Giuseppe Cardillo

Localized (solitary) fibrous tumors of the pleura: an analysis of 55 patients

BACKGROUND Localized (solitary) fibrous tumors (LFTPs) of the pleura are rare, slow-growing neoplasms thought to originate from submesothelial connective tissue. The aim of this article is to present 55 new cases of LFTP, and to discuss the treatment of choice and the clinical behavior of such neoplasms. METHODS From July 1990 to November 1999, 55 patients (32 male, 23 female) with an LFTP were surgically treated at our Institution. Neoplasms were considered to be malignant if one or more of the following histologic features were present: high cellularity with crowding and overlapping of nuclei; high mitotic activity; or mild, moderate, or marked pleomorphism. RESULTS No operative mortality was reported. Forty-eight of the cases arose from the visceral pleura and seven arose from the parietal pleura. A local removal of the neoplasm with free surgical margins was accomplished by video-assisted thoracic surgery in 39 patients and by standard thoracotomy in 10 patients. Four patients underwent formal lung resections, 1 had thymectomy, and 1 had en bloc chest wall resection. Four malignant variants were identified. One patient developed local recurrence and underwent redo surgery with chest wall resection. One patient died of unrelated disease. The remaining patients are alive and disease free at a median follow-up of 53.2 months. CONCLUSIONS LFTPs show a benign outcome in most of the cases. Video-assisted thoracic surgery, with intraoperative assessment of the surgical margins, represents the treatment of choice.

Videothoracoscopic treatment of primary spontaneous pneumothorax: A 6- year experience

BACKGROUND Timing and surgical approach in the treatment of primary spontaneous pneumothorax (PSP) are not well defined. The objective of this study is to propose a treatment protocol by videothoracoscopy (VATS) in PSP. METHODS From July 1992 to May 1998, 432 patients underwent VATS treatment of PSP. Indications were: recurrent ipsilateral pneumothorax: 322 cases; persistent air leak following a first episode: 93 patients; recurrence following VATS: 16 cases; recurrence following thoracotomy: 1 patient. Vanderschuerens classification was used for staging. Surgical indications were: stages I and II, subtotal pleurectomy or talc poudrage; stages III and IV, stapling or ligation of the bullae and subtotal pleurectomy or talc poudrage. Differences in recurrence rates were calculated to compare the specific procedures. RESULTS No postoperative deaths occurred. Complication rate was 4.16%. Conversion rate was 2.3%. Mean follow-up was 38 months (2 to 72 months). Overall recurrence rate was 4.4%. Specific recurrence rates following stapling and talc poudrage were, respectively, 1.27% and 1.79%. Talc poudrage and stapling of the bullae are respectively superior to subtotal pleurectomy (p < 0.0001) and ligation (p < 0.0001). CONCLUSIONS Stapling of the bullae and talc poudrage by VATS represent the treatment of choice of PSP.

Long-term follow-up of video-assisted talc pleurodesis in malignant recurrent pleural effusions

OBJECTIVE Recurrent pleural effusion is a common condition and often presents a challenge for treatment. The aim of this report is to evaluate the long-term follow-up of thoracoscopic management of malignant recurrent pleural effusions. METHODS From July 1st, 1992 to February 28th, 2001, out of 2311 VATS procedures performed at our Institution, 690 patients (29.85%) underwent videothoracoscopy (VATS) for recurrent pleural effusion. Of these 611 (88.55%) were treated for a malignant pleural effusion. There were 374 male and 237 female, with a mean age of 61.2 years. In all patients VATS was performed under general anaesthesia. The pleural effusion was carefully aspirated; fibrinous adhesions were taken down while dense fibrous adhesions were selectively divided; some limited decortications were also performed. Multiple pleural biopsies were always performed. Pleurodesis was performed with 5 g of sterile purified talc insufflated through a talc atomizer. One chest tube was left in situ for 3-5 days. RESULTS Operative mortality was 0.81% (five cases). Postoperative complications occurred in 19 cases (3.1%). Specific histologic diagnosis was obtained in all patients. Follow-up was available for 602 patients (98.5%). After a median follow-up of 64 months (range 5-105 months), talc pleurodesis was successful in controlling recurrence of effusion in 92.7% (558 out of 602) of patients. The success rate did not show any statistically significant difference between patients who underwent postoperative adjuvant therapy and patients who did not. In two patients with failure of talc pleurodesis a redo-VATS was performed. CONCLUSIONS VATS represents the method of choice for both diagnosis and treatment of malignant recurrent pleural effusions. Talc poudrage is safe and effective in obtaining pleurodesis.

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.

Videothoracoscopic management of the solitary pulmonary nodule: a single-institution study on 429 cases.

BACKGROUND Solitary pulmonary nodules (SPNs) sometimes are malignant. We evaluated our 9-year experience in the videothoracoscopic (VATS) management of indeterminate SPNs in order to identify malignant nodules on the basis of clinical and radiologic characteristics. METHODS From July 1992 to May 2001, 429 patients (276 men and 153 women) were treated by VATS because of a SPN. RESULTS Three hundred and seventy lesions were benign (86.24%): mean age, 49 years; mean diameter, 1.8 cm; evidence of calcifications, 43 cases (11.62%); smokers, 201 cases (54.32%); history of previous cancer, 11 cases (2.97%). Fifty-nine lesions (13.75%) were malignant (52 NSCLC and seven metastases): mean age, 59 years; mean diameter, 2.31 cm; evidence of calcifications, two cases (3.38%); smokers, 40 cases (67.79%); history of previous cancer, 12 cases (20.33%). Solitary pulmonary nodules were succesfully resected by VATS in 333 (77.62%) cases (309 benign and 24 malignant). Minithoracotomy was necessary to locate the SPNs in 93 (21.67%) cases (61 benign and 32 malignant). Multivariate analysis showed that age greater than 55 years (OR 4.9), diameter of the lesion greater than 2 cm (OR 4.7), history of previous cancer (OR 17.7), and need for conversion to thoracotomy (OR 6.6) to locate the nodule were statistically significant factors in order to identify malignant SPNs. CONCLUSIONS VATS represents the approach of choice for both diagnosis and treatment of SPNs. The probability of malignancy for SPNs increases with size of the lesion, age of the patients, history of previous cancer, and the need for thoracotomy to locate the nodule.

Congenital diarrheal disorders: Improved understanding of gene defects is leading to advances in intestinal physiology and clinical management

Congenital diarrheal disorders (CDD, Online Mendelian Inheritance in Man [OMIM] 251850) represent one of the most challenging clinical conditions for pediatric gastroenterologists because of the severity of the clinical picture and the broad range of disorders in its differential diagnosis. The number of conditions included within CDD has gradually increased. Recent advances made in the pathophysiology of these conditions have led to a better understanding of the more common diarrheal diseases. Based on the body of data accumulated in recent years, we suggest that CDD be classified in 4 categories depending on the alteration in absorption and transport of nutrients and electrolytes, enterocyte differentiation and polarization, enteroendocrine cell differentiation, and modulation of the intestinal immune response. Our knowledge of the genes responsible for CDD is also rapidly increasing, thanks to linkage studies based on genome-wide analysis of polymorphisms. In this context, the identification of disease genes is a step forward in the diagnostic approach to a patient in whom CDD is strongly suspected. However, it is conceivable that faster, less expensive molecular procedures will, in the near future, become available. This approach could spare the patient invasive procedures and limit complications associated with a delay in diagnosis. Furthermore, carrier and prenatal molecular diagnosis may help pediatricians better manage the condition in the early stages of life.

ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax

Primary spontaneous pneumothorax (PSP) affects young healthy people with a significant recurrence rate. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research. The European Respiratory Societys Scientific Committee established a multidisciplinary team of pulmonologists and surgeons to produce a comprehensive review of available scientific evidence. Smoking remains the main risk factor of PSP. Routine smoking cessation is advised. More prospective data are required to better define the PSP population and incidence of recurrence. In first episodes of PSP, treatment approach is driven by symptoms rather than PSP size. The role of bullae rupture as the cause of air leakage remains unclear, implying that any treatment of PSP recurrence includes pleurodesis. Talc poudrage pleurodesis by thoracoscopy is safe, provided calibrated talc is available. Video-assisted thoracic surgery is preferred to thoracotomy as a surgical approach. In first episodes of PSP, aspiration is required only in symptomatic patients. After a persistent or recurrent PSP, definitive treatment including pleurodesis is undertaken. Future randomised controlled trials comparing different strategies are required. A European Task Force reviews scientific evidence and suggests future research for primary spontaneous pneumothorax http://ow.ly/MWhuF

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.