Leonardo Duranti

Primary chest wall chondrosarcomas: results of surgical resection and analysis of prognostic factors

OBJECTIVES Wide surgical excision with tumour-free margins is the mainstay of therapy for primary chest wall chondrosarcoma (PCWC). Few studies on treatment outcome and prognostic factors of PCWC requiring chest wall resection are available. We analysed our experience on surgical treatment of PCWC with emphasis on survival and recurrence prognostic factors. METHODS From 1986 to 2012, 89 patients (65.2% males, median age 55 years) with PCWC were operated on. The median tumour maximum diameter was 7 cm (range 2-30 cm). RESULTS We performed 23 sternectomies and 66 lateral chest wall resections (median ribs resected: 2; range 1-7). Resections were extended to lung (n = 19), diaphragm (n = 13), vertebral body (n = 6) or clavicle (n = 1). Negative margins were obtained in 85.4% of cases. Chest wall reconstruction was obtained mainly by prosthetic non-rigid or rigid materials and muscle flap coverage. In the last years, 3 patients received a sternal replacement with cadaveric allograft, and 2 had a chest wall reconstruction with titanium bars and 17 with a rib-like prosthesis. Perioperative mortality and morbidity rates were 0 and 12.4%, and 5- and 10-year overall and disease-free (on R0 resections) survival rates were 67.1 and 57.8%, and 70 and 52%, respectively. A favourable outcome (univariate analysis) was seen for G1 tumours (P < 0.0001), negative surgical margins (P < 0.0001), age ≤55 years (P = 0.005), no adjuvant treatment (P < 0.001) and diameter ≤6 cm (P = 0.005). Independent predictors of better survival (multivariate analysis) were negative surgical margins (P = 0.0001), G1 tumours (P = 0.02), age ≤55 years (P = 0.006) and diameter ≤6 cm (P = 0.006). A predictive risk factor for recurrence was histological grade. CONCLUSIONS Surgical resection of PCWC leads to good oncological outcome. Wide surgical margins and G1 tumours predicted a better prognosis and a lower recurrence rate. The evolution of surgical technique and the introduction in clinical practice of new prosthetic materials allowed larger resections, and safe and anatomical reconstruction.

Diagnosis and management of typical and atypical lung carcinoids.

An estimated 20% to 30% of all neuroendocrine tumours originate in the bronchial tree and lungs. According to the 2015 World Health Organization categorization, these tumours are separated into four subtypes characterized by increasing biological aggressiveness: typical carcinoid, atypical carcinoid, large-cell neuroendocrine carcinoma and small-cell carcinoma. Although typical and atypical lung carcinoids account for less than 1-5% of all pulmonary malignancies, the incidence of these neoplasms has risen significantly in recent decades. Surgery is the treatment of choice for loco-regional disease but for advanced lung carcinoids there is no recognized standard of care and successful management requires a multidisciplinary approach. The aim of this review is to provide a useful guide for the clinical management of lung carcinoids.

A Prognostic Model Including Pre- and Postsurgical Variables to Enhance Risk Stratification of Primary Mediastinal Nonseminomatous Germ Cell Tumors: The 27-Year Experience of a Referral Center

BACKGROUND Primary mediastinal germ cell tumors (PMGCTs) poorly benefit from chemotherapy and half of patients die because of disease progression. Enhancing the risk stratification might result in tailoring a more personalized treatment strategy from the time of diagnosis. PATIENTS AND METHODS Between the years 1985 and 2012, 86 patients with PMGCT were treated at our center. Cox proportional hazards regression analysis was conducted in the population of nonseminomas to examine the prognostic effect of candidate factors on progression-free and OS. OS curves were compared using the Kaplan-Meier method and the log-rank test. RESULTS Mean age was 29.8 years (range, 15-63 years). Twenty-five patients (29.1%) had lung and 8 (9.3%) liver, bone, or brain metastases. Twelve patients (13.9%) received upfront high-dose chemotherapy and 45 patients (52.3%) underwent surgery after chemotherapy. Cox analyses included 61 evaluable primary mediastinal nonseminomatous germ cell tumors (PMNSGCTs). The final model of factors indicating a poor prognosis included the combination of surgery and histological response (overall P = .011) and lung metastases (hazard ratio, 3.03; 95% confidence interval, 1.12-8.15; P = .028). The model showed a bootstrap-corrected Harrel c-statistic for OS of 0.66. A risk stratification model based on the combination of these factors and accounting for a 50% 5-year survival cutoff identified 2 groups (poor prognosis, n = 33 vs. good prognosis, n = 28) with distinct OS curves (P < .001). Preoperative serum tumor marker level was not associated with the final histology (P = .853, χ(2) test). Results were limited by small numbers. CONCLUSION Patients with PMNSGCT included 2 subpopulations with distinct prognosis, and therapeutic improvements are needed for patients with poor-risk features.

Baseline C-reactive protein level predicts survival of early-stage lung cancer: evidence from a systematic review and meta-analysis.

Purpose The prognostic impact of baseline C-reactive protein (CRP) in non-small-cell lung cancer (NSCLC) is debated. To evaluate this issue, we performed a systematic review and meta-analysis to explore the role of CRP value in predicting early-stage NSCLC survival. Methods Ten articles on early-stage NSCLC were eligible and included in our study. We performed a random-effects meta-analysis and assessed heterogeneity and publication bias. We pooled hazard ratio (HR) estimates and their 95% confidence intervals (CIs) on mortality for the comparison between the study-specific highest category of CRP level versus the lowest one. Results In overall analysis, elevated pretreatment CRP values were significantly associated with poor overall survival (HR 1.60, 95% CI 1.30-1.97, p<0.001, I2 = 71.9%). Similar results were observed across considered strata. However, higher mortality risk was reported in studies in which CRP was combined with other factors (HR 1.96, 95% CI 1.58-2.45) and in those using a cutoff value of 3 mg/L (HR 1.89, 95% CI 1.52-2.35). Conclusions Based on our analysis, baseline high CRP level is significantly associated with poor prognosis in early-stage NSCLC. Further prospective controlled studies are needed to confirm these data.

Pulmonary resections: cytostructural effects of different-wavelength lasers versus electrocautery

AIMS AND BACKGROUND There are few papers on the cytostructural effects of surgical instruments used during pulmonary resections. The aim of the present study was to evaluate the parenchymal damage caused by different surgical instruments: a new generation electrosurgical scalpel and two different-wavelength lasers. METHODS Six surgical procedures of pulmonary resection for nodules were performed using a new generation electrosurgical scalpel, a 1318 nm neodymium (Nd:YAG) laser or a 2010 nm thulium laser (two procedures for each instrument). Specimens were analyzed using optical microscopy and scansion electronic microscopy. RESULTS Severe cytostructural damage was found to be present in an average of 1.25 mm in depth from the cutting surface in the patients treated using electrosurgical cautery. The depth of this zone dropped to less than 1 mm in patients treated by laser, being as small as 0.2 mm using the laser with a 2010 nm-wavelength and 0.6 mm with the 1318 nm-wavelength laser. DISCUSSION These preliminary findings support the use of laser to perform conservative pulmonary resections (i.e., metastasectomies), since it is more likely to avoid damage to surrounding structures. Controlled randomized trials are needed to support the clinical usefulness and feasibility of new types of lasers for pulmonary resections.

Lung metastasectomy in adenoid cystic cancer : is it worth it?

BACKGROUND AND PURPOSE Adenoid cystic carcinoma (ACC) of salivary glands is characterized by long-term distant metastasis, most commonly in lungs. No agreement has been reached about the role of surgical treatment of pulmonary lesions. We evaluated the long-term results of lung metastasectomy for ACC in order to identify factors that should be taken into account in selecting patients eligible for surgery and treatment planning. PATIENTS AND METHODS A retrospective study was conducted on 109 patients selected from our institutional experience and from the International Registry of Lung Metastases. Survival was calculated by Kaplan-Meier estimate and prognostic factors endowed with a predictive power for most other metastatic cancers were investigated. RESULTS The cumulative survival was 66.8% at 5years and 40.5% at 10years. In patients with a disease-free interval (DFI) greater than 36months, the overall survival was 76.5% at 5years. Survival in case of complete surgical resection was 69.5% at 5years. Multivariate analysis confirmed DFI and completeness of resection resulted in the best prognostic variables. DISCUSSION Lung metastasectomy should be considered as a therapeutic option to achieve local control of disease when 2 conditions are met: (1) complete surgical resection is feasible and (2) the time to pulmonary relapse after primary tumor treatment is greater than 36months. Symptomatic benefits of an incomplete lung resection in slow-growing tumors such as ACC remain uncertain. The turning point in the management of disseminated cancers will be clarified with biological profiling of ACC and the development of targeted therapies.

Permeable Nonabsorbable Mesh for Total Diaphragmatic Replacement in Extended Pneumonectomy

After complex thoracic exenterations, total diaphragmatic resection and reconstruction is challenging. We describe our novel technique for total diaphragmatic replacement with permeable nonabsorbable mesh after extended pneumonectomy.

Thulium laser versus staplers for anatomic pulmonary resections with incomplete fissures: negative results of a randomized trial.

Aims This randomized trial evaluated the feasibility and safety of thulium 2010-nm laser to perform anatomic lung resections in patients with incomplete fissures, as compared to mechanical staplers with or without sealants. Study Design Seventy-two patients scheduled for segmentectomy or lobectomy were enrolled. After intraoperative confirmation of the extent of resection and incomplete fissures (Craig type 2, 3 or 4), they were randomized and allocated to one of the following arms: laser resection by thulium (group A) or standard resection with mechanical staplers with or without sealants (group B). The primary endpoints of the study included analysis of intraoperative and postoperative course, and costs. Results Thirty-eight patients were assigned to group A (32 lobectomies, 6 segmentectomies) and 34 to group B (31 lobectomies, 3 segmentectomies). No 30-day mortality was observed. Median operative times were 145.0 minutes (group A) and 142.5 minutes (group B, P = 0.83). The median time to drainage removal was 5 days (group A) and 4 days (group B), while the median length of hospital stay was the same (7 days). Prolonged air leaks >7 days were observed in 12 patients of group A (32%) and 10 patients of group B (29%, P = 0.46). Unpredictable late pneumothorax occurred in 3 patients of group A (2 readmissions, need for 1 repeat thoracotomy). Cost analysis demonstrated an intraoperative advantage for group A (mean 807 ± 212 euro) versus group B (mean 1,047+/-276 euro, P <0.0001), but the differences in total costs could be due to chance (P = 0.83). Conclusions The use of laser to complete fissures can lead to late pneumothorax, even in the absence of postoperative air leaks. Moreover, the use of laser to complete fissures did not prove to reduce overall costs. Trial Registration Identification Number: 41/10 (IRB00001457 – FWA00001798 – IORG0001063).

Dynamic Magnetic Resonance Imaging and Postoperative Motion of Diaphragm

We read with interest the article by Kocher and colleagues [1] about the effect of phrenic nerve palsy on early postoperative lung function after pneumonectomy. Their well-designed randomized trial supports the importance of phrenic nerve function preservation when performing a pneumonectomy, even if the authors concluded that further trials are needed to validate the results, particularly due to the small sample size. We would suggest using dynamic magnetic resonance imaging (MRI) in the forthcoming studies. In fact, in their trial the authors chose to evaluate the postoperative motion of the diaphragm through chest sonography, currently one of the possible functional imaging tools along with fluoroscopy and MRI [2]. MRI is described as an emerging and innovative diagnostic modality [3] that allows a quantitative assessment of diaphragmatic movements of excursion, bilateral synchronism, and velocity, even with different postures [4]. In our opinion, this type of “dynamic” MRI could add a more objective evaluation of the motion of the diaphragm rather than sonography, which is undoubtedly a simple and inexpensive useful tool but is operator related and needs significant expertise [3]. Of course, sonography could be sufficient in everyday clinical practice, and MRI might be used for research studies, for which we believe that a moderate increase in costs could be justified, even in these “hard times.”

Pitfalls in oncology: a unique case of thoracic splenosis mimicking malignancy in a patient with resected breast cancer

Thoracic splenosis (TS) is a condition of autotransplantation of splenic tissue into the pleural cavity after thoraco-abdominal trauma, with diaphragmatic and spleen injury. It is usually asymptomatic and discovered as an incidental finding at imaging performed for other reasons. Its differential diagnosis regards different benign and malignant conditions and should be discerned avoiding invasive procedures. We report a case of thoracic mass associated with pleural nodules mimicking malignancy in a patient with resected breast cancer for whom a diagnosis of TS was made early by using non-invasive methods. Briefly, we review the literature data on TS, comment concisely the possible implications of using invasive procedures and describe the current non-invasive techniques available. Furthermore, we highlight the importance of an accurate medical history collection, the role of the multidisciplinary board and their impact on treatment decision making. Finally, we conclude that clinical information and imaging would be the discriminating factors to avoid unnecessary invasive procedures.