Andrea Viti

Neoadjuvant Chemotherapy for Stage III and IVA Thymomas: A Single-Institution Experience with a Long Follow-up

Background: Since 1989 we have enrolled patients with clinical-radiological stage III-IVA thymomas, independent of the surgeons judgment of resectability, into a prospective study of neoadjuvant chemotherapy–surgery and postoperative radiotherapy. In this article, we review our long-term experience of neoadjuvant chemotherapy of advanced stage (III-IVA) thymomas. Methods: From 1989 to 2004, 30 patients with Masaoka stage III and IVA thymomas underwent neoadjuvant chemotherapy, surgery, and postoperative radiotherapy. The neoadjuvant and adjuvant chemotherapy consisted of three courses of cisplatin, epidoxorubicin, and etoposide every 3 weeks. Adjuvant radiotherapy consisted of 45 Gy for complete resections or 60 Gy for incomplete resections. Results: The preoperative diagnosis of invasive thymomas was obtained for 16 patients: five by mediastinotomy, seven by video-assisted thoracic surgery, and four by fine needle aspiration. For 14 patients, no histological diagnosis was available, but a thymus-related syndrome was present in all. Twenty-seven patients are still alive (25 disease-free) and three have died (one disease-free). The 10-year survival rates were 85.7% and 76.1% for stage III and IVA thymomas, respectively (difference not significant). Only the World Health Organization pathological diagnosis significantly affected the survival, with type B3 having a worse prognosis than type AB, B1, and B2 thymomas (p = 0.02). Conclusion: The multimodality treatment of stage III and IVA thymomas by means of neoadjuvant chemotherapy provides good long-term outcomes in both stages of the disease.

Geometrical characteristics of uniportal VATS

In terms of accuracy and efficacy Uniportal Video-Assisted Thoracic Surgery (VATS) resections are comparable to standard VATS. In standard three-ports VATS, the geometric configuration of a parallelogram generates interference with the optical source, creating a plane with a torsion angle not favorable on the flat two-dimensional vision of currently available monitors. The potential advantages of single-port VATS approach include not only the one intercostal space incision (reduction of postoperative pain) but also a translational approach of VATS instruments along a sagittal plane. Accordingly, the Uniportal approach enables VATS instruments to draw two parallel lines on the plane, bringing them to approach the target lesion from a caudo-cranial perspective thus achieving a projective plane. As a consequence, taking advantage of the unique spatial features specific to uniportal VATS, the surgeon is enabled to bring the operative fulcrum inside the chest to address the target lesion in a fashion similar to open surgery.

Intraoperative sentinel lymph node mapping in stage I non-small cell lung cancer: detection of micrometastases by polymerase chain reaction §

OBJECTIVE We previously reported the results achieved in detecting sentinel lymph nodes (SLN). We applied the molecular techniques (RT-PCR) to improve the detection of micrometastasis in order to evaluate an improvement of staging in early non-small cell lung cancer (NSCLC) patients (pts). METHODS This study was carried out on 22 consecutive NSCLC pts with stage I disease. A dose of 37MBq (1 ml (99m)Tc-nanocolloid suspension) was administered. The intralesional injection was performed under CT-guidance (7 pts), by using bronchoscopy (5 pts), VATS (2 pts) and at time of the thoracotomy (8 pts). RT-PCR analysis for cytokeratin 7 and 19 (CK7-CK19) was used to identify tumour-derived material in lymph nodes (LN). Each SLN was bisected: half was used for conventional examination (H&E staining/by immunohistochemistry (IHC), half was snap-frozen to -80 degrees C for RNA-detection of CK7 and CK19. RESULTS SLN was detected in 16 out of 19 pts. In three pts SLN was not identified (due to an incorrect technique). Conventional pathologic examination showed stage I disease in 13 pts, T3N0 disease in 1 pt, N2 in 5 pts. The IHC analysis identified micrometastasis in seven pts (two evaluated N0 according to H&E staining). RT-PCR analysis, performed in 10/16 pts, identified micrometastasis in 6 pts (3 pts evaluated N0 disease by H&E ; 1 of these evaluated N0 even by IHC). All N2 patients relapsed. One patient (N0 pts after H&E and IHC analysis) with positive CK7 and CK19 expression by RT-PCR analysis relapsed (systemic relapse) 3 months after surgery. CONCLUSIONS SLN technique could provide a subgroup of patients in which the use of RT-PCR could be applied on a well-focused target. This approach may be useful for stratifying histologically N0 patients into higher risk and lower risk groups.

Lung Cancer Detection with Digital Chest Tomosynthesis: Baseline Results from the Observational Study SOS

Introduction: Observational studies consistently support strategies for early cancer diagnosis and treatment. Owing to its high prevalence, mortality rate, and easily identifiable at-risk population groups, lung cancer seems ideal for early detection programs. We present the baseline results of the SOS study, a single-arm observational study of digital chest tomosynthesis for lung cancer detection in an at-risk population. Methods: Accrual of study participants started in December 2010 and ended in December 2011. Participants considered eligible were smokers or former smokers aged 45 to 75 years, with a smoking history of at least 20 pack-years, without malignancy in the 5 years before the start of the study. A tomosynthesis examination was performed at baseline and another the year after. Results: Of the 1919 candidates assessed, 1843 (96%) were enrolled into the study: the mean age was 61 years (range, 48–73 years); 1419 (77%) were current smokers. The most prevalent comorbidities were hypertension, chronic obstructive pulmonary disease, and cardiovascular diseases. A total of 1843 tomosynthesis studies were obtained. Pulmonary abnormalities were detected in 268 subjects (14.5%). First-line basal computed tomography (CT) was subsequently carried out in 132 subjects (7.2%), 68 (4.9%) of which were referred for follow-up CT. Positron-emission tomography/CT was performed on 27 individuals (1.46%), and lung cancer was detected in 18 (0.98%) of them. Conclusion: The detection rate of noncalcified lung nodules for tomosynthesis was comparable with rates reported for CT. A small subgroup underwent low-dosage CT and entered a follow-up program. Overall, lung cancer was detected in approximately 1% of cases. Digital chest tomosynthesis holds promise as a first-line lung cancer screening tool.

Ten-year experience of mediastinal robotic surgery in a single referral centre

OBJECTIVE The aim of this study was to report a single referral centre experience in the exeresis of mediastinal lesions with robotic surgical system. The outcomes of all patients were retrospectively investigated with special regard to myasthenic and thymomatous patients. METHODS From February 2001 to December 2010, 69 patients (30 males, 39 females), with a mean age of 55.4 years (range 20-81), underwent robotic surgery for treatment of mediastinal lesions. There were 39 thymectomies, 13 paravertebral neurogenic tumour removals, 9 pleuropericardial cyst removals, 3 teratoma excisions, 4 lymphonodal removals and 1 enterogenous cyst excision. Operative time, conversion rate, morbidity and mortality were analysed. RESULTS There were no intra-operative complications, and no mortality. The mean operative time was 124.3 min (range 45-240). Conversion to open surgery occurred in three cases (4.3%). All post-operative complications (7.2%) were conservatively treated. The mean post-operative stay was 4.3 days (range 3-10). For the myasthenic patients (mean follow-up of 18 months), the Myasthenia Gravis Foundation of America change in status resulted improved in 18 (90%) patients and unchanged in 2 (10%) patients. In cases of thymoma, the pathological analysis revealed Masaoka stage I (seven cases), IIA (three cases), IIB (two cases) and III (one case). No disease recurrence occurred at a mean follow-up of 16 months. CONCLUSIONS Our experience suggests that the surgical system was safe in performing mediastinal mass resection, with low morbidity and conversion rate. The robotic system proved useful, especially in a tiny space such as the mediastinum, and appeared to be an effective treatment for myasthenia gravis and for early-stage thymoma.

What is the role of lymph nodal metastases and lymphadenectomy in the surgical treatment and prognosis of thymic carcinomas and carcinoids

A best evidence topic in thoracic surgery was written according to a structured protocol. We looked at the clinical relevance of lymph node involvement and nodal (N) stage, in thymomas, thymic carcinomas and carcinoids. The possible role of lymphadenectomy in addition to thymectomy was also evaluated. A total of 605 papers were found, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. In the Yamakawa-Masaoka classification, based on 226 patients, lymph nodes were classified as anterior mediastinal (N1), defined as nodes surrounding the thymus gland; intrathoracic (N2), all nodes within the thorax excluding N1; and extrathoracic nodes (N3). Kondo validated the Yamakawa-Masaoka classification in a multicentric cohort of 1320 patients. Thymomas presented nodal involvement in 1.8% of cases, carcinomas in 27% of cases, and carcinoids in 28% of cases. The role of nodal status in defining the stage was even more emphasized in the staging system developed by Tsuchiya for thymic carcinomas. In the Istituto Nazionale Tumori classification, thymomas with N1 or N2 were considered as locally advanced disease with a 95-month disease-free survival rate for locally advanced disease of 46.9 vs 98.6% for locally restricted disease (absence of nodal involvement). Weissferdt and Moran, on a series of 65 thymic carcinomas, underlined the clinical relevance of nodal involvement. Positive lymph nodes were associated with significantly worse survival (P = 0.01070). Okuma, in a series of 68 advanced stage thymic carcinomas, showed that curative-intent surgical treatment was related to prolonged survival (P = 0.03). In particular, IVb tumours due to node-only involvement had better survival when radical resection was achieved when compared with IVb due to distant metastases (P = 0.03). Sung et al. showed the importance of harvesting 10 or more lymph nodes and dissecting intrathoracic lymph nodes to ensure a more complete stadiation of thymic carcinomas. The results underline the clinical relevance and prognostic value of nodal involvement in thymic carcinomas and carcinoids. In these cases, lymphadenectomy is desirable to allow the real definition of N status.

Analysis of spontaneous pneumothorax in the city of Cuneo: environmental correlations with meteorological and air pollutant variables

Background and PurposePrimary spontaneous pneumothorax (PSP) tends to cluster. Previous studies have found a correlation between PSP and atmospheric pressure variations or thunderstorms. We conducted this study to analyze the PSP correlations with meteorological variables and the concentrations of air pollutants in the city of Cuneo in Italy (IT).MethodsWe evaluated prospectively 451 consecutive PSP patients treated between 2004 and 2010. For each day within the period analyzed, the meteorological parameters and pollutants data were recorded. Statistical analyses on PSP were done for distribution characteristics, spectral autocorrelation, and spectral analysis. Multivariate regression analyses were performed using artificial neural networks.ResultsAnalysis of annual, seasonal, and monthly distributions showed no significant correlation between PSP and the time series. The spectral analysis showed that PSP events were not random. Correlations between meteorological and environmental variables confirmed that PSP was significantly more likely to occur on warm windy days with high atmospheric pressure and high mean nitrogen dioxide concentration.ConclusionsMeteorological parameters and atmospheric pollutants might explain the cluster onset of PSP.

The Statistical point of view of Quality: the Lean Six Sigma methodology

Six Sigma and Lean are two quality improvement methodologies. The Lean Six Sigma methodology is applicable to repetitive procedures. Therefore, the use of this methodology in the health-care arena has focused mainly on areas of business operations, throughput, and case management and has focused on efficiency outcomes. After the revision of methodology, the paper presents a brief clinical example of the use of Lean Six Sigma as a quality improvement method in the reduction of the complications during and after lobectomies. Using Lean Six Sigma methodology, the multidisciplinary teams could identify multiple modifiable points across the surgical process. These process improvements could be applied to different surgical specialties and could result in a measurement, from statistical point of view, of the surgical quality.

Lung cancer detection with digital chest tomosynthesis: first round results from the SOS observational study.

OBJECTIVE Baseline results of the Studio OSservazionale (SOS), observational study, a single-arm observational study of digital chest tomosynthesis for lung cancer detection in an at-risk population demonstrated a detection rate of lung cancer comparable to that of studies that used low dose CT scan (LDCT). We present the results of the first round. METHODS Totally 1,703 out of 1,843 (92%) subjects who had a baseline digital chest tomosynthesis underwent a first round reevaluation after 1 year. RESULTS At first round chest digital tomosynthesis, 13 (0.7%) subjects had an indeterminate nodule larger than 5 mm and underwent low-dose CT scan for nodule confirmation. PET/CT study was obtained in 10 (0.5%) subjects and 2 subjects had a low-dose CT follow up. Surgery, either video-assisted thoracoscopic or open surgery for indeterminate pulmonary nodules was performed in 10 (0.2%) subjects. A lung cancer was diagnosed and resected in five patients. The lung cancer detection rate at first round was 0.3% (5/1,703). CONCLUSIONS The detection rate of lung cancer at first round for tomosynthesis is comparable to rates reported for CT. In addition, results of first round digital chest tomosynthesis confirm chest tomosynthesis as a possible first-line lung cancer-screening tool.

Robot-assisted resection of pulmonary sequestrations.

Pulmonary sequestration is a rare congenital malformation and may cause recurrent infections and hemoptysis. Although video-assisted thoracic surgery (VATS) is feasible, some drawbacks remain, mainly dealing the managing of anomalous vessels. We describe the use of a robotic system (da Vinci Robotic System, Surgical Intuitive, Mountain View, CA, USA) in the treatment of four consecutive cases of pulmonary sequestration.