinct ipsilateral or controlateral pulmonary lobes as stage IIIB and IV, respectively. In our opinion this approach does not guarantee the patient the best choice of therapy. Moreover, some studies support the choice of surgery for patients with multiple pulmonary nodules without mediastinal lymph node involvement. Introducing PET may be of considerable help in making an informed choice. In this work we propose a diagnostic/therapeutic decisional algorithm for patients with multiple pulmonary nodules.

The various techniques used to perform percutaneous guided biopsies of mediastinal masses have already been amply described, with particular attention to the type of needle used. In this study our experience with mediastinal transthoracic core needle biopsy has been compared with reported descriptions of ultrasonically guided fine needle aspiration to determine which is better and the respective influence on pathological diagnosis. Between January 1998 and July 2002, 47 patients underwent anterior mediastinal core needle biopsy with ultrasonic guidance. An accurate diagnosis was achieved in all patients, with 100% sensitivity and specificity. In all patients with lymphoma and thymoma it proved possible to establish the histological type. Two cases of pneumothorax were seen with pleural drainage and a 5-day hospital stay required in one of the cases. The remaining 45 patients were treated as outpatients and were discharged within 4 hours of the procedure. Ultrasonically guided percutaneous needle biopsy is a safe procedure; fine needle aspiration usually suffices for solid malignant lesions while a core needle biopsy should be performed when lymphoma or thymoma masses are suspected in order to obtain larger specimens for a precise histological diagnosis. The core needle procedure avoids repetition of unsuccessful fine- needle aspirations and reduces the number of mediastinoscopies and videothoracoscopies carried out for diagnostic purposes.

While liposarcoma is the most common malignant mesenchymal neoplasm in adults, a mediastinal position is rare. We describe here the case of a 74-year-old female with an hourglass-shaped mass in the posterior mediastinum, which was probably present on a roentgenogram 4 years earlier. On a CT scan of the chest, the mass appeared non-homogeneous with a mainly adipose content. A preoperative ultrasonically guided tru-cut transthoracic biopsy revealed the presence of adipose tissue with mildly atypical cytological features. The mass was therefore completely excised by means of a right thoracotomy. The postoperative course was uneventful and the patient is alive and well and has had no recurrence in the 6 months since surgery. We review here the natural history, pathology, and prognosis of the disease, and discuss methods of diagnosis and management of such lesions.

Residual thoracic collections after thoracic traumas occur in 5-30% of patients and are a major risk factor for development of empyema. Management with a thoracostomy tube is the traditional treatment but it requires a prolonged hospital stay and 20% of patients treated continue to have a residual clot. Forty-two haemodynamically stable patients with chest trauma (36 blunt and 6 penetrating) were examined thoracoscopically. Indications for videothoracoscopy included suspected diaphragmatic injury (8 patients), persistent pneumothorax (8), continued haemorrhage (6) and clotted haemothorax (20). Diaphragmatic lacerations were confirmed thoracoscopically in 7 patients. Four of them were successfully repaired with thoracoscopic techniques and three were repaired after conversion to open thoracotomy for large diaphragmatic lacerations. In patients with persistent pneumothorax, limited lung lacerations were correctly diagnosed and repaired thoracoscopically. In all patients with continued haemorrhage intercostal artery injury was confirmed and repaired by diathermy. All clotted haemothorax cases were successfully evacuated. No complications occurred. Videothoracoscopy appears to be a safe, accurate and reliable operative therapy for the assessment of diaphragmatic injuries, control of continued bleeding and evacuation of clotted haemothorax, reducing the hospital stay and possible complications.

A 51-year-old female underwent resection of a solid lesion in the posterior mediastinum, preoperatively interpreted at imaging as thoracic schwannoma, requiring double sequential surgical procedure to be resected. The histologic examination of the resected mass diagnosed a hyaline-vascular Castleman's disease.

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.

A 65-year old woman underwent an exploratory right thoracotomy for haemopneumothorax (Fig. 1) after penetrating chest trauma (double-stabbing). Operative findings included a 1-cm pericardial lesion associated with an apparently superficial wound of the right ventricle (without significant signs of active bleeding and treated with direct suture) and moderate intercostal bleeding. Respiratory failure occurred on the fourth postoperative day. CT scan showed an interventricular communication (Fig. 2) and the patient underwent successful surgical repair (endocardial patch technique) of this defect under total cardiopulmonary bypass.

Penetrating chest injuries account for 1–13% of thoracic trauma hospital admissions and most of these are managed with a conservative approach. Nevertheless, 18–30% of cases managed only with tube thoracostomy have residual clotted blood, considered the major risk factor for the development of fibrothorax and empyema. In addition, 4–23% of chest injury patients present persistent pneumothorax and 15–59% present an injury to the diaphragm, which is missed in 30% of cases. In order to make a correct diagnosis, reduce the number of missed injuries, chronic sequelae and late mortality we propose performing surgical exploration of all patients with a penetrating injury of the pleural cavity. 1270 patients who sustained thoracic trauma were admitted to our hospital between 1994 and 2004. Of these, 16 patients had penetrating injuries: thirteen were surgically explored by means of Video Assisted Thoracic Surgery (VATS), and 3 with thoracotomy due to hemodynamic instability or suspected lesion of the heart or great vessels. In the 13 patients who underwent VATS, 5 injuries to the diaphragm, 3 lesions to an intercostal artery, and 1 lesion to the diaphragmatic artery were detected. In 12 of these patients a laceration of the pulmonary parenchyma was also present. A conversion to thoracotomy was necessary due to a broad laceration of the diaphragm and due to hemostasis of an intercostal artery. In all but one case, which was later converted, diagnostic imaging missed the diagnosis of laceration of the diaphragm. There was no intra- or postoperative mortality, and average hospital stay was five days. VATS is a safe and effective way to diagnose and manage penetrating thoracic injuries, and its extensive use leads to a reduction in the number of missed, potentially fatal lesions as well as in chronic sequelae.

Epithelioid angiosarcoma is an extremely rare tumor. It is generally a secondary tumor and the preferred sites of such metastases are the heart, pericardium, lung, breast, liver, spleen, bone, and brain. In rare cases the lung has been described as the primary site. The prognosis of this neoplasm is extremely poor. We report a case of epithelioid angiosarcoma with multiple bilateral lung infiltration, bone metastasis, and metastasis of the lamina propria of a tubulovillous adenoma of the colon.