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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.

Simple Summary Thymic epithelial tumors were originally staged using the Masaoka–Koga staging system, even if recently the adoption of the tumor node metastases staging system was recommended. However, it remains controversial as to which staging system is the most effective in prognosis prediction for these patients. The aim of this study was to analyze the prognostic effectiveness of these staging systems and to verify a possible improvement. Abstract Background: The aim of this study was to evaluate the Masaoka–Koga and the tumor node metastases (TNM) staging system in thymic epithelial tumors (TET) considering possible improvements. Methods: We reviewed the data of 379 patients who underwent surgical resection for TET from 1 January 1985 to 1 January 2018, collecting and classifying the pathological report according to the Masaoka–Koga and the TMN system. The number of involved organs was also considered as a possible prognostic factor and integrated in the two staging systems to verify its impact. Results: Considering the Masaoka–Koga system, 5- and 10-year overall survival (5–10YOS) was 96.4% and 88.9% in stage I, 95% and 89.5% in stage II and 85.4% and 72.8% in stage III (p = 0.01), with overlapping in stage I and stage II curves. Considering the TNM system, 5–10YOS was 95.5% and 88.8% in T1, 84.8% and 70.7% in T2 and 88% and 76.3% in T3 (p = 0.02), with overlapping T2–T3 curves. Including the number of involved structures, in Masaoka–Koga stage III, patients with singular involved organs had a 100% and 76.6% vs. 87.7% 5–10YOS, which was 76.6% in patients with multiple organ infiltration. Considering the TNM, T3 patients with singular involved structures presented a 5–10YOS of 100% vs. 62.5% and 37.5% in patients with multiple organ involvement (p = 0.07). Conclusion: The two staging systems present limitations due to overlapping curves in early Masaoka–Koga stages and in advanced T stages for TNM. The addition of the number of involved organs seems to be a promising factor for the prognosis stratification in these patients.

Surgical scientific literature contains relatively little information regarding the surgical outcomes of anatomic sublobar resections performed with the uniportal video-assisted thoracoscopic surgery (U-VATS) technique. This paper attempts to evaluate the role of U-VATS segmentectomies in the landscape of a minimally invasive approach to the treatment of early stage non small cell lung cancer (NSCLC).

A 46-year-old woman arrived at our ED for the worsening of a thoracic pain localized in the left interscapulo-vertebral region that she had been commenting on for the past few days. Anamnestic data were collected; vital parameters, blood tests, and ECG were normal.

Incorrect preoperative evaluation can lead to some problems in anesthesiologic management, particularly in thoracic anesthesia. We present the case of an old man with a history of adenocarcinoma of the rectum, diagnosed with a solid pulmonary nodule. The thoracic surgery team scheduled an Uniportal Video-Assisted Thoracoscopy (U-VATS) atypical resection of the right lower lobe. Intraoperative airway management was complicated by the unexpected presence of a tracheal diverticulum, a rare pathological issue that can cause many difficulties in airways management Mastery of the bronchoscopy technique by experienced anesthesiologists and their knowledge of alternative choices for pulmonary exclusion, allowed to choose an alternative for the one lung ventilation, without causing any harm to the patient. Correct handling of the bronchoscope is a gold standard tool for modern anesthesiologist. It is also mandatory, from our point of view, to examine diagnostic images with a critical eye, looking for those details that could make the difference on anesthesiologic management of the patients.

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

We read with interest the paper “Significance of chest ultrasound in the early postoperative period following thoracic surgery” of Dr. Thomas G. Lesser (1), underlining the limited use of chest ultrasonography (CU) in post-operative.

Primary breast sarcoma represents less than 0.1% of breast cancers and less than 5% of all sarcomas. It derives from the mesenchymal tissues of the breast and can originate a histologically heterogeneous group of neoplasms. It has a poor prognosis and the median 5-year overall survival is 63.5% (range, 55–73%). Currently, diagnosis and treatment of this neoplasm are a challenge for pathologists, surgeons and oncologists. We describe the case of a 56-year-old Macedonian woman, who presented with local recurrence of a high-grade chondrosarcoma of the right breast. She had been treated elsewhere six months earlier with radical mastectomy and ipsilateral axillary dissection. The actual heteroplasia was 29 centimeters wide, ulcerated and infected. The computed tomography (CT) scan documented infiltration of pectoralis muscles, of III and IV right ribs and sternal body, but no distant metastases. Considering the patient’s clinical conditions and stage of the disease, a multidisciplinary discussion lead to the decision to attempt surgery. A multidisciplinary surgical teamwork was indispensable for attempting such a highly complex and demolitive surgery and a challenging reconstruction of the thoracic wall and an intensive post- operative monitoring of the patient was needed to manage complications related to tissue loss. Nowadays it is difficult to find patients suffering from tumors of this size and consequently the treatment is made more complicated by the lack of experience. With this case report we share our experience in the treatment of an infrequent pathology that has presented itself to us with dimensions rarely reported in the literature.

Background: Intrathoracic neurogenic tumor account between 12% and 21% of all mediastinal masses and represent for 75% of posterior mediastinal tumors and the elective treatment of these tumors is surgical excision, also if the outcome after minimally invasive excision has not well described yet. Aim of this study is to analyze the outcome of surgically treated patients especially regarding the use of minimally-invasive techniques. Methods: We conducted a retrospective study on 28 patients surgically treated for posterior mediastinal tumors during the period from 1/1/2007 to 31/12/2918. Data regarding the surgical technique, intra-operative findings and post-operative outcome were collected and retrospectively considered. Results: Muscle sparing lateral thoracotomy was performed in 8 patients while 20 patients underwent minimally invasive surgery: 11 were subjected to three-port video-assisted thoracoscopic surgery (VATS); 1 to two-port VATS; 5 to uniportal VATS and 3 to robotic excision. Histology proved the masses to be benign neurogenic tumors in all cases. Complete surgical excision was achieved in 26 patients, in the other two there were no recurrences of disease during follow up. Conclusions: VATS is a reliable approach with better post-operative results than traditional surgery in the treatment of neuronal tumors. The thoracotomy approach to these tumors should be reserved for large tumors or those with an involvement of the vertebral canal.

Nowadays, endometriosis is considered a common benign disease. It affects between 6% and 10% of women of childbearing and it’s characterized by the presence of islands of endometrial-like cells outside the uterine cavity, more often located on the intraperitoneal surface of reproductive organs. The thoracic cavity is the second major district where it’s possible to find islands of endometriosis affecting the parietal and/or visceral pleural surface, the diaphragm or the lung parenchyma, therefore causing a variety of symptoms and manifestations, all together named as thoracic endometriosis syndrome (TES). The first line therapy for TES is medical aimed at suppressing ovarian steroid hormone production. Indications for pulmonary surgery as a second line therapeutic management of patients with TES are hormonal therapy failure, intolerable adverse effects or symptom recurrence after cessation of medical treatment. Surgery should be the preferred therapeutic option when the patient is planning future pregnancies. To date, video-assisted-thoracoscopy (VATS) represents an important surgical tool in TES patients, as it allows to carry out many procedures for diagnostic and therapeutic purposes. In patients with centrally located bronchial endometriosis, sub-segmentectomies, segmentectomies or lobectomies may be required. We present the case of a patient with TES, treated with a feasible, safe and least invasive thoracic surgical technique available nowadays in many settings: uniportal-VATS.

Background: Post-operative pain management has always been a fundamental topic in thoracic surgery. Common analgesic techniques may have important side effects. Minimally invasive surgery provides reduction of post-operative pain if compared with open thoracic surgery, but it doesn’t solve the issue. The aim of this study was to evaluate the role of “serratus plane block” (SPB) in uniportal video-assisted thoracic surgery (U-VATS) and to compare the effectiveness of “continuous” vs . “one-shot” administration of it. Methods: Forty-four patients undergoing U-VATS surgery were involved in this study: SPB was performed in 22 patients by using a catheter that was positioned above the serratus to obtain a “continuous” SPB through a local continuous application of the anesthetic for 72 hours after surgery, a “one-shot” SPB in other 22 patients, applying a single dose of the anesthetic drug on the serratus superficial fascia before the end of the surgical time. Results: There was a statistical significance since the first post-operative day for patients in the continuous SPB (cSPB) group, who had better pain control compared with the “one-shot” SBP (osSBP) group. Patients in the cSPB required less systemic pain therapy administration. Conclusions: cSPB performed after U-VATS surgery seems to offer patients gain in good level of pain tolerance with no observed side effects.

Bronchogenic cysts (BCs) are the most common benign cystic lesions in the mediastinum, 15–25% of cases originating from pulmonary parenchyma. It is often found incidentally as it is mostly asymptomatic until its growth in size and compression of surrounding structures, causing tachycardia, dysphagia, dyspnea, cough and chest pain or its complication (with symptoms such as fever, dyspnea and sputum production if the cyst communicates with a bronchus). In this paper we present the case of a 68-year-old female patient presenting a recurrent bronchogenic giant cyst in the right hemithorax, partially solved after drainage at its first presentation and finally resolved by excision in video-assisted thoracoscopic surgery (VATS) uniportal surgery after recurrence. Diagnosis was confirmed by a thoracic CT scan and pulmonary ultrasound. A multidisciplinary approach was necessary to decide the best strategy and timing for the treatment of the pathology. The surgical approach was necessary to allow removal of the source of infection that was not possible to treat with only antibiotic therapy. Uniportal-VATS (U-VATS) for the treatment of this case was safe and effective with good outcomes in terms of post-operative recovery. We therefore hope for future randomized studies to define the role of minimally invasive techniques in complicated BCs.

Highlights • Mesenteric vasculitis secondary to polyarteritis nodosa is a potentially life-threatening cause of acute abdomen. • A male patient presented with severe abdominal guarding, pitting edema of the legs, renal failure and bowel wall thickening suggestive of mesenteric ischemia on CT scan. • Early laparoscopy allowed to rule out proximal bowel necrosis and resection was avoided. • The patient was successfully managed with corticosteroid therapy and repeated hemodialysis sessions. • Acute onset of abdominal pain accompanied by pitting edema and renal failure should alert the clinician about the possible diagnosis of polyarteritis nodosa. In such circumstances, early laparoscopy may effectively replace laparotomy., Mesenteric vasculitis secondary to polyarteritis nodosa represents an atypical but potentially life-threatening cause of bowel ischemia and acute abdomen. The patient presented with severe abdominal pain of recent onset, pitting edema of the legs, renal failure and bowel wall thickening suggestive of mesenteric ischemia on CT scan. Early laparoscopy allowed to rule out proximal bowel necrosis and resection was avoided. The patient was successfully managed with corticosteroid therapy and repeated hemodialysis sessions.

Esophageal diverticulum is a rare disease caused by impaired esophageal motility. It may present with disorders like pain, heartburn, dysphagia, episodes of food regurgitation and halitosis, but often the patients are asymptomatic. Diagnosis is based on the esophagogram with barite meal, gastroscopy and esophageal manometry. The diverticula can be classified according to the site of onset in the esophagus: diverticula of the distal third (epiphrenic, 20%), mediothoracic or mediastinal (10%) and proximal diverticula (Zenker diverticula, 70%). Traditionally, surgical treatment involves a thoracotomy approach that allows diverticulectomy and esophageal myotomy. In our centre, we started to use the uniportal video-assisted thoracoscopic surgery (VATS) approach for the treatment of esophageal diseases, both neoplastic and benign. In our preliminary experience with uniportal VATS diverticulectomy, we obtained good results in terms of effectiveness, reduction in hospitalization time, complications, pain control and early recovery of patient’s daily activities.