Alessandro Bandiera

Surgical treatment of catamenial pneumothorax: a single centre experience

We retrospectively reviewed our experience with catamenial pneumothorax (CP) in terms of treatment and follow-up. From 1993 to 2008, ten women presented at our department with CP. CP was right-sided in all patients: seven presented diaphragmatic defects including one endometriosis, five had apical bulla or blebs that in three patients were the only pathological findings. Surgical approach was thoracoscopic with a muscle-sparing thoracotomy when diaphragmatic defects where present. All patients underwent apical resection and apical pleurectomy associated in seven cases with diaphragmatic plication and chemical pleurodesis. After surgery nine patients underwent hormonal treatment: three were put on estrogen-progesterone complex treatment and six received gonadotropin-releasing hormone agonist (GnRH agonist). Recurrence rate was 40% and it was significantly correlated with estrogen-progesterone treatment (P<0.005). The mean follow-up was 52+/-32 months (range 14-168). At the present time, no recurrence has occurred in all women. Occurrence of CP is often underestimated. At the time of surgery the diaphragm should be carefully inspected for defects and/or endometriosis. Standard pleurodesis may not suffice and we suggest apical resection and apical pleurectomy associated with a diaphragmatic procedure when indicated. Hormonal treatment with GnRH agonist seems to improve the outcome.

Montgomery T-tube placement in the treatment of benign tracheal lesions

INTRODUCTION Although surgery remains the gold standard for the treatment of benign tracheal stenosis, airway stenting may be indicated in the event of complex lesions or associated diseases. We retrospectively investigated Montgomery T-tube placement as an alternative or complementary treatment to surgery. METHODS From January 1984 to March 2008, 158 patients were treated for benign tracheal lesions. Eighty-three patients underwent airway resection and reconstruction as the only treatment. Seventy-five other patients with complex lesions or major associated diseases were treated with a T-tube and were retrospectively analysed. Seven of them had undergone unsuccessful treatment with Dumon stents. T-tube placement was the only procedure adopted in 51 patients with a contraindication to surgery (group I), a temporary measure in 15 patients prior to surgery (group II), and in 9 patients (group III) for complications of airway reconstruction, 5 of whom were referred from other institutions. RESULTS Complications after T-tube placement were: stent dislocation in 3 (4%) patients, endoluminal granulomas in 14 (19%), subglottic edema in 3 (4%), and sputum retention in 7 (9%). Treatment of complications (tracheostomy cannula, steroid infiltration, Argon/LASER coagulation, and bronchoscopy) was required in 20 (27%) patients. In group I, the tube was removed in 12 (24%) patients after 35.3 +/- 8.2 months following resolution of the stenosis. In group II, the tubes were maintained in place before surgery for 17.1 +/- 4.8 months. In group III, three stents were removed following tracheal healing after 115.3 +/- 3.7 months. After 5 years the stents were in place in 82%, 7% and 100% of the patients, respectively in groups I, II and III. CONCLUSIONS Montgomery T-tube placement represents a useful option in patients with complex benign tracheal stenosis or associated diseases as an alternative or complementary treatment to surgery, and is effective even when other types of stents are unsuccessful.

Preoperative assessment in patients with postintubation tracheal stenosis : Rigid and flexible bronchoscopy versus spiral CT scan with multiplanar reconstructions

BackgroundPostintubation stenosis remains the most frequent indication for tracheal surgery. Rigid bronchoscopy has traditionally been considered the technique of choice for the preoperative diagnostic assessment. However, this technique is not routinely available, and new techniques such as flexible videobronchoscopy and spiral computed tomography (CT) scan with multiplanar reconstructions have been proposed as alternatives to rigid bronchoscopy. The aim of this study was to compare these techniques in the diagnostic assessment of patients with tracheal stenosis submitted to surgical treatment.MethodsTwelve patients who underwent airway resection and reconstruction for postintubation tracheal and laryngotracheal stenosis were preoperatively evaluated with rigid and flexible bronchoscopy and with spiral CT scan with multiplanar reconstructions. The following parameters were examined: involvement of subglottic larynx, length of the stenosis, and associated lesions. The results were compared with the intraoperative findings.ResultsThe accuracy of rigid bronchoscopy, flexible bronchoscopy, and CT scan in the evaluation of the involvement of subglottic larynx was, respectively, 92%, 83%, and 83%. The evaluation of the length of the stenosis was correct in 83%, 92%, and 25% of the patients, respectively, with rigid bronchoscopy, flexible bronchoscopy, and CT scan. A significant correlation was observed between the length of the stenosis measured intraoperatively and preoperatively with rigid (p < 0.001) and flexible bronchoscopy (p < 0.05) but not with CT scan (p = 0.08). The three techniques correctly showed the presence of an associated tracheoesophageal fistula in two patients, but CT scan did not correctly show the exact location of the fistula in relation to the airway. Flexible bronchoscopy was the only effective technique in the assessment of laryngeal function.ConclusionsRigid bronchoscopy remains the procedure of choice in the evaluation of candidates for tracheal resection and reconstruction for postintubation stenosis, and it should be available in centers that perform surgery of the airway. Flexible bronchoscopy and CT scan have to be considered complementary techniques in the evaluation of laryngeal function and during follow-up.

Conservative and Surgical Treatment of Acute Posttraumatic Tracheobronchial Injuries

BackgroundAcute posttraumatic tracheobronchial lesions are rare events associated with significant morbidity and mortality. They are caused by blunt and penetrating trauma, or they are iatrogenic, appearing after intubation or tracheotomy. Although surgery has traditionally been considered the treatment of choice for these injuries, recent reports show that conservative treatment can be effective in selected patients. The aim of this study was to evaluate the role of surgical and conservative management of these lesions, differentiated on the basis of clinical and endoscopic criteria.MethodsFrom January 1993 to October 2010, a total of 50 patients with acute posttraumatic tracheobronchial lesions were referred for treatment to our department. In all, 36 patients had iatrogenic injuries of the airway, and 14 had lesions resulting from blunt or penetrating trauma.ResultsOf the 30 patients who underwent surgery, the lesion was repaired with interrupted absorbable sutures in 29; the remaining patient, with an associated tracheoesophageal fistula, underwent single-stage tracheal resection and reconstruction and closure of the fistula. In all, 20 patients were treated conservatively: clinical observation in 5 patients, airway decompression with a mini-tracheotomy cannula in 4 spontaneously breathing patients, and tracheotomy with the cuff positioned distal to the lesion in 11 mechanically ventilated patients. One surgical and one conservatively-managed patient died after treatment (4% overall mortality). Complete recovery and healing were achieved in all the remaining patients.ConclusionsSurgery remains the treatment of choice for posttraumatic lesions of the airway. However, conservative treatment based on strict clinical and endoscopic criteria—stable vital signs; effective ventilation; no esophageal injuries, signs of sepsis, or evidence of major communication with the mediastinal space—enables favorable results to be achieved in selected patients.

Surgical Treatment of Multiple Primary Adenocarcinomas of the Lung

INTRODUCTION The incidence of lung adenocarcinomas has steadily increased over the last decades. The aim of this study was to assess the results of surgical treatment of multiple primary adenocarcinomas of the lung (MPAL) analyzing the radiological and histological features. METHODS From 1988 to 2005, 26 patients underwent surgical treatment for MPAL at our department, for a total of 52 tumors. Three patients had synchronous and 23 had metachronous tumors. RESULTS Thirty-seven tumors were classified as solid, two as ground-glass opacities (GGO) and 13 as mixed solid/GGO tumors on the basis of CT scan evaluation. Histology revealed 26 adenocarcinomas, five adenocarcinomas with a bronchioloalveolar (BAC) pattern and 21 BAC. There was no postoperative mortality. Five-year survival of patients with synchronous tumors was 66 %. Survival of patients with metachronous tumors was 95 % and 70 % from the first and second operation. Patients with stage II and III a tumors had significantly reduced survival rates ( P < 0.05). Survival was 60 % after lobectomy and 78 % after wedge resection. CONCLUSIONS Surgical treatment of MPAL is associated with favorable results. Sublobar resections, when technically feasible, provide adequate oncological management.

Antineutrophil cytoplasmic antibody positivity in IgG4-related disease: A case report and review of the literature.

Background:IgG4-related disease (IgG4-RD) is a fibroinflammatory condition characterized by serum IgG4 elevation and tissue infiltration of IgG4-positive plasma cells. Substantial overlap between IgG4-RD and antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitides (AAV) exists in terms of organ involvement and histopathological features. A positive ANCA assay is regarded as a highly specific finding in favor of an AAV, and generally influences away from a diagnosis of IgG4-RD. Recent reports, however, have raised the possibility that some patients with IgG4-RD are ANCA positive, thus suggesting reconsideration of the role of ANCA in the diagnostic workup. In the present work, we describe the first case of concomitant biopsy-proven IgG4-RD and granulomatosis with polyangiitis (GPA), demonstrating antiproteinase 3 (PR3) ANCA of the IgG4 subclass in the patients serum. We also review the literature in order to provide clinicians with tools for interpreting ANCA positivity in IgG4-RD patients. Case summary:A 51-year-old woman was referred for left exopthalmos due to lacrimal gland enlargement and increased serum IgG4 concentration. IgG4-RD was suspected and further imaging studies disclosed multiple pulmonary masses in the right lung. Histological analysis of the left lacrimal gland was diagnostic for IgG4-RD, but lung biopsy showed typical features of GPA. ANCA assay was positive for anti-PR3 antibodies. Further immunofluorescence studies demonstrated anti-PR3 antibodies of IgG1 and IgG4 subclass. Treatment with rituximab induced swift remission of both IgG4-RD and GPA manifestations. We identified 9 other reports of patients with IgG4-RD and positive ANCA in the English literature, 5 cases with biopsy-proven IgG4-RD and 4 cases in whom IgG4-RD was diagnosed presumptively. Four patients had also histological evidence of concomitant AAV. Conclusion:The present work demonstrates that ANCA positivity in patients with biopsy-proven IgG4-RD should prompt the exclusion of a concomitant vasculitic process; a positive ANCA does not exclude the diagnosis of IgG4-RD; confirmation through immunoenzymatic assays of the ANCA specificity, clinical-pathological correlation, and histopathological evaluation remain crucial steps for the differential diagnosis between AAV and IgG4-RD.

Prognostic factors in a multicentre study of 247 atypical pulmonary carcinoids.

OBJECTIVES To analyse clinical and biomolecular prognostic factors associated with the surgical approach and the outcome of 247 patients affected by primary atypical carcinoids (ACs) of the lung in a multi-institutional experience. METHODS We retrospectively evaluated clinical data and pathological tissue samples collected from 247 patients of 10 Thoracic Surgery Units from different geographical areas of our country. All patients were divided into four groups according to surgical procedure: sub-lobar resections (SURG1), lobar resections (SURG2), tracheobronchoplastic procedures (SURG3) and pneumonectomies (SURG4). Overall survival analysis was performed using the Kaplan-Meier method and log-rank test. Survival was calculated from the date of surgery to the last date of follow-up or death. The parameters evaluated included age, gender, smoking habits, laterality, type of surgery, 7th edition of TNM staging, mitosis Ki-67 (MIB1), multifocal forms, tumourlets, type of lymphadenectomy and neo/adjuvant therapy. For multivariate analysis, a Cox regression model was used with a forward stepwise selection of covariates. RESULTS Two hundred and forty-seven patients (124 females and 123 males; range 10-84, median 60 years) underwent surgical resection for AC in the last 30 years as follows: n = 38 patients in SURG1, 181 in SURG2, 15 in SURG3 and 14 in SURG4. A smoking history was present in 136 of 247 (55%) patients. The median follow-up period was 98.7 (range 11.2-369.9) months. The overall survival probability analysis of the AC was 86.7% at 5 years, 72.4% at 10 years, 64.4% at 15 years and 58.1% at 20 years. Neuroendocrine multicentric forms were detected in 12 of 247 patients (4.8%; 1 of 12 pts) during the follow-up (range 11.2-200.4, median 98.7 months) and 33.4% had recurrence of disease. There were no significant differences between gender, tumour location and type of surgery at the multivariate analysis. Age [P < 0.001, hazard ratio (HR) 0.60; confidence interval (CI) 0.32-1.12], smoking habits (P = 0.002; HR 0.43, 95% CI 0.23-0.80) and lymph nodal metastatic involvement (P = 0.008; HR 0.46, 95% CI 0.26-0.82) were all significant at multivariate analysis. CONCLUSIONS ACs of the lung are malignant neuroendocrine tumours with a worst outcome in patients over 70 years and in smokers. With the exception of pneumonectomy, the extent of resection does not seem to affect survival and should be accompanied preferably by lymphadenectomy. Pathological staging, along with a mitotic index more than Ki-67 (MIB1), appears to be the most significant prognostic factor at the univariate analysis.

Intercostal artery pseudoaneurysm after computed tomography-guided percutaneous fine needle aspiration lung biopsy.

Intercostal artery pseudoaneurysm is a rare but life-threatening complication. Herein we report an unusual case of an intercostal artery pseudoaneurysm caused by computed tomography-guided percutaneous fine needle aspiration lung biopsy and successfully treated with endovascular embolization. Radiologists performing percutaneous fine needle aspiration lung biopsies should be aware of this rare potential complication.

Transbronchial Needle Aspiration in Lung Cancer Patients Suitable for Operation With Positive Mediastinal Positron Emission Tomography

BACKGROUND The objectives of this study were to analyze our experience with transbronchial needle aspiration as a minimally invasive procedure alternative to mediastinoscopy in the preoperative staging of non-small cell lung cancer patients with positive mediastinal positron emission tomography and to propose a staging algorithm that combines performance characteristics of these three methods. METHODS Fifty-one patients staged N2 or N3 after positron emission tomography imaging underwent transbronchial needle aspiration. RESULTS A malignant adenopathy was identified in 26 patients (51%) that were excluded from operation and referred for neoadjuvant chemotherapy or chemoradiotherapy according to the mediastinal status (N2 or N3), as determined on the positron emission tomography image. In the remaining 25 patients (49%), samples were considered adequate negative in 12 patients, inadequate in 11, or inconclusive in 2. These patients underwent mediastinoscopy. Mediastinoscopy showed N2 disease in 19 cases, and the patients received neoadjuvant chemotherapy. In the remaining 6 cases no mediastinal involvement was identified and patients underwent operation. Postoperatively, 5 patients were staged N0 and 1 was staged N2. For transbronchial needle aspiration, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 76%, 100%, 100%, 33%, and 79%, respectively. CONCLUSIONS Transbronchial needle aspiration avoided a mediastinoscopy in approximately half of lung cancer patients referred for operation with positive mediastinal positron emission tomography, sparing the associated costs and risks of more invasive surgical procedures. The minimally invasive mediastinal staging algorithm that we proposed seems to be efficacious and easily applicable in clinical practice.

Prognostic role of liver X receptor-alpha in resected stage II and III non-small-cell lung cancer

In the search of new therapeutical strategies against non‐small‐cell lung cancer (NSCLC), the identification of new prognostic factors is crucial.