Andrea Bille

Videothoracoscopic Repair of Diaphragm and Pleurectomy/Abrasion in Patients With Catamenial Pneumothorax: A 9-Year Experience

BACKGROUNDnCatamenial pneumothorax (CP) is a cause of recurrent pneumothorax in women of child-bearing age. Surgical treatment has been associated with high recurrence rates. We report our experience with a totally videothoracoscopic approach involving diaphragmatic repair, pleurectomy/abrasion, and hormonal treatment in patients with proven CP.nnnMETHODSnThis was a retrospective study of all patients with proven CP operated on by a single surgeon using a videothoracoscopic approach, diaphragmatic repair, and pleurectomy/pleural abrasion. A polytetrafluoroethylene mesh was used to cover the diaphragm in patients with pores or fenestrations. All patients received hormone therapy for 6 to 12 months postoperatively and were followed up to assess complications and recurrence.nnnRESULTSnTwelve patients were identified as having CP. All patients except one had suffered right sided pneumothorax only. One patient also had a history of left-sided pneumothorax managed conservatively at another institution. All cases except one underwent a primary operation. One patient had previously had videothoracoscopic pleurodesis without diaphragm repair at another center. In all cases, findings typical of CP were identified within the pleural cavity, mainly on the diaphragm. In three patients, no diaphragmatic pores or fenestrations were noted. There were no postoperative complications and no mortality. Median follow-up was 45.8 28.6 months. One patient suffered a single episode of recurrence before starting hormonal therapy, treated conservatively.nnnCONCLUSIONSnA totally videothoracoscopic approach to CP including diaphragmatic cover with a mesh and pleurectomy/pleural abrasion is feasible, safe, and highly effective. Routine hormonal treatment (gonadotropin-releasing hormone analog) may also help reduce recurrences.

Contemporary Analysis of Prognostic Factors in Patients with Unresectable Malignant Pleural Mesothelioma

Introduction: Previous prognostic scoring systems for malignant pleural mesothelioma (MPM) included patients managed surgically and predated the use of pemetrexed. We analyzed prognostic factors in a contemporary cohort of patients with unresectable MPM who received pemetrexed‐based chemotherapy. Methods: This single‐institution analysis included patients with MPM who were managed nonsurgically from 2000 to 2013. Variables correlated with overall survival (OS) included sex, performance status (PS), asbestos exposure, tumor laterality, histology, clinical stage, initial positron emission tomography maximum standardized uptake value, hemoglobin level, platelet count, lymphocyte count, white cell and neutrophil counts, treatment type, and clinical benefit from treatment. OS was analyzed by the Kaplan‐Meier method, and significance (p < 0.05) of prognostic factors was analyzed by the log‐rank test and Cox regression. Results: A total of 191 patients met the study criteria: median age 71 years (range 46–90), 147 men (77%), 128 epithelioid tumors (67%), and 157 cases of stage III or IV MPM (82%). Median OS for all patients was 13.4 months. According to a univariate analysis, histology (p < 0.001), platelet count (≤450,000 versus >450,000, p < 0.001), initial PS (0–1 versus ≥2), maximum standardized uptake value (≤8.1 versus >8.1, p = 0.037), and lymphocyte counts (p = 0.019) were associated with OS. According to a multivariable analysis, only histology, platelet count, and PS were independent prognostic factors. Epithelioid histology, PS, and elevated lymphocyte count at diagnosis were significantly associated with clinical benefit from first‐line chemotherapy. Conclusions: Our results confirm the significance of elements of the Cancer and Leukemia Group B and European Organisation for Research and Treatment of Cancer prognostic scoring systems, identify factors associated with clinical benefit from chemotherapy, and emphasize the impact of histology and clinical benefit of chemotherapy on outcomes.

Intracavitary ‘T4 immunotherapy’ of malignant mesothelioma using pan-ErbB re-targeted CAR T-cells

Malignant mesothelioma remains an incurable cancer. We demonstrated that mesotheliomas expressed EGFR (79.2%), ErbB4 (49.0%) and HER2 (6.3%), but lacked ErbB3. At least one ErbB family member was expressed in 88% of tumors. To exploit ErbB dysregulation in this disease, patient T-cells were engineered by retroviral transduction to express a panErbB-targeted chimeric antigen receptor (CAR), co-expressed with a chimeric cytokine receptor that allows interleukin (IL)-4 mediated CAR T-cell proliferation. This combination is referred to as T4 immunotherapy. T-cells from mesothelioma patients were uniformly amenable to T4 genetic modification and expansion/enrichment thereafter using IL-4. Patient-derived T4+ T-cells were activated upon contact with a panel of four mesothelioma cell lines, leading to cytotoxicity and cytokine release in all cases. Adoptive transfer of T4 immunotherapy to SCID Beige mice with an established bioluminescent LO68 mesothelioma xenograft was followed by regression or eradication of disease in all animals. Despite the established ability of T4 immunotherapy to elicit cytokine release syndrome in SCID Beige mice, therapy was very well tolerated. These findings provide a strong rationale for the clinical evaluation of intracavitary T4 immunotherapy to treat mesothelioma.

Recurrent pleural effusion in yellow nail syndrome successfully treated with video-assisted thoracic surgery: comparison of two surgical strategies in two cases

Pleural effusions as part of the yellow nail syndrome (YNS) can often be recurrent, requiring multiple thoracocentesis. The optimal surgical treatment of such recurrent effusions remains unclear and various methods including thoracoscopic pleurodesis, pleuroperitioneal shunts and pleurectomy have been described. We report two cases of recurrent pleural effusions in YNS, the first case with bilateral effusions and the second with right-sided effusions treated 2 months apart from bilateral long-term tunnelled catheters and thoracoscopic pleurectomy and compare the results of the two treatment strategies.

Incidence of occult pN2 disease following resection and mediastinal lymph node dissection in clinical stage I lung cancer patients.

ObjectivesnEarly clinical stage (T1 and T2) non-small cell lung cancer (NSCLC) is commonly treated with anatomic lung resection and lymph node sampling or dissection. The aims of this study were to evaluate the incidence and the distribution of occult N2 disease according to tumour location and the short- and long-term outcomes.nnnMethodsnWe performed a retrospective review of patients with clinical stage I NSCLC who underwent anatomic lung resection and lymphadenectomy. Mediastinal lymphadenectomy (ML) was defined as resection of at least 2 mediastinal stations, always including station 7 lymph nodes. Patients who had a lobe-specific lymphadenectomy were excluded.nnnResultsnOne thousand six hundred and sixty-seven consecutive patients met inclusion criteria and were included. Overall, 9% (146/1667) of the patients had occult pN2 disease. At multivariable analysis, adenocarcinoma histology and vascular invasion were independently associated with greater risk of occult pN2 disease. In left and right upper lobe tumours, station 7 nodes were involved in 5 and 13% of pN2 positive cases, respectively. Station 5 and station 2/4 nodes were involved in 29 and 18% of left and right lower lobe pN2 tumours, respectively. There was no postoperative mortality, and postoperative morbidity was 28%. The median overall survival was 77.4 months. N0 patients had a median overall survival of 83.7 months vs 48.0 months and 37.9 months in N1 and N2 populations, respectively ( P u2009<u20090.001).nnnConclusionsnSixteen percent of pN2 patients had mediastinal lymph node metastasis beyond the lobe-specific lymphatic drainage. We recommend a complete lymphadenectomy be performed, even in clinical stage I NSCLC.

Surgical therapy of thymic tumours with pleural involvement: an ESTS Thymic Working Group Project

Abstract OBJECTIVES: Surgery for thymic epithelial tumours (TETs) with pleural involvement is infrequently performed. Thus, the value of surgical therapy for primary or recurrent TETs with pleural involvement is not sufficiently defined yet. METHODS: Twelve institutions contributed retrospective data on 152 patients undergoing surgery (1977–2014) on behalf of the ESTS Thymic Working group. Outcome measures included overall (OS), cause-specific (CSS) and disease-free (DFS) survival as well as freedom from recurrence (FFR). RESULTS: In 70.4% of cases, pleural involvement was present at the time of primary intervention, whereas 29.6% had surgery for recurrent disease involving the pleura. Pleural involvement resulted from thymomas (88.8%) and thymic carcinomas (11.2%). Forty extrapleural pneumonectomies (EPPs), 23 total pleurectomies (TPs), and 88 local pleurectomies (LPs) were performed (completeness of resection in 76.8%). OS for the entire patient population at 1, 3, 5 and 10 years was 96.4%, 91.0%, 87.2% and 62.7%, respectively. There was no statistically significant difference regarding FFR and OS for patients with local or advanced disease undergoing EPP, TP or LP. Thymic carcinomas in comparison with thymomas had a negative impact on OS [hazard ratio 6.506, Pu2009=u20090.002], CSS and FFR. Incomplete resections predicted worse OS [hazard ratio 6.696, Pu2009=u20090.003]. CONCLUSIONS: Complete resection remains the mainstay of treatment for TETs with pleural involvement. Study populations treated with EPP, TP and LP had similar survival that may be factual as observed, but in the presence of selection bias, we can further conclude from the results that EPP, TP and LP are equally effective procedures. Procedural choice depends upon the extent of tumour distribution. EPPs, TPs and LPs performed within a multimodality setting seem to be efficient procedures for local control of disease, as they yield excellent results regarding OS, DFS, CSS and FFR.

Detection of Recurrence Patterns After Wedge Resection for Early Stage Lung Cancer: Rationale for Radiologic Follow-Up

BACKGROUNDnWedge resection for selected patients with early stage non-small cell lung cancer is considered to be axa0valid treatment option. The aim of this study was to evaluate the recurrence patterns after wedge resection, toxa0analyze the survival of patients under routine follow-up, and to recommend a follow-up regimen.nnnMETHODSnA retrospective analysis was done of 446 consecutive patients between May 2000 and December 2012 who underwent a wedge resection for clinical stage I non-small cell lung cancer. All patients were followed upxa0with a computed tomography scan with or without contrast. The recurrence was recorded as local (involving the same lobe of wedge resection), regional (involving mediastinal or hilar lymph nodes or a different lobe), orxa0distant (including distant metastasis and pleural disease).nnnRESULTSnMedian follow-up for survivors (nxa0= 283) was 44.6 months. In all, 163 patients died; median overall survival was 82.6 months. Thirty-six patients were diagnosed with new primary non-small cell lung cancer, and 152 with recurrence (79 local, 45 regional, and 28 distant). There was no difference in the incidence of recurrence detection detected by computed tomography scans with versus without contrast (pxa0= 0.18). The cumulative incidence of local recurrences at 1, 2, and 3 years was higher than the cumulative incidence for local, regional, and distant recurrences: 5.2%, 11.1%, and 14.9% versus 3.7%, 6.6%, and 9.5% versus 2.3%, 4.7%, and 6.4%, respectively. Primary tumor diameter was associated with local recurrence in univariate analysis.nnnCONCLUSIONSnWedge resection for early stage non-small cell lung cancer is associated with a significant risk for local and regional recurrence. Long-term follow-up using noncontrast computed tomography scans at consistent intervals is appropriate to monitor for these recurrences.

Vascular occlusion device closure of bronchial stump fistulae: a straightforward approach to manage bronchial stump breakdown

Post lung resection surgery bronchopleural fistula (BPF) continues to be a dangerous complication associated with very high mortality and morbidity. Traditional treatments have included primary closure of the fistula with muscle flaps and thoracic window formation. New techniques for secondary stump closure have included glues, stents and coils. We report another bronchoscopic treatment of BPF using an atrial septal closure/vascular occlusion device combined with bioglue.

Operative planning in Thoracic Surgery: A pilot study comparing imaging techniques and 3D printing

BACKGROUNDnCareful preoperative planning in thoracic surgery is essential for positive outcomes, especially in video-assisted thoracic surgery (VATS), where palpation and 3-dimensional (3D) imaging is restricted. This study evaluated the ability of different imaging techniques, such as computed tomography (CT) scanning, maximal intensity projection imaging, 3D reconstruction, and 3D printing, to define the anatomy of the hilar structures before anatomical lung resection.nnnMETHODSnAll patients undergoing elective lung resections by VATS for cancer under a single surgeon were identified over a 3-month period. The surgeon was asked to record the number of pulmonary artery branches supplying the lobe to be resected by using the preoperative CT scans, maximal intensity projection images, and 3D-reconstructed CT images. The lung hilum in 3 patients was printed. These were then compared with the intraoperative findings.nnnRESULTSnThe preoperative imaging of 16 patients was analyzed. The lung hilum was printed in a further 3 patients. Although not statistically significant, the 3D prints of the hilum were the most accurate measurement, with a correlation of 0.92. CT, 3D-reconstructed CT, and maximal intensity projection images tended to underrecognize the number of arterial branches and therefore scored between 0.26 and 0.39 in absolute agreement with the number of arteries found at operation.nnnCONCLUSIONSn3D printing in the planning of thoracic surgery may suggest a benefit over contemporary available imaging modalities, and the use of 3D printing in practicing operations is being established.

Unusual late presentation of metastatic extrathoracic thymoma to gastrohepatic lymph node treated by surgical resection

In advanced stages, thymic tumors tend to spread locally. Distant metastatic disease is rare. We present the first report of single metastatic abdominal lymph node in a 37-year-old female patient and 5xa0years after an extrapleural pneumonectomy for stage IV thymoma followed by radiotherapy with no other evidence of abdominal disease successfully treated by robotic surgical resection.