Guido Caroli

Early and long-term results of pulmonary resection for non-small-cell lung cancer in patients over 75 years of age: a multi-institutional study.

OBJECTIVES Older lung cancer patients with multiple morbidities are increasingly referred to thoracic surgery departments. The aim of this multicenter study was to analyse the prognostic factors for in-hospital morbidity and mortality and to elucidate the predictors of long-term survival and oncological outcomes. METHODS We identified 319 patients aged ≥ 75 years who underwent intended curative lung resection for lung cancer in three different thoracic surgery departments between January 2000 and December 2010. RESULTS Seventy-one patients underwent limited resection, 202 had lobectomy, 16 had bilobectomy and 30 had pneumonectomy. The in-hospital mortality was 6.6%. Chronic renal failure, low respiratory reserve and pneumonectomy were predictors of in-hospital mortality. The mean follow-up time was 3.9 years, ranging from 1 month to 10.4 years. The disease-free survivals at 1, 3 and 5 years were 82, 60 and 47%, respectively. The overall survivals at 1, 3 and 5 years were 86, 59 and 38%, respectively. The long-term overall survival was negatively influenced by pneumonectomy, extended resection, N(1-2) subgroups and pathological TNM stage. CONCLUSIONS Nowadays, we can consider surgery a safe and justifiable option for elderly patients. Careful preoperative work-up and selection are mandatory to gain satisfactory results. Good long-term results were achieved in elderly patients with early stage who underwent lobar or sublobar lung resection. The role of surgery or other alternative therapies, in patients with advanced stages, extensive nodal involvement and/or requiring extensive surgical resection for curative intent, is still unclear and further studies are certainly needed.

Can Topical Application of Tranexamic Acid Reduce Blood Loss in Thoracic Surgery? A Prospective Randomised Double Blind Investigation

OBJECTIVE The systemic or topical use of antifibrinolytic agents is effective in reducing postoperative bleeding and blood product transfusion in cardiac surgery. We sought to study the effect of the topical application of tranexamic acid into the pleural space to reduce postoperative bleeding after lung surgery. METHODS This was a prospective randomised double blind placebo controlled investigation. From May-2010 to February-2012, 89-patients, scheduled for pulmonary resection, were randomly allocated to one of the two study groups. Group-A received 5 g of tranexamic-acid in 100 ml of saline solution. Group-B received 100 ml of saline solution as placebo. RESULTS The blood loss in the first 12-h was significantly less in group-A. The same trend was observed in the first 24-h but without reaching a true statistical significance. The mean volume of blood transfusion was statistically lower in group-A. The analysis between post-operative haemoglobin concentration, haematocrit, platelet-count, international-normalised-ratio, fibrinogen and partial-thromboplastin-time of both groups was not statistically significant. CONCLUSION In our experience, the topical use of tranexamic-acid after lung surgery reduces postoperative bleeding and blood transfusion volume. The topical administration of tranexamic-acid is safe without increasing the risk of post-operative complications related to pharmacological side-effects.

Allogenic sternal transplant after sternectomy for metastasis of ovarian carcinoma.

Sternal metastasis from ovarian carcinoma is extremely rare. We report a case of a young woman in whom a single metastasis at the level of the upper portion of the sternum developed. Surgical excision of the sternum was performed with replacement by a sternal allograft stabilized by titanium plates and transosseous high-tension sutures. With this simple and reproducible technique, we obtained a stable and dynamic reconstruction of the sternoclavicular joints and shoulder girdle. The use of a sternal allograft provides excellent functional and cosmetic results. The implantation technique is simple and reproducible.

Surgical results and long-term follow-up of T4-non-small cell lung cancer invading the left atrium or the intrapericardial base of the pulmonary veins

Patients with locally advanced non-small cell lung cancer infiltrating the left atrium (LA) or the intrapericardial base of the pulmonary veins (PVs) are generally not considered good candidates for surgery because of the poor long-term survival. In the last 10 years, 31 consecutive patients with non-small cell lung cancer directly invading the LA or the intrapericardial base of the PVs underwent surgery. Pneumonectomy was the operation performed most frequently. In-hospital mortality was 9.7% and overall morbidity was 52%. One-, 2- and 3-year survival rates were 64, 46 and 30%, respectively with a mean survival of 22 months. The systemic recurrence of disease was the major cause of death at follow-up. At statistical analyses, the N-factor and the type of operation were related to poor long-term survival. In these patients, surgery could be performed with an acceptable operative mortality and morbidity. Surgery should be considered whenever a complete resection is technically possible. A careful preoperative evaluation is mandatory to select good candidates for surgery.

Accuracy of transthoracic ultrasound for the prediction of chest wall infiltration by lung cancer and of lung infiltration by chest wall tumours.

BACKGROUND We wanted to determine the accuracy of transthoracic ultrasound in the prediction of chest wall infiltration by lung cancer or lung infiltration by chest wall tumours. METHODS Patients having preoperative CT-scan suspect for lung/chest wall infiltration were prospectively enrolled. Inclusion criteria for lung cancer were: obliteration of extrapleural fat, obtuse angle between tumour and chest wall, associated pleural thickening. The criteria for chest wall tumours were: rib destruction and intercostal muscles infiltration with extrapleural fat obliteration and intrathoracic extension. Lung cancer patients with evident chest wall infiltration were excluded. Transthoracic ultrasound was preoperatively performed. Predictions were checked during surgical intervention. RESULTS Twenty-three patients were preoperatively examined. Sensitivity, specificity, positive and negative predictive values of transthoracic ultrasound were 88.89%, 100%, 100% and 93.3%, respectively. Youden index was used to determine the best cut-off for tumour size in predicting lung/chest wall infiltration: 4.5cm. At univariate logistic regression, tumour size (<4.5 vs ≥ 4.5cm) (p=0.0072) was significantly associated with infiltration. CONCLUSIONS Transthoracic ultrasound is a useful instrument for predicting neoplastic lung or chest wall infiltration in cases of suspect CT-scans and could be used as part of the preoperative workup to assess tumour staging and to plan the best surgical approach.

Surgery for non-small cell lung cancer in younger patients: what are the differences?

BACKGROUND Non-small cell lung cancer (NSCLC) in young adults is uncommon. The objective of this study was to evaluate the clinicopathological characteristics, outcomes and prognosis of people younger than 50 years old treated surgically for NSCLC. METHODS A retrospective study was conducted using the institutional database of four thoracic surgery units to collect patients with NSCLC younger than 50 years who had undergone surgery. These patients were compared with older patients (>75-years) operated in the same institutions and in the same period. RESULTS We identified 113 young patients and 347 older patients. Younger patients were more likely to be female, non-smokers, with fewer comorbidities. Younger patients were more likely to be symptomatic at the time of diagnosis. Risk factors for poor prognosis in younger patients were T-stage, and disease-free-interval less than 548 days. Kaplan-Meier analysis showed a lower five-year survival in older patients compared with the younger ones (66% vs 38%, p=0.001). CONCLUSIONS In conclusion NSCLC in younger patients has some distinct clinicopathological characteristics. The overall-survival of young patients is better than in older patients. Young patients receive more complete and aggressive treatment that could explain better survival. Further prospective studies with larger patient populations are required, to clarify the biological and genetic variance of NSCLC in younger patients.

Sternal Resection and Reconstruction for Local Recurrence of Breast Cancer Using the Sternal Allograft Transplantation Technique

Sternal involvement in patients with breast cancer is relatively rare and its treatment is still controversial. Surgery is usually indicated in cases of single metastases in a multimodality protocol. Partial or complete sternectomy associated or not with the resection of surrounding tissues is the technique of choice to obtain safety margins and radical treatment of the disease. The most challenging part of the operation is the reconstruction of the anterior chest wall in order to avoid secondary complications and respiratory failure. In the last few years, different techniques and materials have been used to reconstruct the sternum. We report our experience in two patients with recurrent breast cancer using the sternal allograft technique to replace the sternum after partial sternectomy. The use of a sternal-allograft provides excellent functional and cosmetic results without complications during the follow-up period. The implantation technique is simple and reproducible.

Synchronous Thymoma and Lung Adenocarcinoma Treated with a Single Mini-invasive Approach

A 75 year-old man with a lesion in the middle lobe of the lung was discovered to also have, during the follow-up period, a mass in the mediastinum, diagnosed as a multi-thymic cyst. Both pathologies were successfully treated with a single surgical approach by video-assisted thoracoscopy. We performed a middle VATS lobectomy with complete lymphadenectomy followed by radical thymectomy without additional incision. The postoperative course was uneventful.

Paraneoplastic dermatomyositis as presentation of thymic carcinoma

Thymic carcinomas are very rare and heterogeneous groups of anterior mediastinum neoformations with an extremely aggressive behavior. Often, the diagnosis is made in the advanced stages. Paraneoplastic syndromes associated with thymic carcinoma are extremely rare. We report a case of a 64-year-old man presenting with early stage thymic carcinoma which was discovered because of associated paraneoplastic dermatomyositis. The dermatomyositis disappeared completely after radical resection of the tumor. After 20-month follow-up, the patient is in good clinical condition without recidivism of disease.

Video-assisted thoracoscopic lobectomy for non-small cell lung cancer: a morbidity limiting approach in a patient on chronic hemodialysis and double agent antiplatelet therapy

Patients with end-stage renal disease on hemodialysis undergoing surgery for lung cancer represent a high-risk group because of electrolyte imbalance, anemia, hemodynamic instability, bleeding tendency, and immunocompromised state. We describe a patient on hemodialysis with three lung adenocarcinoma of the right lower lobe as an incidental finding during the clinical course of a myocardial infarction treated with drug-eluting stent implantation and double-agent antiplatelet therapy. Considering patient comorbidities, we decided to perform a right lower lobectomy and complete lymph node dissection by a minimally invasive technique. In our experience, the thoracoscopic approach allowed us to perform lobectomy with complete lymph nodes dissection without morbidity. The use of ultrasound scalpel permits a complete lymph node dissection minimizing bleeding even in a double antiplatelet therapy patient.