Francesco Carleo

Solitary Fibrous Tumors of the Pleura: An Analysis of 110 Patients Treated in a Single Institution

BACKGROUND Solitary (localized) fibrous tumors of the pleura (SFTP) are rare slow-growing neoplasms that generally have a favorable prognosis. The aim of this paper is to evaluate the predictors of outcome in a series of 110 patients with SFTP. METHODS The records of 110 patients (63 men; mean age 56.4 years; range, 17 to 79) surgically treated for SFTP from July 1990 to February 2008, were evaluated for demographics, operative procedure, histopathology, morbidity, mortality, postoperative chemotherapy or radiotherapy, and long-term follow-up. RESULTS Operative mortality was 0.9% (1 of 110) and the overall morbidity was 10.9% (12 of 110). The main surgical approach was video-assisted thoracoscopic surgery (69 procedures with a conversion rate of 14.5%); 40 patients underwent thoracotomy and 1 had sternotomy. The visceral pleura was the site of origin in 95 tumors, the parietal pleura in 13, the mediastinal pleura in 2 cases. Sixty-three tumors were pedunculated, 35 were sessile, and 12 were inverted fibroma. Tumors were pathologically benign in 95 cases (86.4%), and malignant in 15 (13.6%). Symptomatic patients presented with malignant tumors more often than asymptomatic (19.1% versus 9.5%). Overall 10-year survival rate was 97.5%. The overall disease-free survival rate was 90.8% (95.7% in benign cases and 67.1% in malignant cases; p < 0.05). Eight patients presented with recurrence of disease, 4 cases of which were malignant and 4 were benign. CONCLUSIONS Solitary fibrous tumor of the pleura is a rare disease that includes both benign and malignant variants.The outcome is mostly benign, with an overall 10-year survival rate of 97.5%. Pathologically benign lesions show a better disease-free survival rate than malignant lesions (95.7% versus 67.1%; p < 0.05). Surgery is the gold standard of treatment as neither radiotherapy nor chemotherapy proved to be effective.

Chronic postpneumonic pleural empyema: comparative merits of thoracoscopic versus open decortication.

OBJECTIVE We seek to evaluate the comparative merits of thoracoscopic versus open decortication in the surgical management of patients with chronic postpneumonic pleural empyema. METHODS From January 1996 to December 2006, 308 patients (180 males, 128 females, mean age: 56.3 years, range: 17-82 years) with chronic postpneumonic pleural empyema underwent decortication after failure of conservative treatment. RESULTS Decortication was performed by open thoracotomy in 123 (39.9%) patients (OT) and by videothoracoscopy (VT) in 185 (60.1%). Mortality was 1.29% (4/308). Morbidity was 21.1% (65/308). At 6 months follow-up, three VT patients showed recurrent empyema and underwent re-do surgery by video-assisted-thoracoscopy (VATS) (one patient) or by thoracotomy (two patients). The videothoracoscopic approach showed statistically significant better results in terms of in-hospital postoperative (day 1 and day 7), pain (p<0.0001), postoperative air leak (p=0.004), operative time (p<0.0001), hospital stay (p=0.020) and time to return to work (p<0.0001). The analysis of postoperative pain at 6 months follow-up showed no significant differences among the different groups. CONCLUSIONS In the light of our experience, videothoracoscopic decortication appears to be the surgical treatment of choice for chronic postpneumonic pleural empyema even if a multicentric-randomised trial should be performed before videothoracoscopic decortication becomes the gold standard for the treatment of pleural empyema.

Predictors of survival in patients with locally advanced thymoma and thymic carcinoma (Masaoka stages III and IVa)

OBJECTIVE We sought to evaluate factors influencing long-term survival of patients with locally advanced thymoma/thymic carcinoma (Masaoka stages III and IVa) treated by immediate surgery or induction therapy plus surgery. METHODS From January 1991 to April 2007, we surgically treated 61 patients with locally advanced thymoma/thymic carcinoma (Masaoka stages III and IVa). Staging included total body computed tomography (CT) scan in all patients, and chest magnetic resonance imaging (MRI) in 27 selected patients. All patients had histological confirmation before surgery. Thirty-one patients (group A) underwent induction chemotherapy followed by surgery. Thirty patients (group B) underwent immediate surgery. Thirty-four patients (group A: 13; group B: 17) received postoperative radiation therapy. RESULTS No intra-operative mortality was reported. World Health Organization (WHO) histological classification included 19 AB, four B1, seven B2 and 13 B3 thymomas and 18 thymic carcinomas. Thirty-four patients were Masaoka stage III (group A: 18; group B: 16) and 27 patients were stage IVa (group A: 13; group B: 14). After a median follow-up of 77 months, six patients of group A and seven patients of group B died of disease. The overall 10-year survival rate was 50.6%. The 10-year survival rate was 57.9% in group A and 38.1% in group B (p=0.03). Multivariate analysis showed complete resection (p=0.02), Masaoka stage (III vs IVa) (p=0.02), induction chemotherapy (group A vs group B) (p=0.003) and histological WHO subtype (AB vs B1, B2 and B3) (p=0.01) to be statistically significant independent predictors of survival. Sex, age and adjuvant radiation therapy showed no statistically significant difference. CONCLUSIONS Complete resection, Masaoka stage, induction chemotherapy and histological WHO classification showed to be independent predictors of survival in locally advanced thymoma/thymic carcinoma.

Tracheal lacerations after endotracheal intubation: a proposed morphological classification to guide non-surgical treatment

OBJECTIVE Postintubation tracheobronchial lacerations (PITLs) are traditionally managed surgically. We sought to evaluate the rationale for non-surgical management of PITL. METHODS From January 2003 to November 2008, 30 patients with PITL were observed in our institution. PITL were graded as follows: Level I - mucosal or submucosal tracheal involvement without mediastinal emphysema and without oesophageal injury; Level II - tracheal lesion up to the muscular wall with subcutaneous or mediastinal emphysema without oesophageal injury or mediastinitis; Level IIIA - complete laceration of the tracheal wall with oesophageal or mediastinal soft-tissue hernia without oesophageal injury or mediastinitis; Level IIIB - any laceration of the tracheal wall with oesophageal injury or mediastinitis. All patients with Level I, II and IIIA PITL were treated conservatively with endoscopic instillation of fibrin glue (Tissucol, Baxter Healthcare, Deerfield, MA, USA). RESULTS All patients with Level I (n=3), II (n=24) and IIIA (n=2) PITL were successfully treated conservatively. The patient with a Level IIIB injury underwent posterolateral thoracotomy repair of the trachea. No mortality was reported. Mean hospital stay was 12.9 days. Flexible bronchoscopy at 7, 28, 90 and 180 days showed no abnormalities. Complete healing was attained in all patients by day 28. CONCLUSIONS Level I or II PITL should be managed non-surgically. When adequate respiratory status is present, Level IIIA PITL can be managed conservatively in selected institutions only, because these injuries are high-risk injuries. Any PITL associated with injury involving the oesophagus or with mediastinitis (Level IIIB) must be treated as soon as possible by surgery.

Solitary fibrous tumors of the pleura.

Purpose of review Solitary fibrous tumor of the pleura (SFTP) is a rare neoplasm of the pleura. Although an increasing number of case series have been reported in recent years, so far clinical behavior is still unpredictable. The following article presents a detailed review of the recent larger series of SFTP with particular attention to the clinical presentation, pathologic characteristics and surgical features in order to define more precisely the long-term outcome after treatment of this rare entity. Recent findings Usually, after a complete surgical resection a very long survival could be expected in almost all cases. However, the preoperative detection and management of malignant SFTPs are still challenging issues. Summary SFTP remains an enigmatic tumor. Clinical and radiological assessment is often unsatisfactory to obtain a definitive diagnosis. Benign SFTPs are almost always cured with complete surgical resection, and in cases of recurrence the re-do resection of benign recurrences is usually curative. Long-term survivals are also possible for malignant SFTPs, although a higher recurrence rate and higher tumor-related mortality can be expected in these cases. Histologic characteristics distinguishing benign from malignant variants are crucial in estimating the risk of recurrence and planning adjuvant therapies.

Surgical treatment of benign neurogenic tumours of the mediastinum: a single institution report §

OBJECTIVE Neurogenic tumours of the mediastinum are uncommon neoplasms arising from nerve tissues within the thorax. We sought to evaluate and compare the outcome following surgical resection of such tumours by VATS, open thoracotomy, and by either combined with hemilaminectomy. METHODS From February 1992 to March 2007, 93 patients underwent surgical resection of neurogenic tumours of the mediastinum in our institution. A videothoracoscopic approach was used in 57 cases (61.3%) (group V), of which 44 underwent VATS only and 13 required conversion to open approach. In the remaining 36 cases, 32 patients underwent thoracotomy (group T) and 4 had combined procedure with the neurosurgeons (group N). RESULTS No postoperative mortality was reported. Postoperative morbidity rate was 23.6% (22/93; 14 of group T, 4 of group N, and 4 of group V; p<0.0001). Histology showed benign neurogenic tumours in all patients. Statistical analysis showed differences between the two groups (group V and T respectively) in mean operative time (111.3+/-58.2 min vs 149.06+/-77.05 min; p: 0.01), median postoperative stay (4 days vs 6 days p: 0.0009) and median postoperative pain on day 1, day 7 and 1 month after surgery (respectively p<0.0001, p<0.0001 and p: 0.001). At a mean follow-up of 73 months no patients showed recurrence of the tumour. CONCLUSIONS VATS represents the gold standard for the treatment of benign neurogenic tumours of the mediastinum with better results in terms of morbidity, operative time, postoperative stay and postoperative pain compared to open approach. Dumbbell tumours require a combined thoracic and neurosurgical approach.

Primary neuroendocrine tumours of the thymus: a clinicopathologic and prognostic study in 19 patients §

BACKGROUND We sought to evaluate factors influencing long-term survival in 19 patients with primary neuroendocrine tumours of the thymus. METHODS From January 1990 to December 2004, 19 patients (14 males, 5 females; mean age 48.6 years) were surgically treated for a primary neuroendocrine tumour of the thymus. RESULTS All patients underwent radical R0 thymomectomy and were followed up for a total of 1,459 months (median: 69 months; range: 8-180). Nine patients had associated paraneoplastic syndrome. No operative mortality occurred. Two patients underwent re-do surgery because of local recurrence, respectively, 25 and 35 months after surgery. Five patients died of disease, respectively, 51, 70, 95, 131 and 153 months after surgery. One patient died of myocardial infarction with no evidence of disease. Thirteen patients are alive, of which 10 are free from disease and three with disease. The overall 5-year and 10-year actuarial survival rates were 91.6% and 69.8%, respectively (median survival: 153 months). The 10-year survival was evaluated according to histology (typical carcinoid 100%; atypical carcinoid: 66.6%; large cell neuroendocrine tumours: 0%), Masaoka staging (stage I: 100%; stage II: 50%; stage III: 66.6%; stage IV: 0%), presence of paraneoplastic syndrome (no: 87.5%; yes: 0%) and postoperative radiotherapy (yes: 40%; no: 83.3%). CONCLUSIONS The prognosis of primary neuroendocrine tumours of the thymus is related to the grading of the neoplasm, the presence of a paraneoplastic syndrome and to the Masaoka staging but not to the postoperative radiotherapy.

Primary neuroendocrine tumors of the thymus: a multicenter experience of 35 patients.

BACKGROUND Primary neuroendocrine tumors of the thymus (NETT) are rare tumors and represent a distinct category of tumors collectively displaying morphologic and biological neuroendocrine features. We sought to evaluate factors influencing long-term survival in patients with primary NETT. METHODS From January 1990 to April 2011, 35 patients (27 male patients and 8 female patients) were surgically treated for primary NETT at 5 institutions. RESULTS No operative (30-day) mortality occurred. Morbidity was 37.14% (13/35 patients). All patients were followed for a total of 2,703 months. Fourteen patients had associated paraneoplastic syndrome. Twenty-four patients are alive, 19 of whom are free of disease and 5 of whom continue to have disease. The median overall survival was 153 months. The overall 5-year and 10-year actuarial survival rates were 84.34% and 60.82%, respectively. The 10-year survival was evaluated according to histologic type (typical carcinoid, 77.92%; atypical carcinoid, 54.55%; large-cell neuroendocrine carcinomas, 0%; Masaoka staging (stage I, 100%; stage II, 66.67%; stage III, 61.9%; stage Iva, 25%; stage IVb, 0%), presence of paraneoplastic syndrome (no = 70.67%; yes = 32.14%), postoperative radiotherapy (yes = 39.71%; no = 85.71.%), Surveillance, Epidemiology, and End Results (SEER) staging system (localized disease, 83.3%; regional disease, 53.3%; distant disease, 0%), tumor size (<7 cm = 90.9%; ≥7cm = 28.7%; p = 0.0007), and Ki67 expression, which was available in 23 patients (<10% = 85.71%; ≥10% = 0%; p = 0.0037). CONCLUSIONS The prognosis of primary NETT is statistically significantly related to tumor size >7 cm and to the proliferation index (evaluated by Ki67 expression >10%). The histologic type of the neoplasm, the presence of a paraneoplastic syndrome, the Masaoka staging, the evidence of distant disease, and postoperative radiotherapy also impact prognosis.

Prognostic factors in a multicentre study of 247 atypical pulmonary carcinoids.

OBJECTIVES To analyse clinical and biomolecular prognostic factors associated with the surgical approach and the outcome of 247 patients affected by primary atypical carcinoids (ACs) of the lung in a multi-institutional experience. METHODS We retrospectively evaluated clinical data and pathological tissue samples collected from 247 patients of 10 Thoracic Surgery Units from different geographical areas of our country. All patients were divided into four groups according to surgical procedure: sub-lobar resections (SURG1), lobar resections (SURG2), tracheobronchoplastic procedures (SURG3) and pneumonectomies (SURG4). Overall survival analysis was performed using the Kaplan-Meier method and log-rank test. Survival was calculated from the date of surgery to the last date of follow-up or death. The parameters evaluated included age, gender, smoking habits, laterality, type of surgery, 7th edition of TNM staging, mitosis Ki-67 (MIB1), multifocal forms, tumourlets, type of lymphadenectomy and neo/adjuvant therapy. For multivariate analysis, a Cox regression model was used with a forward stepwise selection of covariates. RESULTS Two hundred and forty-seven patients (124 females and 123 males; range 10-84, median 60 years) underwent surgical resection for AC in the last 30 years as follows: n = 38 patients in SURG1, 181 in SURG2, 15 in SURG3 and 14 in SURG4. A smoking history was present in 136 of 247 (55%) patients. The median follow-up period was 98.7 (range 11.2-369.9) months. The overall survival probability analysis of the AC was 86.7% at 5 years, 72.4% at 10 years, 64.4% at 15 years and 58.1% at 20 years. Neuroendocrine multicentric forms were detected in 12 of 247 patients (4.8%; 1 of 12 pts) during the follow-up (range 11.2-200.4, median 98.7 months) and 33.4% had recurrence of disease. There were no significant differences between gender, tumour location and type of surgery at the multivariate analysis. Age [P < 0.001, hazard ratio (HR) 0.60; confidence interval (CI) 0.32-1.12], smoking habits (P = 0.002; HR 0.43, 95% CI 0.23-0.80) and lymph nodal metastatic involvement (P = 0.008; HR 0.46, 95% CI 0.26-0.82) were all significant at multivariate analysis. CONCLUSIONS ACs of the lung are malignant neuroendocrine tumours with a worst outcome in patients over 70 years and in smokers. With the exception of pneumonectomy, the extent of resection does not seem to affect survival and should be accompanied preferably by lymphadenectomy. Pathological staging, along with a mitotic index more than Ki-67 (MIB1), appears to be the most significant prognostic factor at the univariate analysis.

Safety and Effectiveness of a New Fibrin Pleural Air Leak Sealant: A Multicenter, Controlled, Prospective, Parallel-Group, Randomized Clinical Trial

BACKGROUND This study evaluated the sealing capacity and safety of a new fibrin sealant (FS) to reduce alveolar air leaks (AALs) after pulmonary resections in a randomized controlled clinical trial conducted in 3 Italian centers. METHODS The study randomized (1:1) 185 patients with an intraoperative AAL graded 1 to 3 according to the Macchiarini scale: 91 received FS and 94 had standard lung closure. The primary outcomes were the length of postoperative AAL duration and the mean time to chest drain removal. Other end points included the percentage of patients without AAL, the development of serum antibodies against bovine aprotinin, and any adverse event related to FS. Chest drains were removed when fluid output was 100 mL/day or less, with no air leak. RESULTS The study groups were comparable with respect to demographic variables and surgical procedures. The FS group showed a statistically significant reduction in duration of postoperative AALs (9.52 vs 35.8 hours; p < 0.005) and in the percentage of patients with AALs at wound closure (81.11% vs 100%; p < 0.001); the difference in time to chest drain removal was not significant. Pleural empyema developed in 1 patient with FS treatment vs in 4 with standard treatment, and antibodies against bovine aprotinin were found in 34 of 91 FS-treated patients. CONCLUSIONS The present study showed that the new FS is safe and effective in preventing AALs after lung resections and in shortening the duration of postoperative AALs.