Giovanni Maria Comacchio

Multi-institutional European experience of robotic thymectomy for thymoma

BACKGROUND Robotic thymectomy for early-stage thymomas has been recently suggested as a technically sound and safe approach. However, due to a lack of data on long term results, controversy still exists regarding its oncological efficacy. In this multi-institutional series collected from four European Centres with high volumes of robotic procedures, we evaluate the results after robot-assisted thoracoscopic thymectomy for thymoma. METHODS Between 2002 and 2014, 134 patients (61 males and 73 females, median age 59 years) with a clinical diagnosis of thymoma were operated on using a left-sided (38%), right-sided (59.8%) or bilateral (2.2%) robotic approach. Seventy (52%) patients had associated myasthenia gravis (MG). RESULTS The average operative time was 146 minutes (range, 60-353 minutes). Twelve (8.9%) patients needed open conversion: in one case, a standard thoracoscopy was performed after robotic system breakdown, and in six cases, an additional access was required. Neither vascular and nerve injuries, nor perioperative mortality occurred. A total of 23 (17.1%) patients experienced postoperative complications. Median hospital stay was 4 days (range, 2-35 days). Mean diameter of resected tumors was 4.4 cm (range, 1-10 cm), Masaoka stage was I in 46 (34.4%) patients, II in 71 (52.9%), III in 11 (8.3%) and IVa/b in 6 (4.4%) cases. At last follow up, 131 patients were alive, three died (all from non-thymoma related causes) with a 5-year survival rate of 97%. One (0.7%) patient experienced a pleural recurrence. CONCLUSIONS Our data suggest that robotic thymectomy for thymoma is a technically feasible and safe procedure with low complication rates and short hospital stays. Oncological outcome appears to be good, particularly for early-stage tumors, but a longer follow-up period and more cases are necessary in order to consider this as a standard approach. Indications for robotic thymectomy for stage III or IVa thymomas are rare and should be carefully evaluated.

Extended criteria donor lung reconditioning with the organ care system lung: A single institution experience

Lung transplantation is a life‐saving procedure limited by donors availability. Lung reconditioning by ex vivo lung perfusion represents a tool to expand the donor pool. In this study, we describe our experience with the OCS™ Lung to assess and recondition extended criteria lungs. From January 2014 to October 2016, of 86 on‐site donors evaluated, eight lungs have been identified as potentially treatable with OCS™ Lung. We analyzed data from these donors and the recipient outcomes after transplantation. All donor lungs improved during OCS perfusion in particular regarding the PaO2/FiO2 ratio (from 340 mmHg in donor to 537 mmHg in OCS) leading to lung transplantation in all cases. Concerning postoperative results, primary graft dysfunction score 3 at 72 h was observed in one patient, while median mechanical ventilation time, ICU, and hospital stay were 60 h, 14 and 36 days respectively. One in‐hospital death was recorded (12.5%), while other two patients died during follow‐up leading to 1‐year survival of 62.5%. The remaining five patients are alive and in good conditions. This case series demonstrates the feasibility and value of lung reconditioning with the OCS™ Lung; a prospective trial is underway to validate its role to safely increase the number of donor lungs.

Is there an indication to robotic approach for advanced stage thymic tumors

Thymectomy is the main therapeutic option in the treatment of thymoma. Different surgical techniques have been described, but transternal approach is still considered the gold standard. Anyway, in the last decades, robotic approach has gained attention and nowadays may be considered a standard operation for early stage disease. The improvement of the robotic surgical technique and the introduction of dedicated instruments have allowed challenging resections, thus rendering the robotic approach indicated also for advanced stage thymoma in highly experienced centers.

Effectiveness of minimally invasive thymectomy versus open: comments on an international registry analysis

Although thymectomy represents one of the most common surgical procedure in the field of thoracic surgery, it is still one of the operations with more pending issues, both in terms of surgical indications and technique.

Predictors of unexpected nodal upstaging in patients with cT1-3N0 non-small cell lung cancer (NSCLC) submitted to thoracoscopic lobectomy

Background In the last decades, the use of video-assisted thoracoscopic surgery (VATS) lobectomy for the treatment of early stage non-small cell lung cancer is continuously growing. This is mainly due to the development of more advanced surgical devices, to the rising incidence of peripheral lung tumors and is also favored by the increased reliability of preoperative staging techniques. Despite this progress, postoperative unexpected nodal upstaging is still a relevant issue. Aim of this study is to identify possible predictors of unexpected nodal upstaging in patients affected by cT1-3N0 NSCLC submitted to VATS lobectomy. Methods A total of 231 cases of cT1-3N0 patients submitted to thoracoscopic lobectomy at our centre between June 2012 and October 2016 were retrospectively reviewed. All data regarding clinical staging by means of computed tomography (CT) and positron-emission tomography (PET)/CT were collected and reviewed. The subsequent pathological staging has been analyzed, with special regards to the possible type of nodal involvement, and the number of pathological nodal stations. Results Most of the patients included in this study were in a clinical stage cT1aN0, cT1bN0 (stage IA) and cT2aN0 (stage IB), 86 (37.2%) patients, 73 (31.6%) patients and 62 (26.8%) patients, respectively. Postoperative histopathological analysis showed that the most frequent tumor histotype was adenocarcinoma (192 patients, 83.1%). Thirty-eight (16.5%) patients had a nodal upstaging; among these, 17 (7.4%) patients had N2 disease (8 patients with isolated mediastinal nodal involvement, 9 patients with N1 + N2 disease) and 21 (9.1%) patients had an isolated hilar nodal involvement (N1). At bivariate analysis, the clinical T (cT)-parameter (P=0.023), the histotype (P=0.029) and the pathological T (pT)-parameter (P=0.003) were identified as statistically significant predictors of nodal upstaging. Concerning the type of nodal upstaging, the pT was found to be statistically significant (P=0.042). At bivariate analysis for the number of involved nodal stations, a statistical significance was highlighted for the parameters cT (P=0.030) and pT (P=0.027). With linear logistic regression, histology as well as pT reached statistical significance (P=0.0275 and P=0.0382, respectively). No correlation was found between nodal upstaging and the intensity of FDG uptake in the primary lung tumor or with the timing between PET and surgery. Conclusions There is a strong correlation between the clinical staging of the parameter T evaluated with CT and the possible unexpected nodal upstaging. The same correlation with nodal upstaging is found for pT. At equal clinical stage, in patients affected by adenocarcinoma of the lung the relative risk of having a postoperative unexpected nodal upstaging is almost 7 times higher than in patients with squamous cell carcinoma.

Thoracoscopic wedge resection in single-lung patients

Background The thoracoscopic approach has become a standard procedure in the field of lung resections. However, its advantage in single-lung patients has not yet been well studied. We describe a series of successful thoracoscopic wedge resections in patients presenting with lung cancer after contralateral pneumonectomy. Methods Eight patients, with a previous pneumonectomy (5 right and 3 left) for lung cancer, underwent resection for a suspicious neoplasm on the remaining lung. All lesions were detected in the asymptomatic phase during regular follow-up after pneumonectomy based on repeated computer tomography (CT). Only single peripheral lesions less than 2 cm were eligible for wedge resection were eligible for surgery. Video-assisted thoracoscopic, margin-free tumor wedge resections, were performed during apnea windows with the lung in a deflated position. Results All patients were treated by a wedge resections smaller than a single segment. Only one patient needed a mini-thoracotomy conversion to accomplish a safe margin-free resection. Median total surgical operative time was 37 minutes. There were no postoperative deaths, while morbidity was 12.5%. Conclusions Thoracoscopic surgery represents a feasible surgical option in selected patients after contralateral pneumonectomy, with careful preoperative assessment and using short apnea windows in good collaboration with anesthesiologists. Histological definition, made possible by the surgical-procedure, gives patients the possibility to eventually undergo further targeted therapies. Randomized prospective trials are necessary to assess the best management of peripheral small lung nodules in single-lung patients, in particular to define which patients can benefit from a surgical approach.

Comparing robotic and trans-sternal thymectomy for early-stage thymoma: a propensity score-matching study†

OBJECTIVES Minimally invasive techniques seem to be promising alternatives to open approaches in the surgical treatment of early-stage thymoma, although there are controversies because of lack of data on long-term results. The aim of the study was to evaluate the surgical and oncological results after robotic thymectomy for early-stage thymoma compared to median sternotomy. METHODS Between 1982 and 2017, 164 patients with early-stage thymoma (Masaoka I and II) were operated on by median sternotomy (108 patients) or the robotic approach (56 patients). Duration of surgery, amount of blood loss, complications, duration of chest drainage, postoperative hospital stay, oncological results and total costs were retrospectively evaluated. Data were analysed also after propensity score matching. RESULTS Compared to the trans-sternal group, robotic thymectomy had significantly longer average operative times (P < 0.001) but less intraoperative blood loss (P = 0.01), less perioperative complications (P = 0.03), shorter time to chest drainage removal and hospital discharge (P < 0.001). The median expense for the trans-sternal approach was significantly higher than the cost of the robotic procedure (P < 0.001), mainly due to longer hospitalization. From an oncological point of view, there were no differences in thymoma recurrence, although follow-up of the trans-sternal group was significantly longer (P < 0.001). Data were confirmed after propensity score matching. CONCLUSIONS Robotic thymectomy for early-stage thymoma is a technically safe and feasible procedure with low complication rate and shorter hospital stay compared to the trans-sternal approach. Cost analysis revealed lower expenses for the robotic procedure due to the reduced hospital stay. The oncological outcomes seemed comparable, but longer follow-up is needed.

Anterior approach to Pancoast tumors

Pancoast tumors, or tumors of the superior sulcus, are rare non-small cell lung cancers arising from the apex of the lung and involving the structures of the apical chest at the level of the first rib or above (1). The involvement of the chest wall and the frequent infiltration of vital structures, such as the spine, the brachial plexus and the subclavian vessels, make surgical resection particularly challenging.

Robotic approach for mediastinal lesions: the surgery of extreme locations

In the recent issue of Neurosurgical Focus, Pacchiarotti et al. described their experience with robotic resection of paravertebral tumors, particularly focusing on the extreme locations into the thorax, as the superior and the inferior sulci (1).

AB046. PS02.10: ROBOTIC thymectomy for early stage thymoma: single center experience

Background: Robotic-assisted thymectomy seems to be a promising alternative to sternotomy in the treatment of early stage thymomas. Anyway, minimally invasive thymectomy is still controversial because of the supposed increased risk of local recurrence and the lack of long-term oncological follow-up. We reviewed our experience reporting surgical and oncological results after robotic thymectomy in early-stage thymoma. Methods: Between 2002 and 2016, 56 patients (25 men and 31 women; median age, 57 years) with early-stage thymoma (Masaoka I and II) were operated by left-sided (89.3%) or right-sided (10.7%) robotic approach. Thirty patients (53.6%) had associated myasthenia gravis. Duration of surgery, postoperative complications, postoperative hospital stay and oncological results were evaluated. Results: Average operative time was 144.6 minutes (range, 60–290 minutes). Two (3.5%) patients needed open conversion, in one case because of the dimension of the lesion leading to unsafe dissection/manipulation, in the other in the suspicion of pericardial infiltration. In one case (1.7%) a cervicotomy was performed to complete thymectomy. No vascular and nervous injuries were recorded, and no perioperative mortality occurred. Two patients (3.5%) had postoperative complications (1 myasthenic crisis and 1 hemothorax). Median hospital stay was 3 days (range, 2–10 days). Median diameter of resected tumors was 4.5 cm (range, 1–9 cm), and Masaoka stage was stage I in 11 patients (19.6%) and stage II in 45 patients (80.4%). After a median follow up of 30 months (range, 5– 180 months) one patient died for non-thymoma related cause and one (1.7%) experienced a single pleural recurrence 32 months after initial surgery. Conclusions: Robotic thymectomy for early-stage thymoma is a technically feasible procedure with low complication rate and a short hospital stay. Oncological outcome seems promising, but longer follow-up is needed to validate this as a standard approach.