Dania Nachira

Induction Therapy Followed by Surgery for T3-T4/N0 Non-Small Cell Lung Cancer: Long-Term Results

BACKGROUND The aim of this study was to analyze the impact of the induction chemoradiotherapy (IT) on the survival pattern in T3/T4-N0 non-small cell lung cancer (NSCLC) patients. METHODS The data of 71 patients treated from January 1992 to May 2007 were reviewed. Of these, 31 patients received IT prior to surgery (IT group: T3, 20 patients; and T4, 11 patients), and 40 directly underwent surgery (S group: T3, 34 patients; and T4, 6 patients). Survival rates were compared using the Kaplan-Meier analysis and the Cox proportional hazards models. RESULTS Mean ages were 62.5±9.9 years in the IT group and 67.7±7.1 in the S group. All patients but 1 completed the IT treatment and 27 patients (87%) were operated. A radical resection was possible in 21 patients (78%). In the IT group a complete pathologic response was obtained in 6 patients (22%), where 8 patients ended up in pI stage, 7 in pII stage, and 6 in pIII stage. The overall 5-year survival (long-term survival [LTS]) and disease-free 5-year survival (DFS) for the entire cohort were 40% and 34%, respectively. No significant differences were found when LTS in the IT group (44%) and in the S group (37%) were compared. At multivariate analysis, the completeness of resection was the only independent predictive factor (hazard ratio [HR]=5.18; 95% confidence interval [CI]=2.55 to 10.28) while Cox multivariate analysis (on the IT group only) confirmed the critical role of the pathologic downstaging (HR=4.62; 95% CI=1.54 to 13.89). CONCLUSIONS A multimodal strategy with IT treatment followed by surgery is a safe and reasonable treatment in T3/T4-N0 NSCLC patients, but no clear evidence of prognostic improvement may be assumed at the present time. Nevertheless, patients with radical resection and complete pathologic response have a very rewarding survival.

Chest wall tumors and prosthetic reconstruction: A comparative analysis on functional outcome

To address the question of how much chest‐wall (CW) resections and prosthetic reconstructions influence functional outcome.

Uniportal video-assisted thoracic surgery for major lung resections: pitfalls, tips and tricks

Nearly six years since inception, uniportal video-assisted thoracic surgery (VATS) has become a growing part of major lung resections and has revolutionized the way thoracic surgeons treat pulmonary lesions. This technique is being touted for various benefits. It ensures direct visualization together with a better exposure of the lung and allows the chance of a digital palpation of the lesion through a small incision. Postoperative pain is reduced due to the involvement of only one intercostal space without rib spreading and muscle disruption. The comfort and aesthetics factors are improved significantly since the oncological principles and radicality of open surgery are restored. As the surgeons gain more experience in uniportal-VATS lobectomy, more complex cases can be managed by this technique. The objectives of this work are to set the basic steps for performing major lung resections (lobectomy, bilobectomy and pneumonectomy) by utilizing uniportal-VATS and to analyze some common pitfalls that thoracic surgeons face when practicing this technique and provide practical tips and tricks on how to avoid.

Analysis of risk factors in the development of bronchopleural fistula after major anatomic lung resection: experience of a single centre

The bronchopleural fistula (BPF) is a rare but potentially fatal complication of major thoracic surgery. The purpose of this work is to investigate the risk factors associated with the development of fistulas after lobectomy and pneumonectomy.

Lung metastasectomy following kidney tumors: outcomes and prognostic factors from a single-center experience

Background The lung is one of the sites most frequently affected by metastatic renal cell carcinoma (mRCC). Nonsurgical therapy for mRCC has limited efficacy, while the 5-year survival rates data published in literature after pulmonary surgery for metastasectomy, emphasize the role of surgery as the treatment that guarantees the best effectiveness in pulmonary resectable metastases. Methods From January 2000 to March 2016, 27 patients underwent pulmonary metastasectomy for metastatic renal cancer was retrospectively reviewed. Primary renal cancer was controlled in all patients and there was no other metastatic site in addition to the lung, at the time of metastasectomy. The aim of the study was to identify outcomes and prognostic factors in association with survival after complete pulmonary resection of metastases in a subgroup of patients with isolated pulmonary metastases from RCC. Results Five- and 10-year overall survival (OS) from first pulmonary metastasectomy was 75% and 59%, respectively. Independent prognostic factor influencing survival were: dimension of pulmonary metastases ≥2 cm (3-year survival: 67% vs. 100%; P=0.014) and disease free interval (DFI) ≥5 years (3-year survival: 94% vs. 28%; P=0.05). The only independent prognostic factors affecting DFI was the dimension of pulmonary metastases ≥2 cm (5-year DFI: 67% vs. 89%; P=0.03) at univariate analysis. Conclusions Considering the good results based on high long-term efficacy and low morbidity after metastases surgical resection, we always recommend metastasectomy in patients with technically resectable metastases, especially in case of long DFI and reduced dimension of pulmonary lesions.

Giant air-inflated hydatid cyst of the lung mimicking massive pneumothorax

A 68-year-old Caucasian man was admitted to our emergency department with a 6-month history of progressive dyspnoea, tachycardia, chronic cough and purulent sputum production. The patients medical history was notable for hepatic echinococcosis diagnosed in 2002. Physical examination revealed no chest wall movement, a hyper-resonant sound on percussion, absent tactile fremitus and no audible breath sound in the right hemithorax. A slight tracheal deviation towards the left could also be felt on palpation …

Successful Three-Stage Ethanol Ablation of Esophageal Mucocele

their anatomic proximity to other vital organs, visceral vessels are rarely injured alone (1), and isolated IMA injury as a result of blunt trauma is extremely rare. To the best of our knowledge, only one case has been reported, in which the injury involved a low-speed motor vehicle accident (2). Two mechanisms have been proposed to explain traumatic visceral artery injury. The first is shearing force causing avulsion of the artery at the junction between the retroperitoneal portion and unfixed portion of the bowel. The second mechanism is compression injury, in which the artery is crushed between the object producing the blunt force and the lumbar spine, as in the present case. In cases involving visceral branch avulsion at the orifice, embolization of the lacerated arterial stump and the arterial orifice is mandatory to achieve hemostasis. Trottier et al (3) reported a similar case with renal artery avulsion. Avulsion of the right renal polar artery originating from the right common iliac artery was treated by placing a stent graft into the right common iliac artery; however, subsequent enlargement of a retroperitoneal hematoma as a result of subclinical back-bleeding from the lacerated arterial stump led to abdominal compartment syndrome. Transcatheter embolization of lacerated IMA origins is another treatment option. Hamid et al (4) reported transcatheter embolization for lumbar artery avulsion using N-butyl cyanoacrylate (Histoacryl; B. Braun Melsungen AG, Melsungen, Germany) glue injected from the artery’s origin. However, glue injection has the potential risk of unintentional distal embolization or reflux to the aorta, and transcatheter embolization using detachable microcoils might be a safer alternative. Our method is a simple and safe method of controlling hemorrhage caused by visceral branch avulsion.

Non-Small Cell Lung Cancer with Chest Wall Involvement: Integrated Treatment or Surgery Alone?

BACKGROUND  The aim of this study was to identify prognostic factors in patients affected by non-small cell lung cancer (NSCLC) with chest wall (CW) involvement, analyzing different strategies of treatment and surgical approaches. METHODS  Records of 59 patients affected by NSCLC with CW involvement underwent surgery were retrospectively reviewed, from January 2000 to March 2013. RESULTS  Induction therapy was administered to 18 (30.5%) patients while adjuvant treatment to 36 (61.0%). In 36 (61%) patients, lung resection was associated only with a parietal pleural resection while in 23 (39%) with CW en-bloc resection. Overall 5-year survival was 34%. Prognostic factors were evaluated in the 51 (86.4%) completely resected (R0) patients.Five-year survival was 60% in patients undergoing induction therapy followed by surgery and 24% in those who underwent surgery as first treatment (p = 0.11). Five-year survival was better in the neoadjuvant group than that in the surgery group in IIB (T3N0) p-stage (100 vs 28%, p = 0.03), while in the IIIA (T3N1-2,T4N0) p-stage it was of 25 vs 0%, respectively (p = 0.53).No 5-year survival difference was found in case of parietal pleural resection versus CW en-bloc resection (p = 0.27) and in case of only parietal pleural involvement versus soft tissue (p = 0.78).In case of incomplete resection (R1), patients undergoing adjuvant radiotherapy had better 2-year survival than patients untreated: 60% vs 0% (p = 0.025). CONCLUSIONS  Type of surgical resection and the deep of infiltration of disease do not influence survival in this subset of patients. Integrated treatments seem to be suitable: neoadjuvant therapies ensure a better survival rate than surgery alone in IIB and IIIA patients, instead adjuvant radiotherapy proves a fundamental option in incomplete resections.

Uniportal video-assisted thoracic lung segmentectomy with near infrared/indocyanine green intersegmental plane identification

In the era of lung cancer screening and early detection of lung lesions, pulmonary segmentectomy has gained wide acceptance between thoracic community reducing the need of lobectomy for diagnostic purpose and treatment in case of centrally located benign, multiple or undetermined lesions. In rigorously selected patients with stage I non-small cell lung cancer (NSCLC), segmentectomies seem to offer similar survival outcomes rather than lobectomies, but associated with a better conservation of lung function. However, segmentectomy is a more challenging procedure to be performed compared to lobectomy, especially by video-assisted thoracic surgery (VATS). Many difficulties could arise during video-assisted segmentectomy, making the procedure more demanding and stressful. Following the introduction of the near infrared (NIR)/indocyanine imaging system on standard endoscopic module, we decided to adopt peripheral intravenous injection of indocyanine green (ICG) to identify intersegmental plain during uniportal VATS lung segmentectomy. Our technique herein is widely illustrated.

Video-assisted thoracoscopic lobectomy in lung cancer patients: a “patient-tailored” surgical approach according to the degree of pulmonary fissure completeness

In the past few years, the advantages of mini-invasive pulmonary video-assisted thoracoscopic lobectomy (VATS-lobectomy) have been gaining increasing evidence, if compared to those of previous “traditional” approach (open thoracotomy), particularly as management of post-operative pain is concerned, Nevertheless, following VATS lobectomy (1), postoperative cardiopulmonary complications (PCCs) still record 20–35% rates even in high-volume top-quality Centres, thus affecting both short-term and long-term outcomes of lung cancer surgery (2).