Cristiano Breda

Allograft sternochondral replacement after resection of large sternal chondrosarcoma

Surgical excision with a safety margin is the cornerstone of treatment of malignant sternal tumors. After sternal resection, the primary goals of chest wall reconstruction are to prevent flail chest with ventilatory impairment, protect the underlying mediastinal structures, and avoid chest deformity. Various techniques and several materials have been used over the years for this purpose. This report describes the use of sternal allograft to reconstruct the chest wall after sternal resection.

Single-staged laryngotracheal resection and reconstruction for benign strictures in adults

Laryngotracheal stenosis (LTS) is a challenging problem, and its management is complex. This study evaluated both short- and long-term outcomes following laryngotracheal resection and anastomosis. Between 1994 and 2006, 37 patients underwent surgery for LTS. The cause of stenosis was post-intubation or post-tracheostomy injury in 28 cases and idiopathic in nine. Pearsons technique was used for anterolateral cricotracheal resection (n=23), and Grillos technique of providing a posterior membranous tracheal flap was used in cases of circumferential stenosis (n=14). Since 1998, we have modified the techniques in 21 cases, using a continuous 4/0 polydioxanone suture for the posterior part of the anastomosis. No peri-operative mortality was recorded. Three (8.1%) patients developed major complications (two fistulae and one early stenosis) that required a second surgical look. We had 16 minor complications in 14 (37.8%) patients. The long-term results were excellent to satisfactory in 36 patients (97.3%) and unsatisfactory in one (2.7%). Single-staged laryngotracheal resection is a demanding operation, but can be performed successfully with acceptable morbidity in specialized centers. The continuous suture in the posterior part of the anastomosis simplifies the procedure without causing technique-related complications. In our experience, this procedure guaranteed excellent to satisfactory results in more than 90% of patients.

Multidisciplinary approach for advanced stage thymic tumors: Long-term outcome

BACKGROUND In advanced stage thymic tumors complete surgical resection is not always achievable. Although surgery remains the cornerstone of therapy, there is growing evidence that multimodality treatment increases resectability and reduces the incidence of local and systemic relapses. METHODS Between 1980 and 2008, 75 patients with stages III (n = 51), IVA (n = 18) and IVB (n = 6) thymic tumors were treated. Twenty-six patients had A-AB-B1 and 49 B2-B3-C histotype. Thirty-eight (50.6%) patients considered not radically resectable at preoperative workup, received induction chemotherapy; postoperatively 37 (49.3%) had radiotherapy, 25 (33.3%) chemoradiotherapy and 4 (5.3%) chemotherapy. RESULTS No perioperative mortality was recorded. Sixty-one (81.3%) had complete resection (CR) and 14 (18.7%) incomplete resection (IR). CR was lower in patients who received induction chemotherapy (73.7% vs 89.2%, p = 0.02). In 11 (14.7%) cases a vascular procedure was carried out. Overall 5- and 10-year survivals were 70% and 57%, respectively. Five and 10-year tumor-related survival was 78% and 70%. Ten-year survival was better for CR vs IR resection (62% vs 28%; p = 0.003) and for type A-AB-B1 vs B2-B3-C (60% vs 53%; p = 0.03). No statistical difference was found between stage III and IV (10-year survival: 63% and 43%; p = 0.42) and induction vs no induction chemotherapy (10-year survival: 52% vs 56%; p = 0.54). At multivariate analysis CR (p = 0.001) and type A-AB-B1 (p = 0.04) were independent predictors of better survival. During follow-up, 34.4% of CR developed tumor recurrence. CONCLUSIONS Multimodality treatment of stages III and IV thymic tumors guarantees good disease control and provides high survival and acceptable recurrence rates.

Pneumonectomy for lung cancer over the age of 75 years: is it worthwhile?☆

The objective of the study was to evaluate the outcome in elderly patients (>75 years) submitted to pneumonectomy for lung cancer. Records of 40 elderly patients, who underwent pneumonectomy at our Institution from 1990 to 2008, were retrospectively reviewed. This group was compared with 289 younger patients submitted to pneumonectomy in the same period. In the older group median age was 77 years (range 75-84 years), 16 were right-side procedures. In the younger group median age was 62 years (range 24-74 years), 114 were right-sided procedures. The overall mortality rate was 7.5% and 6.2% in the older and younger groups, respectively (P=0.75); morbidity rate was 35.1% and 17.7% (P=0.01) and five-year survival rate was 32% and 30%, respectively (P=0.85). Right-sided procedures (P=0.0006) were associated with higher risk of mortality and age over 75 years (P=0.01) with increased risk of morbidity; pathological stage was the only predictor of five-year survival. Pneumonectomy appears to be justified even in patients older than 75 years, because short- and long-term outcomes can be acceptable and comparable with those of younger patients. Advanced age alone does not justify denying curative resection of lung cancer, but right-sided procedures require a careful pre- and postoperative approach.

Results of surgical resection after induction chemoradiation for Pancoast tumours

OBJECTIVES Pancoast tumour is a rare neoplasia in which the optimal therapeutic management is still controversial. The traditional treatment of Pancoast tumour (surgery, radiotherapy or a combination of both) have led to an unsatisfactory outcome due to the high rate of incomplete resection and the lack of local and systemic control. The aim of the study was to determine the efficacy of the trimodality approach. METHODS Fifty-six patients (male/female ratio: 47/9, median age: 64 years) in stage IIB to IIIB were treated during a period between 1994 and 2013. Induction therapy consisted of 2-3 cycles of a platinum-based chemotherapy associated with radiotherapy (30-44 Gy). After restaging, eligible patients underwent surgery 2 to 4-week post-radiation. RESULTS Thirty-two (57.1%) patients were cT3 and 24 (42.9%) cT4, 47 (83.9%) were N0 and 9 (16.1%) N+. Forty-eight (85.7%) patients underwent R0 resection and 10 (17.9%) had a complete pathological response (CPR). Thirty-day mortality rate was 5.4%, major surgical complications occurred in 6 (10.7%) patients. At the end of the follow-up, 17 (30.4%) patients were alive and 39 (69.6%) died (29 for cancer-related causes), with an overall 5-year survival of 38%. At statistical analysis, stage IIB (P = 0.003), R0 resection (P = 0.03), T3 tumour (P = 0.002) and CPR (P = 0.01) were significant independent predictors of better prognosis. CONCLUSIONS This combined approach is feasible, and allows for a good rate of complete resection. Long-term survival rates are acceptable, especially for early stage tumours radically resected. Systemic control of disease still remains poor, with distant recurrence being the most common cause of death.

Pleurectomy-decortication in malignant pleural mesothelioma: are different surgical techniques associated with different outcomes? Results from a multicentre study†

OBJECTIVES The potential benefit of surgery for malignant pleural mesothelioma (MPM), especially concerning pleurectomy/decortication (P/D), is unclear from the literature. The aim of this study was to evaluate the outcome after multimodality treatment of MPM involving different types of P/D and to analyse the prognostic factors. METHODS We reviewed 314 patients affected by MPM who were operated on in 11 Italian centres from 1 January 2007 to 11 October 2014. RESULTS The characteristics of the population were male/female ratio: 3.7/1, and median age at operation was 67.8 years. The epithelioid histotype was observed in 79.9% of patients; neoadjuvant chemotherapy was given to 57% of patients and Stage III disease was found following a pathological analysis in 62.3% of cases. A total of 162 (51.6%) patients underwent extended P/D (EP/D); 115 (36.6%) patients had P/D and 37 (11.8%) received only a partial pleurectomy. Adjuvant radiotherapy was delivered in 39.2% of patients. Median overall survival time after surgery was 23.0 [95% confidence interval (CI): 19.6-29.1] months. On multivariable (Cox) analysis, pathological Stage III-IV [ P  = 0.004, hazard ratio (HR):1.34; 95% CI: 1.09-1.64], EP/D and P/D ( P  = 0.006, HR for EP/D: 0.46; 95% CI: 0.29-0.74; HR for P/D: 0.52; 95% CI: 0.31-0.87), left-sided disease ( P  = 0.01, HR: 1.52; 95% CI: 1.09-2.12) and pathological status T4 ( P  = 0.0003, HR: 1.38; 95% CI: 1.14-1.66) were found to be independent significant predictors of overall survival. CONCLUSIONS Whether the P/D is extended or not, it shows similarly good outcomes in terms of early results and survival rate. In contrast, a partial pleurectomy, which leaves gross tumour behind, has no impact on survival.

Multiple-running suture technique for bronchial anastomosis in difficult sleeve resection.

We present a simplified technique for bronchial anastomosis in difficult sleeve resection using multiple running sutures. During the last 5 years we used this technique in 11 patients. We recorded no anastomotic-related complications in all of them. We found this technique easier, faster, and effective; we consider it a potential routine bronchial anastomotic technique.

Bilateral Pancoast syndrome in a patient with metachronous primary lung cancer

A rare case of double Pancoast tumor in a patient with metachronous primary cancer of the lung was treated with irradiation and operation. Both tumors were managed with pulmonary wedge resection and excision of involved chest wall. Six years after the first operation the patient is doing well without pain and respiratory failure.

Preoperative concomitant chemo-radiotherapy in superior sulcus tumour: A mono-institutional experience.

UNLABELLED Superior sulcus tumour (SST) is an uncommon neoplasia whose optimal treatment remains controversial. Usually resected after induction RT or treated with definitive chemo-radiotherapy, it has recently aroused more interest because of preoperative chemo-radiotherapy. Treatment consisted of a platinum-based chemotherapy: carboplatin AUC 5 on days 1 and 22, combined with mitomycin-C 8 mg/m(2) on days 1 and 22, and vinblastine 4 mg/m(2) on days 1, 8, 22 and 29 (MVC) from 1994 to 1999, or combined with navelbine 25mg/m(2) on days 1, 8, 22 and 29 (NC), from 2000 to 2007. Radiotherapy was administered 5 days/week, 30 Gy in 10 fractions on days 22-35 (from 1994 to 1996), or 44 Gy in 22 fractions on days 22-52 (from 1997 to 2007). SURGERY was planned after 2-3 weeks since the completion of radiotherapy. Since 1994, 37 pts were treated with induction chemo-radiotherapy, 1 with induction radiotherapy only. Induction chemotherapy: 16 pts had MVC (43%) and 21 NC (57%); induction radiotherapy: 7 patients treated with MVC had 30 Gy/10F, 9 had 44 Gy/22F; all the patients treated with NC had 44 Gy/22F, but 2 of them did not complete radiotherapy because of early death (after 16 Gy/8F) and toxicity (after 38 Gy/19F). Grade 3-4 haematological toxicity of induction chemo-radiotherapy was found in 13 patients (35%); the most frequent non-haematological toxicities were constipation and oesophagitis. One complete, 18 partial and 8 minimal responses/stable disease were observed. Moreover, 1 progression disease and 1 early death occurred. SURGERY 30 upper lobectomies (17 right, 13 left) and 4 segmentectomies, with chest wall resections, were performed (89% resection rate); 4 pts were not operated. Radical resections were achieved in 74% of the patients, with 5 pathologic complete remissions at resection. Twenty-seven patients (71%) had improvement of shoulder/arm pain. Median progression-free survival was 64 weeks and median survival was 148 weeks. The 5-year overall and progression-free survivals were 40% and 29%, respectively. In the multimodality treatment of SST, concurrent carboplatin-based chemotherapy plus radiotherapy were active and feasible without major toxicities. This resulted in high resectability rate and favourable progression-free and overall survival rates.

Techniques of Right Extended Pneumonectomy

Tracheal sleeve pneumonectomy is considered the operation of choice for tumors involving the right tracheobronchial angle, even though the procedure is burdened by a high rate of perioperative morbidity and mortality. In this report, we present our experience with two different techniques to avoid sleeve pneumonectomy: the tangential tracheal suture and the tracheoplasty.