Daniele Diso

Thymoma and thymic carcinoma

Thymoma and thymic carcinoma are an extremely heterogeneous group of neoplastic lesions with an exceedingly wide spectrum of morphologic appearances. They show different presentations with a variable and unpredictable evolution ranging from an indolent non-invasive attitude to a highly infiltrative and metastasising one. Prognosis can be predicted on the basis of a number of variables, mainly staging, the WHO histological pattern and diameter of the tumour. Complete surgical resection is certainly the gold standard to achieve cure. However, especially in patients with lesions at advanced stage, complete resection may be difficult and recurrence often occurs; at these stages, disease-free long-term survival may be difficult to be accomplished. Chemo- and radiotherapy protocols have been designed to complete surgical treatment and improve results in inoperable patients as well, based on the reported sensitivity of thymic tumours to these treatment modalities. The integration of clinical staging and histology, with the new histogenetic morphological classification, has contributed to design multimodality treatment protocols that help to improve prognosis. Induction therapy can now be applied before surgery in patients with tumours considered inoperable, improving resectability and outcome without adding morbidity and mortality to the surgical procedure. This newly developed approach helps to reduce the recurrence rate and to ameliorate disease-free survival. New therapies are now being evaluated as for many other tumours; however, they still need confirmation in prospective randomised studies. In the future, integrated treatment modality should be incorporated in a standardised approach that goes from a careful assessment of histology, staging and lymph node status, and a constructive and non-empirical co-operation between medical and radiation oncologists, pathologists and thoracic surgeons.

Left atrial size predicts the onset of atrial fibrillation after major pulmonary resections

OBJECTIVESnAtrial fibrillation (AF) is a frequent complication after pulmonary resections. Notwithstanding prevention and early treatment it may show a negative impact on the outcome. We assessed the role of echocardiographic variables to predict the onset of this complication.nnnMETHODSnOne-hundred and thirty-four patients were prospectively evaluated: 72 (53.7%) (Group I) underwent lobectomy or pneumonectomy; 62 (46.3%) receiving minor thoracic procedures were included in Group II. Previous AF was the only exclusion criteria. All patients preoperatively underwent bidimensional echocardiography. Demographics, type of resection, histology, staging, diagnosis of chronic obstructive pulmonary disease , induction chemotherapy, smoking history, magnesium levels, other cardiologic diseases, electrocardiographic and echocardiographic findings (atrial and ventricular diameters, left atrial area, left ventricular ejection fraction and diastolic dysfunction) were assessed.nnnRESULTSnPreoperative variables did not show any statistically significant difference between the groups. In 21 patients (15.7%) AF was observed 3.7 ± 1.8 days after surgery. All AF episodes occurred in Group I. Three patients (2.2%) with AF died during the postoperative course. The left atrial diameter and area were significantly enlarged in patients with AF (P = 0.001 and P < 0.0002); 18 AF episodes (86%) occurred in patients with atrial enlargement. At univariate analysis low postoperative magnesium levels, LV diastolic dysfunction, left atrial antero-posterior diameter >40 mm, left atrial area above 20 mm(2) and extended resections were statistically significant. At multivariate analysis only left atrial area enlargement was an independent predictive prognostic factor for postoperative AF.nnnCONCLUSIONSnEchocardiographic left atrial size evaluation may be useful to predict the onset of postoperative AF in patients undergoing lobectomy and pneumonectomy.

Anterior approach to the thoracic spine

An anterior approach affords the spine surgeon excellent visualization and access to the anterior thoracic spine, the vertebral bodies, intervertebral disks, spinal canal, and nerve roots. This approach is currently used in the surgical treatment of thoracic disk disease, vertebral osteomyelitis or discitis, fractures and tumors of the vertebral bodies, allowing for proper decompression of neural elements and spine stabilization. Over a 10-year period in a single institution, a total of 142 patients with a mean age of 49.6 years underwent anterior thoracic exposure of the spine. The indication for surgery was trauma fracture in 20 patients, malignancy in 35, degenerative disease in 29 and correction of scoliosis in 58. Surgical approaches were determined based on the location and length of spinal involvement, including cervico-thoracic approach (15) thoracotomic approach (85) video-assisted thoracoscopy (10) and thoracolumbar exposure (32). Mean operative time was 334 min (range from 256 to 410 min). There was no perioperative mortality. Thirty-one patients (21.8%) developed postoperative complications. The anterior approach to the thoracic spine is safe and effective and even the presence of complications can be appropriately managed. An adequate preoperative evaluation stratifying the risk and instituting measures to reduce it, accurate surgical planning and careful surgical technique are key to yielding a good outcome and to reduce the risk of complications.

Sub-Lobar Lung Resection of Peripheral T1N0M0 NSCLC Does Not Affect Local Recurrence Rate

Background and Aims: The use of sub-lobar resection versus lobectomy for stage I non small cell lung cancer is still controversial. This study was undertaken to compare the results of limited resection in terms of survival and local recurrence rate to lobectomy in patients with peripheral stage I non small cell lung cancer. Material and Methods: During the 8 year period from 1999 to 2007, 152 consecutive patients with stage I non-small cell lung cancer underwent lung resection at our thoracic surgery unit. In 116 cases we performed a standard lobectomy while in the remaining 36 cases we did sub lobar resection through mini-thoracotomy or video-assisted thoracoscopy. The survival, local recurrence rate and the clinical outcome were analyzed and compared. Results: Fifty-one patients were staged as T1 N0 M0, 22 in the sub-lobar resection group (61,1%) and 29 (25%) in the lobectomy group. The remaining were staged as T2 N0 M0. Although the patient population undergone to sub-lobar resection was older, with poorer lung function and more co-morbidities, the Kaplan-Meier survival proportion at 5 year did not differ significantly between the two groups: 64% for lobectomy group vs 66,7% for sub-lobar resection group. Overall local recurrence did approach significance in favour of lobectomy group but analyzing only T1 patients, no differences in terms of survival and local recurrence rate were observed. Conclusions: The results of this study indicate that in patients with peripheral T1N0M0 non small cell lung cancer the outcome of limited resection is comparable with that of pulmonary lobectomy.

Sequential Bilateral Bronchoscopic Lung Volume Reduction With One-Way Valves for Heterogeneous Emphysema

BACKGROUNDnClinical benefits of bronchoscopic lung volume reduction with one-way endobronchial valves have been reported for heterogeneous emphysema after unilateral treatment. We assessed the potential role of contralateral treatment to prolong the benefits obtained with the first procedure.nnnMETHODSnThis was a retrospective multicenter study including consecutive patients with heterogeneous emphysema undergoing bronchoscopic valves deployment during the last 4 years. Patients were split into two groups depending on the procedure (unilateral versus bilateral). The intergroup differences were evaluated to assess the viability, effectiveness, and safety of the bilateral procedure.nnnRESULTSnForty-nine patients were enrolled. Of these, 14 (28%) had a sequential bilateral procedure mainly due to loss of the clinical benefits obtained with the first treatment. A significant improvement of forced expiratory volume in 1 second (p < 0.05), forced vital capacity (pxa0<xa00.05), residual volume (p < 0.05), 6-minute walking test (pxa0< 0.05), and St. George respiratory questionnaire (pxa0< 0.02) was achieved after the second procedure. These results were maintained during follow-up. There was noxa0significant difference regarding the changes of forced expiratory volume in 1 second (pxa0= 0.4), forced vital capacity (pxa0= 0.08), residual volume (pxa0= 0.9), 6-minute walking test (pxa0= 0.3), and St. George respiratory questionnaire (pxa0= 0.1) between the bilateral and unilateral groups.nnnCONCLUSIONSnA sequential bilateral approach seems to be a valid strategy to improve respiratory function in patients with bilateral heterogeneous emphysema who have lost the benefits obtained with the first procedure.

Minimally invasive pectus excavatum repair: migration of bar and ossification

Minimally invasive repair of pectus excavatum is an effective treatment option, with satisfactory results. Nevertheless, complications may occur during bar removal. We describe the case of a 16-year-old boy operated on for pectus excavatum with the Nuss procedure, who developed bar migration into the rib, with ossification, making its removal very difficult.

Emergency lung transplantation contributes to knock down mortality on the waiting list

We read with interest the manuscript from Saueressig et al. [1] entitled ‘Urgent lung transplantation in cystic fibrosis patients: experience of a French center’. This is an important paper stressing a new way to knock down mortality on the waiting list for lung transplantation. In Italy, a similar approach has been employed exactly 1 year ago, allowing us to ask for an emergency transplant (the first lung available in the whole country) for patients younger than 50 years requiring mechanical ventilation and/or extracorporeal membrane oxygenation (ECMO); non-invasive ventilation (NIV) was not a criteria for emergency allocation. We have previously stressed the importance of prioritizing patients with pulmonary hypertension (PH) on the waiting list [2]. Since the approval of the emergency list in our country, we have performed six procedures (out of 20 transplants—30%) in 1 year. The characteristics of the donors were identical to those of the group of patients receiving elective transplantation. Lungs become available after a mean of 5.8 days. All patients had cystic fibrosis but one with histiocytosis and they all received double-lung transplantation; they all had PH and they were all under mechanical ventilation with a tracheostomy and ECMO (five veno-venous and one veno-arterial). All these patients have been on NIV before further deterioration and institution of mechanical ventilation and ECMO. Four of them were weaned from ECMO in the operatory theatre, immediately after the procedure and two of them were weaned within the first 5 postoperative days. There was no operative mortality and all patients are alive after a mean follow-up of 7.3 ± 4.4 months. There was no primary graft failure and the incidence of acute rejection was in line with the rest of the transplanted population. One patient had bronchial complications requiring stenting. In this group of patients, there was a longer intensive care unit (ICU) stay and length of hospitalization. There were seven major complications in three patients, including haemothorax (2), cardiac tamponade (1), tracheo-oesophageal fistula (1), renal failure (1), abdominal bleeding (1) and femoral nerve transitory damage (1). This emergency approach allowed us to knock down mortality on the waiting list in patients younger than 40 years: in fact, there was no pre-transplant mortality during the last year when compared with an approximate previous 20% mortality. However, although this policy dramatically changed the outcome in this specific subset of patients, it decreased the number of elective procedures, since the lungs retrieved in emergency had to be returned to the centre that had priority in the rotation; this mechanism delayed the availability of organs on the elective list. We would like to congratulate the authors and ask them if they can produce more details on the donor population (PaO2, length of ICU stay, cause of death), comparing them with those used in the elective transplant group. This could be important to justify the increased mortality rate in their series. We would also like to know if the emergency approach affected the number of elective transplants performed at their centre.

Chest Tubes: Generalities

Insertion, management, and withdrawal of chest tubes is part of the routine activity of thoracic surgeons. The selection of the chest tube and the strategy for each of these steps is usually built on knowledge, practice, experience, and judgment. The indication to insert a chest tube into the pleural cavity is the presence of air or fluid within it. Various types and sizes of chest tubes are now commercially available.

Surgical treatment of esophageal carcinoma with curative intent: analysis of a single center experience

BackgroundWe retrospectively reviewed our series of 76 patients who underwent esophagectomy, with curative intent, for esophageal carcinoma over the last 10 years.MethodThe mean age was 60 years ranging between 46 to 76 years. Fifty-seven patients had a squamous cell carcinoma and 19 patients had an adenocarcinoma. In 15 cases induction therapy was accomplished prior to surgery. A narrow gastric tube was used to restore continuity in 74 patients (97.3%). Medical records were reviewed and data analysis was performed.ResultsPeri-operative mortality was 2.6%. Overall survival at 1, 3 and 5 years was 85,5%, 67,7% and 52,7%, respectively, with no significant difference between the squamous cell disease group and the adenocarcinoma group. Although T factor and stage at the time of surgery influenced overall survival, the presence of nodal metastasis had the major impact on survival as confirmed by univariate and multivariate analysis with a 5 year survival rate of 32% regardless of the use or not of adjuvant chemo-radiotherapy and the pathologic stage.ConclusionsEsophagectomy still represents a valid treatment for esophageal carcinoma in well selected patients. Both pT stage and N stage appear to be the most important factors determining survival for patients with completely resected esophageal carcinoma.

Do Repeated Operations for Recurrent Colorectal Lung Metastases Result in Improved Survival

BACKGROUNDnLung metastases occur in 10% to 20% of patients with colorectal cancer (CRC). Lung metastatic pathways of CRC are poorly known, and the optimal management for recurrent lung metastases remains uncertain.nnnMETHODSnLong-term oncologic outcomes of 203 patients with CRC lung metastases who underwent metastasectomy were investigated in this multicenter retrospective study. Ninety-two patients (45.3%) with tumor relapse underwent repeated metastasectomy andxa011 (5.4%) received a third metastasectomy for a second relapse. Demographic and clinical data, including histologic grade of primary tumor, presence of CRC liver metastases, type of primary tumor resection, number, size, location, and resection type of pulmonary metastases, were evaluated. Overall survival (OS) and disease-free survival were analyzed. Cox regression model was performed to identify variables that influenced OS.nnnRESULTSnOne hundred seventy-three patients (85.2%) received a wedge resection, 21 (10.3%) underwent pulmonary lobectomy, and 9 (4.4%) underwent other procedures (pneumonectomy, bilobectomy). The mean follow-up was 39 months (range: 7 to 154 months). One-, 3-, and 5-year global OS from CRC diagnosis was 99%, 80%, and 60%, respectively, and 97%, 60%, and 34% from the first metastasectomy, respectively. Log-rank test between OS (one versus repeated metastasectomy) did not show significant differences (pxa0= 0.659). Cox regression model showed that nodal status (hazard ratio [HR] 17.7, pxa0= 0.008) and administration of adjuvant chemotherapy (HR 0.33, pxa0= 0.026) are risk and protective factors, respectively, for OS.nnnCONCLUSIONSnRepeated pulmonary metastasectomy should be offered to patients with metastatic CRC because there are no differences in terms of OS between patients undergoing single and repeated metastasectomy. Adjuvant chemotherapy should be suggested in case of metastatic CRC.