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Broncho-pleural fistula (BPF) is an atypical communication between the tracheobronchial tree and the alveolar/pleural space, with prolonged air leak (PAL). BPF is frequent and related to significant morbidity, prolonged length of hospital stay, and mortality. Nevertheless, in about 10%, more than 5 days of an air leak is considered a PAL, accounted for significant morbidity. Endobronchial valve is a novel device for the PAL management with minimal morbidity if related to surgical repairs. While it is suggested that surgical treatment should be undertaken when possible, endobronchial valves should be recommended as a therapeutic choice in high-risk patients. Placement techniques remain operator and patient friendly and allow the procedure to be performed with relative ease. Prospectively conducted, randomised, controlled clinical trials are needed where valve treatment is compared with other bronchoscopic techniques, surgical procedures, or both.

A case of endobronchial pagetoid spread of a breast carcinoma metastatic to the lung is described. A 73-year-old woman underwent wedge lung resection after the cytological diagnosis of lung metastasis from ductal invasive breast carcinoma. The breast carcinoma had been surgically removed 6 years previously; at the time of diagnosis it was a T1N0, grade 3 invasive ductal carcinoma, with HER-2 amplification. The lung metastasis measured 1,9 cm and showed the same histology and biological profile of the primary tumor. In addition, numerous neoplastic cells, with large cytoplasm and atypical nuclei, appear to spread along the mucosa of the bronchi adjacent to the metastatic lesion as well as that of the main lobar bronchus, intermingled with the columnar ciliated cells. The neoplastic elements were negative for TTF-1 and strongly HER-2 positive; these features appeared consistent with endobronchial pagetoid spread by the metastatic breast carcinomatous cells.

“ Anger as soon as fed is dead, Tis starving makes it fat. ” Emily Dickinson, Poems, Second Series, 1891.

Extrapleural pneumonectomy (EPP) and pleurectomy-decortication (P/D) are both recognised surgical procedures for selected cases affected by malignant pleural mesothelioma (MPM). Surgical techniques have ameliorated over the last years, remaining the complete macroscopic resection of the disease the main surgical principle. EPP is defined as an en-bloc resection of the visceral pleura, parietal pleura, pericardium and diaphragm alongside the pneumonectomy. The thoracic domain of the International Association for Study of Lung Cancer (IASLC) recently clarified the, previously confused, surgical terminology. "Extended P/D" is considered as parietal and visceral pleurectomy, diaphragmatic and pericardial resection with the purpose to remove all macroscopic disease. The term "radical" was replaced by "extended" to underline that this procedure does not have oncologic radicality aims. Both operations above are technically challenging and associated with a significant rate of peri-operative morbidity and non-negligible mortality. The diaphragmatic and pericardial reconstruction technique is mandatory to avoid respiratory impairment and to reduce post-operative complications like gastric and cardiac herniation. The technical aspects of resection and reconstruction are described and the choice of different prosthetic materials, considering the most recent innovations in the field, are discussed.

A case of endobronchial pagetoid spread of a breast carcinoma metastatic to the lung is described. A 73-year-old woman underwent wedge lung resection after the cytological diagnosis of lung metastasis from ductal invasive breast carcinoma. The breast carcinoma had been surgically removed 6 years previously; at the time of diagnosis it was a T1N0, grade 3 invasive ductal carcinoma, with HER-2 amplification. The lung metastasis measured 1,9 cm and showed the same histology and biological profile of the primary tumor. In addition, numerous neoplastic cells, with large cytoplasm and atypical nuclei, appear to spread along the mucosa of the bronchi adjacent to the metastatic lesion as well as that of the main lobar bronchus, intermingled with the columnar ciliated cells. The neoplastic elements were negative for TTF-1 and strongly HER-2 positive; these features appeared consistent with endobronchial pagetoid spread by the metastatic breast carcinomatous cells.

We herein report a case of a 45-year-old white male who referred to the emergency department for a right pneumothorax. A chest tube was emergently placed. Due to incomplete lung reexpansion, the patient underwent a right thoracoscopy disclosing the presence of several kinky vessels consistent of localized pleural angiomatosis, and a talc pleurodesis was performed. Computed tomographic scan and angiography confirmed an anomalous vascular connection between systemic and pulmonary circulation. Thus, a vascular percutaneous transcatheter embolization of the abnormal vessel was successfully executed and the patient was discharged without consequence.

Althoughthe optimal treatment for patients affected by malignant pleural mesothelioma(MPM) is subject of dispute and a surgical standard has not been yet established, extrapleural pneumonectomy (EPP) is still considered a suitable therapeuticoption. The most challenging passage is diaphragmatic resection andreconstruction since standard fifth intercostal space thoracotomy is unable toassure a comfortable view of the surgical field although a second thoracotomyis usually performed. Lower door (LD) thoracotomy implies the section of theanterior costal arches from the sixth to ninth costal cartilage and thedivision of the oblique abdominal muscles below the costal arch. In thisfashion thorax is anteriorly opened like a door. This approach providesexcellent visibility and exposure of the costophrenic and cardio-phrenicangles. Consequently, diaphragmatic resection/reconstruction and en bloc resection of lung, parietal pleura, pericardium and diaphragm, can be performedradically, accurately and safely.

Video-assisted thoracic surgery (VATS) lobectomies minimize complications, provide less pain and better quality of life, and offer faster recovery, better cosmetic results and better cost-effectiveness. Also, VATS lobectomies deliver long-term results at least equivalent to those observed on thoracotomy and become an exciting alternative to treat high-risk patients with a better risk-benefit ratio. The number of VATS lobectomy cases performed per year is increasing thanks to the growing experience with the technique and the development of dedicated surgical instruments and stapling devices. Development and further refinement of technique have allowed thoracic surgeons to perform a wide variety of complex procedures in a minimally invasive fashion.

In recent years, the uniportal approach has become one of the most exciting and innovative developments in minimally invasive thoracic surgery. While the debate over its supposed advantages, learning curve and complexity continues, this manuscript explores the technical aspects of performing the hilar dissection for a lobectomy via the uniportal approach. Using a step-by-step narration, surgical details and key tips and tricks are laid out for the beginner hoping to clarify basic steps of the technique.

The study was aimed at assessing the influence of the elective ICU admission on the early outcome after major lung resection by analyzing the different postoperative management policies of two centers. Center A managed all patients in a dedicated ward, resorting to ICU for complications requiring invasive assisted ventilation. In center B, high-risk patients were electively transferred to ICU immediately after operation. Propensity score was used to match those patients of center B electively admitted to ICU (96 of 157), with counterparts from center A (96 of 205). The outcome of these matched pairs were then compared. There was a trend of reduced total morbidity (23% vs. 35%, respectively; P=0.06), cardiovascular (13.5% vs. 23%, respectively; P=0.09) and pulmonary complication rates (9.3% vs. 18%, respectively; P=0.09), but a longer postoperative hospital stay (11.5 vs. 9.7, respectively; P=0.015) in the patients electively admitted to ICU, compared to matched center A patients. Mortality rates were not different (7.3% vs. 7.3%; P=1). Since the elective postoperative ICU admission did not show a clear-cut outcome benefit over the management in a dedicated ward, this practice should be limited to highly selected patients in order to efficiently utilize the available resources.

We report a case of a 71-year-old Caucasian woman who was referred to our emergency department for acute onset of dyspnoea and dry cough. She underwent dental filling for caries ~2 h before. During the treatment, the distal part of the odontoiatric drill unintentionally fell off into the patient's oral cavity and was accidentally inhaled. Posteroanterior chest X-ray evidenced the foreign body localized in the right bronchial tree. A chest computed tomography scan showed the drill (with the tip pointed upward) wedged at the beginning of the right basal pyramid. A subsequent fiberoptic bronchoscopy confirmed the tip of the drill in the right lower bronchus, and the foreign body was easily removed due to the favorable position of the tip. The patient was discharged in first postoperative day without consequences.

Background . Transbronchoscopic needle aspiration (TBNA) can offer a unique opportunity to identify surgically unresectable lung cancer and to avoid surgical mediastinal exploration in many patients with mediastinal lymph node extension of the tumor. The aim of this study was to assess the yield of TBNA performed with either histology or cytology needles in mediastinal staging of N2 disease due to non–small cell lung cancer (NSCLC). Methods . Retrospective chart review was carried out on 194 TBNA procedures performed between January 1997 and September 2000 at a single institution. Inclusion criteria were pathologic evidence of NSCLC; contrast enhancement computed tomography scan of the chest suggesting N2 disease; and negative bronchoscopic examination for possible neoplastic lesions at the site of TBNA. Results . Overall sensitivity and diagnostic accuracy were 71% and 73%, respectively, with no significant differences between 19-gauge and 22-gauge cytology needles. Procedures performed for right paratracheal and subcarinal lymph node stations had a significantly higher yield than those for the left paratracheal station. Conclusions . TBNA mediastinal staging, performed during the initial diagnostic evaluation of NSCLC, can spare costs and risks of more invasive procedures in patients with inoperable tumors, in patients who are not candidates for operation because of coexistent significant comorbidities, and in patients with N2 disease.

Inflammatory pseudotumor is a rare clinical entity. We report here the case of a 14-year-old boy who underwent lung resection en bloc with the lower esophagus, the mediastinal pleura and the diaphragm for an inflammatory pseudotumor of the left lower lobe. Postoperative radiotherapy was administered. The patient is well at 9-year follow-up. Inflammatory pseudotumor may present a particularly aggressive behavior. Multimodality approach, including extensive surgical resection, may be necessary in dealing with this disease.

Multimodality treatment, with chemotherapy and surgery, is potentially curative in case of non-seminomatous germ cell tumours. The authors present the case of a primitive mediastinal GTC with bilateral lung metastases. The patient was treated with five cycles of chemotherapy. Restaging showed reduction of the extent and of 18 FDG intake and β-HCG serum levels. The patient underwent two-step surgical excision of the tumours: mediastinal lesion and 35 lung metastases were resected by a right thoracotomy and 39 metastases were removed by a left thoracotomy. Histology showed absence of viable tumour in all the specimens. Twelve months after surgery the patient is free of disease.