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Most patients with undifferentiated thyroid cancer have unresectable disease with a very high rate of airway compromise. Tracheostomy typically entails technical issues in these cases. In fact, it can be very difficult to expose or simply locate the trachea beneath the mass, and the extensive soft tissue involvement can force the surgeon to cut the tumor to place the tracheostomy tube. The combined use of rigid bronchoscopy and percutaneous tracheostomy techniques, applied in an open surgical procedure, can greatly simplify the procedure. Furthermore, by this method, the airways are quickly secured and the risk of intraoperative bleeding is reduced.

Nephrobronchial fistula is an extremely rare complications of renal infections. We present a case of nephrobronchial fistula in a middle age immunocompetent woman who complained cough and weight loss, with underlying asymptomatic nephrolithiasis. She underwent a chest X-ray that showed left lower lobe infiltrate and abdominal ultrasound. Abdominal ultrasound showed a complicated pyonephrosis ; CT of chest-abdomen-pelvis with intravenous contrast was performed in order to stage and define the extension of the pathology. At CT, a suspected diagnosis of stage III xanthogranulomatous pyelonephritis complicated with pyonephrosis and a nephrobronchial fistula was formulated. A nephrostomy tube was placed, and the patient was treated with antibiotics. Follow up CT, performed after 15 days, showed the healing of the fistulous connection between the perinephric abscess and bronchi; the patient underwent nephrectomy with no airway complication during intubation. Histopathological diagnosis confirmed the presence on complicated xanthogranulomatous pyelonephritis.

Pleural empyema of extra pulmonary origin is uncommon and empyema secondary to a fistula between the urinary tract and thorax is extremely rare. We report a case of nephropleural fistula causing massive pleural empyema in a 64-year-old woman with a long history of urological problems, including nephrolitiasis and urinary tract infection. She was admitted with sepsis, fever, chills, tachypnea, productive cough and pyuria. At clinical examination, breath sounds were reduced over the left hemithorax. CT revealed a fistulous connection from the upper left calyceal group and the pleural space. Drainage of thoracic and perinephric collection was carried out, but nephrectomy and pleural decortication were required due to haemopurulent urine and decreased hemoglobin levels during the hospitalization. This case demonstrates the unusual and prolonged evolution of an obstructive hydroureteronephrosis complicated by pyonephrosis, culminating in retroperitoneal abscess that fistulized into the pleural space, leading to empyema.

Introduction: Microalbuminuria (MA) is considered a reflection of systemic capillary leak and an early marker of acute stress reaction to the surgical insult, proportional to the severity of the initiating condition and predictive of the individual response to surgical stress. Objectives: We conducted a prospective study to assess for the variation of MA within 4 days after thoracic surgery. We correlated observed MA levels with both their respective PaO2/FiO2 respiratory ratio and the onset of postoperative complications. Methods: This single-centre study enrolled 255 consecutive patients having an American Society of Anaesthesiologists (ASA)score≤3. The mean age was 62 years with 67% male. All patients were scheduled for elective pulmonary resection. MA was measured in urine samples as the albumin-to-creatinine ratio (A/C), prior to, at and after extubation up to 96 hours. PaO2/FiO2 was measured at extubation and on the first postoperative day. Results: Overall, preoperative A/C levels resulted normal, with a significant average increase at extubation which peaked 6 hours later (P 61mg/g (P=0.0003) was associated with postoperative cardio-pulmonary complications (OR 3.85; P=0.003). Conclusion: Within 6 hours after extubation, MA assessment may be a rapid and relatively inexpensive method for better predicting perioperative risk in an ASA score ≤3 population.

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Non-small-cell-lung cancer accounts for 80-85% of all forms of lung cancer as leading cause of cancer-related death in human. Despite remarkable advances in the diagnosis and therapy of lung cancer, no significant improvements have thus far been achieved in terms of patients' prognosis. Here, we investigated the role of INSL4 - a member of the relaxin-family - in NSCLC. We overexpressed INSL4 in NSCLC cells to analyse in vitro the growth rate and the tumourigenic features. We investigated the signalling pathways engaged in INSL4 overexpressing cells and the tumour growth ability by studying the tumour development in a patient derived tumour xenograft mouse model. We found an INSL4 cell growth promoting effect in vitro in H1299 cells and in vivo in NOD/SCID mice. Surprisingly, in NSCLC-A549 cells, INSL4 overexpression has not similar effect, despite huge basal INSL4-mRNA expression respect to H1299. The INSL4-mRNA analysis of eight different NSCLC-derived cell lines, revealed highly difference in the INSL4-mRNA amount. Transfection of NSCLC lines with INSL4-Myc showed huge level of INSL4-mRNA with a very low amount of protein expressed. Notably, similar discrepancy has been observed in NSCLC patients. However, in a cohort of NSCLC patients analysing a database, we found a significant inverse correlation between INSL4 expression and Overall Survival. By combining the in vitro and in vivo results, suggest that in patients whose NSCLC adenocarcinoma spontaneously expressed high levels of INSL4 post-transcriptional modifications affecting INSL4 do not allow to assess precision therapy in selected patients without consider protein INSL4 amount.

OBJECTIVES Risk factors for pneumothorax recurrence after videothoracoscopy for primary spontaneous pneumothorax are still being debated. The goal of this study was to assess whether the pleurodesis technique and other variables are possibly associated with the postoperative ipsilateral recurrence of pneumothorax. METHODS We retrospectively collected data of 1178 consecutive ≤40-year-old patients who underwent videothoracoscopy for primary spontaneous pneumothorax in 9 centres between 2007 and 2017. We excluded patients with hybrid pleurodesis and/or incomplete follow-up, leaving for analysis 843 cases [80% men; median age (interquartile range) 22 (18–28) years]. Univariable and multivariable analyses were performed by logistic regression and tested by Cox regression model to assess factors related to ipsilateral pneumothorax recurrence including age, gender, body mass index, smoking habit, cannabis smoking, respiratory comorbidity, dystrophic severity score, surgical indication, videothoracoscopy port number and side, lung resection, pleurodesis technique and postoperative prolonged air leak (>5 days). RESULTS Blebs/bullae resection was performed in 664 (79%) patients. Pleurodesis was achieved by partial pleurectomy in 228 (27%) cases; by pleural electrocauterization in 176 (21%); by pleural abrasion in 121 (14%); and by talc poudrage in 318 (38%). During a median follow-up period of 70.0 months (95% confidence interval 66.6–73.4), pneumothorax recurred in 79 patients (9.4%); among these, 29 underwent redo surgery; 34, chest drain/talc slurry; and 16, clinicoradiological observation. The only independent risk factor for recurrence was postoperative prolonged air leak (P CONCLUSIONS In this multicentric series, postoperative ipsilateral pneumothorax recurrence was remarkable and independently related to prolonged postoperative air leak; besides the retrospective study setting, the pleurodesis method did not have an impact on recurrence. To prevent prolonged air leak, blebs/bullae treatment should be accurate and performed only if indicated.

Despite continuous and significant improvements in the diagnosis and treatment of thoracic surgery patients, postoperative complications can be life-threatening. Therefore, the management of these patients can be very challenging. The aim of this chapter is to provide an overview of the most frequent early and late postoperative complications in thoracic surgery, focusing on the most frequent clinical signs, and currently recommended management strategies.

Background: Extra vascular lung water (EVLW) following pulmonary resection increases due to fluid infusion and rises in capillary surface and permeability of the alveolar capillary membranes. EVLW increase clinically correlates to pulmonary oedema and it may generate impairments of gas exchanges and acute lung injury. An early and reliable assessment of postoperative EVLW, especially following major pulmonary resection, is useful in terms of reducing the risk of postoperative complications. The currently used methods, though satisfying these criteria, tend to be invasive and cumbersome and these factors might limit its use. The presence and burden of EVLW has been reported to correlate with sonographic B-line artefacts (BLA) assessed by lung ultrasound (LUS). This observational study investigated if bedside LUS could detect EVLW increases after major pulmonary resection. Due to the clinical association between EVLW increase and impairment of gas exchange, secondary aims of the study included investigating for associations between any observed EVLW increases and both respiratory ratio (PaO2/FiO2) and fluid retention, measured by brain natriuretic peptide (BNP). Methods: Overall, 74 major pulmonary resection patients underwent bedside LUS before surgery and at postoperative days 1 and 4, in the inviolate hemithorax which were divided into four quadrants. BLA were counted with a four-level method. The respiratory ratio PaO2/FiO2 and fluid retention were both assessed. Results: BLA resulted being increased at postoperative day 1 (OR 9.25; 95% CI, 5.28–16.20; P

Background: The surgical techniques for Pancoast tumors are as variable as the clinical pictures. Involved structures and location/size of the tumor deeply affect the choice of technique and surgical approaches. Methods: Results of the surgical therapy in 23 consecutive patients with Pancoast tumor over an eighteen-year period was reviewed. Disease free survival (DFS) and overall survival (OS) were calculated by the Kaplan-Meier method. Results: Clinical stage was cT3N0M0 in 17 patients, cT3N1M0 in 2 and cT4N0M0 in 4. No cN2 patients were considered for surgery. Eighteen patients underwent induction chemoradiotherapy. The posterior approach was performed in 61%, the transmanubrial approach in 22% and an original “double step” approach in 17% of patients. A combined approach was performed in 39.1% of patients, mostly through an additional thoracotomy; a combined VATS approach was chosen just in one patient. The prosthetic stabilization of the chest wall was performed in 5 cases. No postoperative mortality was observed with a total complication rate of 48%. The type of approach did not influence the complication rate. Median follow-up was 52.24 months with IQR 13.16–85.39 months (range, 1.48–164.7 months). Median OS was 62.3 months (95% CI, 18.39–104.21 months). The 5-year OS was 55.6% (95% CI, 31.7–74.1%). Median DFS was 65.9 months (95% CI, 12.1–104.2 months); 5-year DFS was 51.5% (95% CI, 28.2–70.7%). Patients with R1 resection had a median OS of 13.1 months (95% CI, 12.2–18.4 months). Conclusions: Complete resection of the tumor represents one of the strongest prognostic factors of OS and DFS, along with T status and complete pathological response to therapy. Every effort should be made to obtain pathologic negative margin and combined approaches may facilitate this goal in anterior Pancoast tumors.

Objectives Preoperative chemotherapy may play a role in postoperative respiratory complications due to subclinical parenchymal damage. We investigated the gene expression of lung tissue components after neoadjuvant chemotherapy of alveolar-capillary membrane, extracellular matrix and membrane proteins. Methods The study group included 14 patients submitted to pulmonary resection for lung cancer after 3 cycles of gemcitabine-cisplatin, while the control group included 14 naive-treatment patients. RNA was extracted from frozen tissue obtained by healthy lung specimens using EZ1 RNA Universal Tissue kit and automatically purified by BioRobot EZ1 instrument. Three hundred nanograms of total RNA was reverse transcribed to complementary DNA and used to evaluate the gene expression of type I and III collagen, elastin, syndecan, metalloproteinase 13 and aquaporins (AQPs) in real-time polymerase chain reaction. Results were expressed as the mean ± standard deviation of 3 independent experiments. Analysis of variance followed by Sheffe's F-test was performed. Results Among the alveolar-capillary membrane and extracellular matrix genes, type I-III collagens and syndecan were significantly up-regulated (+645%, +327% and +261%, respectively), while elastin and metalloproteinase 13 were down-regulated in the study group versus control group (-46% and -77%, respectively). Furthermore, chemotherapy was associated with a significant up-regulation of AQP expressions (AQP1:+51% and AQP5:+36%). Conclusions We observed, in the treated group, increases in the mean values of gene expressions for macromolecules involved in the remodelling of both the alveolar septa and parenchyma scaffold, thereby supporting the hypothesis that induction chemotherapy may foster a fibrosing effect on the pulmonary parenchyma and lead to altering the alveolar-capillary membrane.

The aim of the study was to prospectively evaluate the outcome of myotomy plus diverticulopexy over short and long-terms. A prospectively collected consecutive series (2007–2017) of 37 patients undergoing myotomy plus diverticulopexy was analyzed for clinical condition, operative information, peri-operative events, and follow-up by means of interview and physical examination. Diverticulopexy was scheduled regardless of the diverticulum’s features and patient condition, other than operability. There was no choice or selection between possible treatment options. Patients were evaluated pre-operatively, at post-operative day 30 and after 1 year. Follow-up aimed at assessing the subjective condition following treatment. During the interview, patients were asked to self-assess their ability to swallow before and after surgery. No patient had peri-operative events, complications associated with the procedure, wound infection or impaired swallowing. All patients could start drinking the day after operation, could return to solid diet on post-operative day 2 and be discharged on post-operative days 3–4. Barium swallowing was not necessary before discharge. Full solid diet was resumed according to patient’s compliance from post-operative day 2 (some patients refused solid diet soon after the operation even if asymptomatic). Follow-up ranged between 1 and 8 years. No patient was lost at follow-up. No disease recurrence was observed. Finally, no patient needed or sought for a clinical examination between the follow-up calls. Patients reported at least 50% improvement of symptomatology after 1 year. Diverticulopexy appears to be clinically safe, methodologically reproducible, and an effective procedure; it avoids suturing and offers good outcome results along with high patient satisfaction.

Background Patent foramen ovale (PFO) is present in as many as 25% of the general population and is considered an irrelevant condition in healthy subjects. Here, we sought to determine an association between an asymptomatic PFO at baseline and postoperative short-term adverse events in patients undergoing major pulmonary resection for lung cancer. In addition, we evaluated for the rate of PFO after pulmonary resections. Methods This prospective, observational study assessed patients by transcranial Doppler with contrast at baseline and discharge. To confirm interatrial shunting, patients with positive transcranial Doppler at baseline also underwent contrast transthoracic echocardiography. Multivariate logistic regression models were adopted to investigate for independent factors that could have been associated with complications. Backward stepwise procedure was used for model selection. Results Median age was 67.7 ± 9.2 years (range, 36 to 86), and 67% were men. Overall, 18 patients underwent pneumonectomy, 11 bilobectomy, and 118 lobectomy; 54% underwent right-sided procedure and 46%, left-sided. One perioperative death was recorded, and 34 patients had one or more cardiopulmonary complications. At baseline, PFO was positive in 25% (37 of 147) and negative in 75% (110 of 147); of the latter, 11% were positive at discharge. Detection of PFO at baseline, on multivariate analysis, was significantly associated with a risk of postoperative complications (odds ratio 2.5; 95% confidence interval: 1.1 to 5.8). Specifically, we observed a significant association between atrial fibrillation and positive PFO at baseline (odds ratio 3.5; 95% confidence interval: 1.4 to 9.0). Conclusions Preoperative asymptomatic PFO was independently associated with postoperative adverse events. Moreover, 11% of patients who had negative transcranial Doppler studies at baseline had asymptomatic PFOs at discharge. Larger prospective studies are needed to further investigate for a prognostic impact of PFO in thoracic surgery.

An innovative technique for airway management, using a small-diameter, short-cuffed orotracheal tube for assisting rigid bronchoscopy in critical airway obstruction is reported. The device, part of the translaryngeal tracheostomy kit, "Fantoni method" (DAR TLT, Covidien, Minneapolis, MN), was placed beyond the stenosis and used in combination with the rigid bronchoscope. This procedure improves safety during the management of critical tracheal stenoses because the airway is constantly under the anesthesiologist's control. Consequently, inhalation anesthesia is feasible, use of neuromuscular blockade is possible, end-tidal carbon dioxide monitoring is reliable, and the distal airway is protected from blood and debris soilage during tumor debulking. Surgery is faster because it is uninterrupted.

Several cancers, especially non-small cell lung cancer (NSCLC), are able to escape the immunosurveillance of tumor-infiltrating lymphocytes (TILs); among the molecules involved, the indoleamine 2,3-dioxygenase 1 (IDO-1) and the programmed cell death ligand-1 (PD-L1) play a crucial role. These aspects are of great interest in the current immunotherapeutic era, therefore the current study analyses the TILs, IDO-1, and PD-L1 interactions and their correlations with clinicopathological parameters and prognosis in NSCLC. One hundred ninety-three NSCLC surgical specimens, formalin-fixed, and paraffin-embedded were assessed for TILs density, TILs localization, IDO-1 (clone 4.16H1), and PD-L1 (clone E1L3N) immunohistochemical expressions. This data was correlated with clinicopathological parameters, disease free, and overall survivals. IDO-1 and PD-L1 high expressions were related to the solid pattern of adenocarcinomas (respectively p = 0.036 and p = 0.026); high PD-L1 expression was correlated with squamous histotype (p = 0.048). IDO-1 overexpression correlated with former smokers (p = 0.041), higher adenocarcinoma stages (p = 0.039), and with both higher TILs density and PD-L1 expression (respectively p = 0.025 and p = 0.0003). A better prognosis was associated with TILs intratumoral or mixed localizations (p = 0.029). TILs localization affects NSCLC prognosis; the higher expression of IDO-1 and PD-L1 in poorly differentiated and more aggressive lung adenocarcinomas, as well as the correlation between high PD-L1 expression and squamous cell histotype, confirm the more efficient immunoescaping of these NSCLC subgroups.

In the February 2018 issue of Annals of Thoracic Surgery, the results of the “Thoracoscopic Surgery Versus Thoracotomy For Lung Cancer: Short Term Outcomes Of A Randomized Trial” by Hao Long et al . were published (1). The aim of this non-inferiority, phase 3, multicenter randomized controlled trial both for short-term and oncologic outcome, was “to confirm that VATS lobectomy is non-inferior to open surgery for the treatment of early-stage NSCLC”. The results of this study merit the attention of thoracic surgeons for several reasons.

Lung cancer is the main cancer killer in both men and women, mostly due to the rapid development of drug resistant metastatic disease. Here, we evaluate the potential involvement of SRC family kinases (SFK) in lung cancer biology and assess the possible benefits of their inhibition as a therapeutic approach. We demonstrated that various SRC family members, including LYN and LCK, normally expressed solely in hematopoietic cells and neural tissues, are overexpressed and activated in a panel of SCLC and NSCLC cell lines. This was clinically relevant as LYN and FYN are also overexpressed in lung cancer clinical specimens. Moreover, LYN overexpression correlated with decreased patient survival on univariate and multivariate analysis. Dasatinib (BMS-354825), a SRC/ABL inhibitor, effectively blocked SFK activation at nanomolar concentrations which correlated with a significant decrease in cell numbers of multiple lung cancer cell lines. This effect was matched by a decrease in DNA synthesis, but only moderate induction of apoptosis. Indeed, dasatinib as well as PP2, another SFK inhibitor, strongly induced autophagy that likely prevented apoptosis. However, inhibition of this autophagic response induced robust apoptosis and sensitised lung cancer cells to dasatinib in vitro and in vivo. Our results provide an explanation for why dasatinib failed in NSCLC clinical trials. Furthermore, our data suggest that combining SFK inhibitors with autophagy inhibitors could provide a novel therapeutic approach in this disease.

Lobectomies with bronchial and/or vascular reconstruction are conservative procedures aimed at managing locally advanced lung cancer, avoiding a pneumonectomy. Considering morbidity, mortality and the functional consequences of a pneumonectomy, such procedures must be in the technical armamentarium of every thoracic surgeon. Vascular reconstruction of the pulmonary artery (PA) is seldom performed with or without the bronchial sleeve resection. Both functional and oncologic outcomes have been reported to be better than after a pneumonectomy. Different technical options are now available but some aspects and technical details are not standardized. Indications, possible complications, planning and even definitions need to be more solid to allow for definitive improvement in such procedures. This analysis is aimed at assessing the acquired technical data with special emphasis on the PA reconstruction with autologous tissues.

Talc pleurodesis has been associated with pleuropulmonary damage, particularly long-term damage due to its inert nature. The present model series review aimed to assess the safety of this procedure by examining inflammatory stimulus, biocompatibility and tissue reaction following talc pleurodesis. Talc slurry was performed in rabbits: 200 mg/kg checked at postoperative day 14 (five models), 200 mg/kg checked at postoperative day 28 (five models), 40 mg/kg, checked at postoperative day 14 (five models), 40 mg/kg checked at postoperative day 28 (five models). Talc poudrage was performed in pigs: 55 mg/kg checked at postoperative day 60 (18 models). Tissue inspection and data collection followed the surgical pathology approach currently used in clinical practice. As this was an observational study, no statistical analysis was performed. Regarding the rabbit model (Oryctolagus cunicoli), the extent of adhesions ranged between 0 and 30%, and between 0 and 10% following 14 and 28 days, respectively. No intraparenchymal granuloma was observed whereas, pleural granulomas were extensively encountered following both talc dosages, with more evidence of visceral pleura granulomas following 200 mg/kg compared with 40 mg/kg. Severe florid inflammation was observed in 2/10 cases following 40 mg/kg. Parathymic, pericardium granulomas and mediastinal lymphadenopathy were evidenced at 28 days. At 60 days, from rare adhesions to extended pleurodesis were observed in the pig model (Sus Scrofa domesticus). Pleural granulomas were ubiquitous on visceral and parietal pleurae. Severe spotted inflammation among the adhesions were recorded in 15/18 pigs. Intraparenchymal granulomas were observed in 9/18 lungs. Talc produced unpredictable pleurodesis in both animal models with enduring pleural inflammation whether it was performed via slurry or poudrage. Furthermore, talc appeared to have triggered extended pleural damage, intraparenchymal nodules (porcine poudrage) and mediastinal migration (rabbit slurry).

As of recent, a growing attention is being paid to the importance of preoperatively evaluating patients prior to lung resection. Indeed, numerous studies have sought to identify reliable predictors of patients who are at a high risk of developing postoperative complications.

Background Because there is no detailed description of procedures and perioperative management of major pulmonary resections in swine, we reviewed our experience to delineate the most effective practice in performing left pneumonectomy. Materials and methods Analysis of 11 consecutive left pneumonectomies. Animal data, operative reports, anesthesia records, and perioperative facts were evaluated. Follow-up information until postoperative day 60, methods of care-taking, therapy administration, and all the stabling aspects were systematically assessed. The investigation was aimed at highlighting those procedural steps or details which make the difference in optimizing the available resources (animals, instruments, and personnel). No statistical analysis was performed considering data characteristics and the descriptive nature of information. Results Surgery requires a median time of 2 h and 16 min; two operators and one anesthesiologist represent the basic team. Circulators' number depends on goals to accomplish. The most straightforward procedure requires careful dissection of the pulmonary ligament (limited view), pulmonary veins (low variability), pulmonary artery (delicate), and finally bronchus (no variability observed). The key factors for good anesthesia management have been identified: sedation by caregivers, preoxygenation before induction of general anesthesia, high respiratory rates with low tidal volume after pneumonectomy, and noninvasive ventilation after extubation. Antibiotic prophylaxis has been performed. Postoperative care must be continuous until animals are able to stand up, afterward “preventive noncurative,” and always animal friendly. Ideas for minimally stressful therapy administration are helpful. Conclusions After the delineation of this methodology, the compliance to a routine practice allowed us to reduce time, stress, and cost; quality and quantity of possible research increased.

Amplification of genes of the MYC family (MYC, MYCN, and MYCL1) has been described in a variety of cancer cell lines and tumor specimens including lung cancer.1–4 The MYC gene localized at 8q24.1 is a well-characterized oncogene involved in cell growth, differentiation, metabolism, and apoptosis.5 The prognostic role of MYC amplification has been explored both in small cell lung cancer (SCLC) and non–small cell lung cancer (NSCLC). Lockwood et al6 have investigated 104 cancer cell lines from different tumor tissue origins by array comparative genomic hybridization to identify amplified chromosomal segments. Among 53 lung cell lines, of which 36 were originated from NSCLC, 16 from SCLC, and 1 from Mesothelioma, MYC was the most frequently amplified gene. Some studies on resected NSCLC reported that MYC was associated with tumor progression,7,8 a worse prognosis, and its overexpression was related to metastasis of lung cancer.9 Kubokura et al10 showed that MYC amplification correlated with lymph node metastasis, suggesting a possible negative effect on survival. Iwakawa et al11 showed that MYC amplification was associated with poor prognosis in patients both with small-sized (≤2 cm in greatest dimension) and early-stage I lung adenocarcinoma (ADC). Furthermore, MYC was expressed in large numbers of NSCLCs12 and was amplified or overexpressed in SCC and ADC of the lung.13–15 The MYC increased gene copy number (GCN) leads to overexpression of the MYC protein through Max heterodimer transcription factors that alter gene expression in large part by recruiting histone-modifying enzymes.15 The gain of sequences on the long arm of chromosome 3 (3q) is also a frequent event in many human malignant diseases, including lung cancer.2 Human telomerase gene (TERC), localized on the chromosome 3q26, encodes the RNA component of human telomerase, a ribonucleoprotein enzyme, which acts as a template for the addition of telomeric repeat sequences 5′-TTAGGG-3′16 required for the stability and complete replication of chromosome ends, and it has been associated with cell immortality and the development of cancers. Recently, Fan et al17 reported significantly higher percentages of cells with amplification of TERC in NSCLC than in SCLC, and the phenomenon occurred more frequently in SCC than in ADC.18 Using FISH methodology, Pelosi et al19 studied the 3q26 amplification in preneoplastic/preinvasive squamous cell lesions of the bronchial mucosa and in 2 subsets of lung SCC, the early hilar (EHSCC), and the parenchyma-infiltrating SCC (PISCC). The authors concluded that 3q26 amplification was likely a late event in the development of SCC of the lung and it is more prevalent in EHSCC than in PISCC, suggesting different pathogenesis for these tumor subtypes. Foster et al20 showed that the 3q26 amplification was a common feature of pulmonary SCC, confirming its key role in the transition from high-grade preinvasive neoplasia to invasive carcinoma, as also documented in uterine cervix21 and head-and-neck SCC.22 Yan et al23 reported that 3q and 8q amplifications were significantly higher in smoker than those in nonsmoker SCC patients and was associated with tumorigenesis and/or progression of the disease. In summary, only a few studies are available on MYC and TERC GCN in NSCLC, and no consensus criteria exist on how to assess the status of these genes as prognostic value. This study aimed to evaluate the MYC and TERC gene copy status in NSCLC by FISH using 2 criteria for interpretation, namely, the University of Colorado Cancer Center (UCCC) scoring system proposed for EGFR in lung cancer24 and the receiver operating characteristics (ROC) scoring system. We also evaluated the correlation of these genomic imbalances with clinicopathologic parameters and outcome in resected NSCLC patients.

Background To evaluate the incidence, predictors, and survival of unexpected pN2 disease in patients with clinical stage I non-small cell lung cancer. Methods This is a retrospective observational multicenter study on all consecutive patients operated for clinical stage I non-small cell lung cancer from January 2006 to December 2012. Medical records were reviewed to investigate the incidence and risk factors for unexpected pN2 disease. Then, the survival of patients with unexpected pN2 disease was statistically compared with that of patients with clinical N2 disease operated after induction therapy in the same period. Results Our study population counted 901 patients. An incidence of 12% (108/901) unexpected pN2 disease was found. Among 3,389 lymph nodes sampled, 124 distinct metastases were found. Of the 108 patients, 92 (85%) had metastases in single N2 station and 16 (15%) patients had disease in multiple N2 stations; 47 (44%) had pN2 disease without pN1 involvement (skip metastases) and 61/108 (56%) had also pN1 metastases. Factors associated with unexpected pN2 disease were central tumor location (p 4.0 (0.007). Patients with pN2 disease compared with patients with cN2 disease presented a better median overall survival (56 versus 20 months; p = 0.001) and disease-free survival (46 versus 11 months; p

Objectives Aquaporins (AQPs) are a group of transmembrane water-selective channel proteins thought to play a role in the regulation of water permeability for plasma membranes. Indeed, high AQP levels have been suggested to promote the progression, invasion and metastasis of tumours. Specifically, AQP1 and AQP5 overexpression in lung adenocarcinoma (AC) have been suggested to be involved in molecular mechanisms in lung cancer. The aim of this retrospective cohort single-centre study was to assess both the levels of expression and therein the prognostic significance, regarding outcome of AQP1 and AQP5 in resected AC patients. Methods Patients with histological diagnoses of lung AC submitted to pulmonary resection were included in this cohort study. Tissue microarrays containing cores from 185 ACs were prepared. AQP1 and AQP5 expressions were assessed by immunohistochemistry. Results were scored as either low (Score 0-2) or high (Score 3-9). Clinical data, pathological tumour-node-metastasis staging and follow-up were recorded. Multivariate Cox survival analysis and Fisher's t-test were performed. Results AQP1 overexpression was detected in 85 (46%) patients, while AQP5 overexpression was observed in 45 (24%) patients. AQP1 did not result being significantly correlated with clinical and pathological parameters, while AQP5 resulted more expressed in AC with mucinous and papillary predominant patterns. Patients with AQP1 overexpression had shorter disease-free survival (P = 0.001) compared with patients without AQP1 overexpression. Multivariate analysis confirmed that AQP1 overexpression was significantly associated with shorter disease-free survival (P = 0.001). Conclusions Our results evidenced that AQP1 overexpression resulted in a shorter disease-free survival in lung AC patients. Being so, AQP1 overexpression might be an important prognostic marker in lung AC.

Background: Post-intubation tracheoesophageal fistula (PITEF) is an often mistreated, severe condition. This case series reviewed for both the choice and timing of surgical technique and outcome PITEF patients. Methods: This case series reviewed ten consecutive patients who had undergone esophageal defect repair and airway resection/reconstruction between 2000 and 2014. All cases were examined for patients: general condition, medical history, preparation to surgery, diagnostic work-up, timing of surgery and procedure, fistula size and site, ventilation type, nutrition, post-operative course and complications. Results: All patients were treated according to Grillo’s technique. Overall, 6/10 patients had undergone a preliminary period of medical preparation. Additionally, 3 patients had already had a tracheostomy, one had had a gastrostomy and 4 had both. One patient had a Dumon stent with enlargement of the fistula. Concomitant tracheal stenosis had been found in 7 patients. The mean length of the fistulas was 20.5 mm (median 17.5 mm; range, 8–45 mm), at a median distance from the glottis of 43 mm (range, 20–68 mm). Tracheal resection was performed in all ten cases. The fistula was included in the resection in 6 patients, while it was excluded in the remaining 4 due to their distance. Post-repair tracheotomy was performed in 3 patients. The procedure was performed in 2 ventilated patients. Morbidity related to fistula and anastomosis was recorded in 3 patients (30%), with one postoperative death (10%); T-Tube placement was necessary in 3 patients, with 2/3 decannulations after long-stenting. Definitive PITEF closure was obtained for all patients. At 5-year follow-up, the 9 surviving patients had no fistula-related morbidity. Conclusions: Primary esophageal closure with tracheal resection/reconstruction seemed to be effective treatment both short and long-term. Systemic conditions, mechanical ventilation, detailed preoperative assessment and appropriate preparation were associated with outcome. Indeed, the 3 patients who had received T-Tube recovered from anastomotic complications.

Background and Aims Isolated phrenic nerve nodule is usually a primitive tumour. Surgery is diagnostic and therapeutic at the same time. We report the case of a completely serum-negative Caucasian male with a right diaphragmatic relaxation associated to an isolated small nodule of the phrenic nerve. Methods The patient was referred to our unit complaining shortness of breath and progressive fatigue. A standard chest X-ray showed right diaphragmatic palsy; chest scanning revealed a nodular lesion belonging to the right phrenic nerve. Positron emission tomography was negative for glucose uptake. The preoperative diagnosis of primitive neurogenic tumour was thus supposed, and the patient treated by the lesion's surgical resection along with diaphragmatic plication. Result Histopathological examination revealed an idiopathic inflammatory nodule of the phrenic nerve. Conclusion Such condition has not previously been reported in the literature among the possible aetiology of a diaphragmatic relaxation.

BACKGROUND: The spleen is the most easily injured organ in abdominal trauma. The conservative, operative approach has been challenged by several reports of successful non-operative management aided by the power of modern diagnostic imaging. The aim of our retrospective study was to compare non-operative management with surgery for cases of splenic injury. METHODS: We compared seven patients who were treated with non-operative management (NOM) between 2007 and 2011 to six patients with similar pre-operative characteristics who underwent operative management (OM). RESULTS: The average hospital stay was lower in the NOM group than in the OM group, although the di�耀erence was not statistically significant. The NOM group required significantly fewer transfusions, and no patients in the NOM group required admission to the intensive care unit. In contrast 83% of patients in the OM group were admitted to the intensive care unity. The failure rate of NOM was 14.3% in our experience. CONCLUSION: In our experience, NOM is the treatment of choice for grade I, II and III blunt splenic injuries. NOM is slightly less than surgery, but this is an unadjusted comparison and the 95% confidence interval is extremely wide - from 0.04 to 16.99. Splenectomy was the chosen technique in patients who met exclusion criteria for NOM, as well as for patients with grade IV and V injury.

Objectives The objective of this study was to determine whether measuring post-operative B-type natriuretic peptides (NPs) (i.e., B-type natriuretic peptide [BNP] and N-terminal fragment of proBNP [NT-proBNP]) enhances risk stratification in adult patients undergoing noncardiac surgery, in whom a pre-operative NP has been measured. Background Pre-operative NP concentrations are powerful independent predictors of perioperative cardiovascular complications, but recent studies have reported that elevated post-operative NP concentrations are independently associated with these complications. It is not clear whether there is value in measuring post-operative NP when a pre-operative measurement has been done. Methods We conducted a systematic review and individual patient data meta-analysis to determine whether the addition of post-operative NP levels enhanced the prediction of the composite of death and nonfatal myocardial infarction at 30 and ≥180 days after surgery. Results Eighteen eligible studies provided individual patient data (n = 2,179). Adding post-operative NP to a risk prediction model containing pre-operative NP improved model fit and risk classification at both 30 days (corrected quasi-likelihood under the independence model criterion: 1,280 to 1,204; net reclassification index: 20%; p Conclusions Additional post-operative NP measurement enhanced risk stratification for the composite outcomes of death or nonfatal myocardial infarction at 30 days and ≥180 days after noncardiac surgery compared with a pre-operative NP measurement alone.

Despite centuries of anatomical studies, controversies and contradictions still exist in the literature regarding the definition, anatomical terminology and the limits of the abdominal wall. We conducted a systematic research of books published from 1901 until December 2012 in Google Books. After the index screening, 16 remaining books were further assessed for eligibility. We decided to exclude journals. The aim of the study was to focus on surface landmarks and borders of the abdominal cavity. After this revision of the literature, we propose that the surface landmarks of the abdominal wall should be standardized.

Atraumatic vertebral compression fractures are a common clinical problem, especially in elderly population. Metastases are the most frequent source of bone tumors, and the spine is a common site of metastatic disease; in case of cortical involvement or osteolysis, they may result in pathological compression fractures. Atraumatic compression fractures may result from other primary neoplasms of vertebrae and also from osteomyelitis, Paget's disease, hyperparathyroidism and other metabolic processes. Osteoporosis is a common source of vertebral compression fractures in elderly population, which may be indistinguishable from those of metastatic origin. The differentiation between osteoporotic compression fractures and malignant fracture is necessary to establish an appropriate staging and a therapeutic planning, especially in the acute and subacute stages. Anamnestic data about preexisting disease can be useful to individuate the potential cause of vertebral collapse. Plain radiography shows some difficulties in distinguishing whether the fracture represents a consequence of osteoporosis, a metastatic lesion or some other primary bone neoplasm. Computed tomography is one of the most suitable imaging techniques for the evaluation of bone structure and fragments and to establish the degree of cortical bone destruction; MR imaging (MRI) is the most helpful radiological investigation in order to provide the basis for the distinction between metastatic and acute osteoporotic compression fractures. The most relevant MRI findings to establish a differential diagnosis are described.

Background: It is unclear whether postoperative B-type natriuretic peptides (i.e., BNP and N-terminal proBNP) can predict cardiovascular complications in noncardiac surgery. Methods: The authors undertook a systematic review and individual patient data meta-analysis to determine whether postoperative BNPs predict postoperative cardiovascular complications at 30 and 180 days or more. Results: The authors identified 18 eligible studies (n = 2,051). For the primary outcome of 30-day mortality or nonfatal myocardial infarction, BNP of 245 pg/ml had an area under the curve of 0.71 (95% CI, 0.64–0.78), and N-terminal proBNP of 718 pg/ml had an area under the curve of 0.80 (95% CI, 0.77–0.84). These thresholds independently predicted 30-day mortality or nonfatal myocardial infarction (adjusted odds ratio [AOR] 4.5; 95% CI, 2.74–7.4; P < 0.001), mortality (AOR, 4.2; 95% CI, 2.29–7.69; P < 0.001), cardiac mortality (AOR, 9.4; 95% CI, 0.32–254.34; P < 0.001), and cardiac failure (AOR, 18.5; 95% CI, 4.55–75.29; P < 0.001). For greater than or equal to 180-day outcomes, natriuretic peptides independently predicted mortality or nonfatal myocardial infarction (AOR, 3.3; 95% CI, 2.58–4.3; P < 0.001), mortality (AOR, 2.2; 95% CI, 1.67–86; P < 0.001), cardiac mortality (AOR, 2.1; 95% CI, 0.05–1,385.17; P < 0.001), and cardiac failure (AOR, 3.5; 95% CI, 1.0–9.34; P = 0.022). Patients with BNP values of 0–250, greater than 250–400, and greater than 400 pg/ml suffered the primary outcome at a rate of 6.6, 15.7, and 29.5%, respectively. Patients with N-terminal proBNP values of 0–300, greater than 300–900, and greater than 900 pg/ml suffered the primary outcome at a rate of 1.8, 8.7, and 27%, respectively. Conclusions: Increased postoperative BNPs are independently associated with adverse cardiac events after noncardiac surgery.

Background Currently computed tomography pulmonary angiography (CTPA) has become a widely accepted clinical tool in the diagnosis of acute pulmonary embolism (PE). Objectives To report split-bolus single-pass 64-multidetector-row CT (MDCT) protocol for diagnosis of PE. Patients and methods MDCT split-bolus results in 40 patients suspicious of PE were analyzed in terms of image quality of target pulmonary vessels (TPVs) and occurrence and severity of flow-related artifact, flow-related artifact, false filling defect of the pulmonary veins and beam hardening streak artifacts. Dose radiation to patients was calculated. Results MDCT split-bolus protocol allowed diagnostic images of high quality in all cases. Diagnosis of PE was obtained in 22 of 40 patients. Mean attenuation for target vessels was higher than 250 HU all cases: 361 ± 98 HU in pulmonary artery trunk (PAT); 339 ± 93 HU in right pulmonary artery (RPA); 334 ± 100 HU in left pulmonary artery (LPA). Adequate enhancement was obtained in the right atrium (RA):292 ± 83 HU; right pulmonary vein (RPV): 302 ± 91 HU, and left pulmonary vein (LPV): 291 ± 83 HU. The flow related artifacts and the beam hardening streak artifacts have been detected respectively in 4 and 25 patients. No false filling defect of the pulmonary veins was revealed. Conclusion MDCT split-bolus technique by simultaneous opacification of pulmonary arteries and veins represents an accurate technique for diagnosis of acute PE, removes the false filling defects of the pulmonary veins, and reduces flow related artifacts.

OBJECTIVES: Endothelial progenitor cells are capable of contributing to neovascularization in tumours. In patients with either malignant or transudative pleural effusion, we tested the presence of pleural endothelial progenitor cells. We also measured the number of endothelial progenitor cells in post-surgery pleural drainage of either patients with early non-small-cell lung cancer or control patients with benign lung disease undergoing pulmonary resection. The prospective influence of post-surgery pleural-drainage endothelial progenitor cells on cancer recurrence/survival was investigated. METHODS: Pleural endothelial progenitor cell levels were quantified by fluorescence-activated cell sorting analysis in pleural effusion of 15 patients with late-stage non-small-cell lung cancer with pleural involvement and in 15 control patients with congestive heart failure. Also, pleural-drainage endothelial progenitor cells were measured in pleural-drainage fluid 48 h after surgery in 64 patients with earlystage non-small-cell lung cancer and 20 benign lung disease patients undergoing pulmonary resection. Cancer recurrence and survival was evaluated in patients with high pleural-drainage endothelial progenitor cell levels. RESULTS: The number of pleural endothelial progenitor cells was higher in non-small-cell lung cancer pleural effusion than in transudative pleural effusion. Also, pleural-drainage endothelial progenitor cell levels were higher in patients with non-small-cell lung cancer than in patients with benign lung disease undergoing pulmonary resection (P < 0.05). Non-small-cell lung cancer patients with high pleural-drainage endothelial progenitor cell levels had a significantly 4.9 higher rate of cancer recurrence/death than patients with lower pleural-drainage endothelial progenitor cell levels, irrespective of confounders. CONCLUSIONS: Endothelial progenitor cells are present in the pleural effusion and are higher in patients with late-stage non-small-cell lung cancer with pleural involvement than in congestive heart failure patients. Endothelial progenitor cell levels are higher in the postsurgery pleural drainage of patients with non-small-cell lung cancer than in non-neoplastic pleural-drainage fluid. High pleural-drainage endothelial progenitor cell levels in patients undergoing pulmonary resection for early non-small-cell lung cancer predict an increased risk of cancer recurrence and death.

In the May 2018 issue of Adv Ther , Miller et al. (1), reported on the influence of powered and tissue specific endoscopic stapling technology on clinical and economic results of VATS lobectomy procedures. This was a real world, non-randomized study, based on data extracted from the Premier Healthcare Database.

Introduction: Microalbuminuria (MA) reflects the systemic vascular endothelial dysfunction and could have a role in early identification of systemic inflammatory response syndrome (SIRS) and multiple organ failure. Aims and Objectives: Aim of this study was to serially assess MA after thoracic surgery and to evaluate its role in predicting complications. Methods: Prospective observational study, including patients undergoing 183 major proceedures and 72 wedge resections. MA was expressed as urine albumin-to-creatinine ratio (A/C) before and after surgery at predefined times up to 96 hours and Pa/FiO2 measured at extubation and at first postoperative day. Results: 255 patients, mean age 62, 67% male. The most common comorbidities were COPD 44%, hypertension 39% and diabetes 11%. Preoperative A/C levels were within the normal range but showed a significant increase at extubation reaching a peak 6 hours later p 4 requiring intensive care. 2 patients died and 35 experienced cardiopulmopnary complications. A higher A/C ratio was recorded in patients who developed adverse events compared to the group with uneventful course (p 61mg/g (ROC area=0.669; 95% CI=0.599-0.734; p=0.0003) was associated with cardio-pulmonary impairments (OR 3.85; 95%CIs 1.58-9.36; p=0.003). Conclusions: MA might be and early marker of posoperative increased vascular permeability showing an inverse correlation with PaO2/FiO2 ratio. It could be a useful diagnostic tool for identification of patients at risk for cardiopulmonary complications; its independent prognostic significance remains to be established.

Introduction: Extravascular lung water (EVLW) increases following thoracic surgery because of altered fluid dynamics and vascular permeability. It may lead to alveolar-interstitial syndrome (AIS) that impairs gas exchange. AIS diagnosis is achieved by B-Lines and their absolute number is correlated with EVLW. Aims and Objectives: Aim of this prospective cohort study was to investigate by lung ultrasonography (LUS) the variation in EVLW following major pulmonary resection. Methods: EVLW was assessed at baseline and on postoperative days 1 and 4, using a 3,5 MHz convex probe, with patients undergoing lobectomy or pneumonectomy being examined in the sitting position. 4 sub-regions were identified in the inviolate hemithorax and B-lines were quantified according to a four-level scale analyzed jointly using a proportional odds model for repeated measures with baseline values as covariates. The respiratory ratio PaO2/FiO2 and fluid retention by measuring brain natriuretic peptide (BNP) were also assessed. Results: 48 men and 26 women underwent 64 lobectomies and 10 pneumonectomies; mean age 64. At baseline no patient showed AIS and the mean BNP value was normal. At extubation a significant inverse correlation was found between B-lines and the PaO2/FiO2 (OR-0.72; 95% CI 0.55-0.92; p=0.0096). There was a significant peak of B-lines on postoperative day 1, as well as a significant positiveassociation between B-lines and BNP (OR-1.00537; 95%CI 1.00295-1.00779; p Conclusions: Following major thoracic surgery LUS is able to estimate EVLW increase. The B-lines value is correlated to BNP and provides reliable information on the presence of AIS before it becomes clinically evident.