Marcello Carlo Ambrogi

A pilot study of the role of TC-99 radionuclide in localization of pulmonary nodular lesions for thoracoscopic resection

OBJECTIVE Video-assisted thoracic surgery (VATS) is an interesting and emerging procedure for diagnosis and treatment of peripheral pulmonary nodules. However, thoracoscopy has limits in the detection of small nodules, below the pleural surface, deep in the lung parenchyma, which cannot be seen as much as palpated. Methods to localize such lesions, including the methylene blue injection or the introduction of a hooked-wire under the radiological vision, have some advantages but a lot of limitations. We are developing a new technique for the detection of pulmonary nodules smaller than 2 cm, deep in the lung parenchyma. METHODS The technique consisted of a intra-lesional injection of 0.3 ml of solution of 99m Tc-labelled human serum albumin microspheres (5-10 MBq) under the CT-scan guide, 2 h before surgery. During thoracoscopy a 11 mm diameter-collimated probe connected to a gamma ray detector (Scinti Probe MR 100 - Pol. hi.tech., Aquila - Italy), is introduced by a 11.5 mm trocar and the pleural surface of the suspected area was scanned. A hot-spot indicated the presence of the injected nodule and as a consequence, the area to be resected. RESULTS from June 1997 to June 1999 we treated 39 patients with small pulmonary nodules. The patients were 27 men and 12 women with a mean age of 60.8 years (range: 13-80). In 19 cases the anamnesis was positive for synchronous or metachronous malignant neoplasm. The mean surgical procedure length was 50 min (range 20-100 min). In all the cases the nodule was resected and the resection margins were pathologically free of tumour. The mean post-operative hospital stay was 3 days (range 2-6 days). Histological examination showed 21 benign lesions and 18 malignant lesions (seven metastases and 11 primary lung cancers). Nine pts with primary lung carcinoma underwent a completion lobectomy by open surgery. CONCLUSIONS Radiolocalization by gamma-probe allows the detection and exeresis of small nodules in a easy and safe way. Future and predictable advances in radio-marked monoclonal antibodies, as well as in the development of endoscopic beta-detector probe, will offer a more effective method for detection of primary and metastatic tumours, targets of thoracoscopic resections.

Long-Term Results of Radiofrequency Ablation Treatment of Stage I Non-small Cell Lung Cancer: A Prospective Intention-to-Treat Study

Introduction: About one-fifth of patients with resectable non-small cell lung cancer (NSCLC) are unsuitable for surgical treatment. Radiofrequency ablation offers an alternative minimally invasive option. We report the result of an intention-to-treat study with long-term follow-up. Methods: From 2001 to 2009, we performed 80 percutaneous radiofrequency ablations of 59 stage I NSCLC in 57 inoperable patients. Two patients were treated for two separate lesions. The study group consisted of 45 males and 12 females, with mean age of 74 years (range, 40–88 years). All patients had pathological evidence of NSCLC, which was in stage IA in 44 cases and in stage IB in the other 15 cases. The mean size of the lesions was 2.6 cm (range, 1.1–5 cm). Fourteen lesions were retreated up to five times. The procedure was always performed under local anesthesia and conscious sedation. Most of the procedures were performed under computed tomography guidance, with nine under ultrasonography guidance. Results: In all cases, the procedure was technically successful. No mortality was recorded, and major morbidity consisted of four cases of pneumothorax requiring pleural drainage. At a mean follow-up of 47 months, the complete response rate was 59.3% (stage Ia 65.9%, stage Ib 40%, p = 0.01), with a mean local recurrence interval of 25.9 months. Median overall survival and cancer-specific survival were 33.4 and 41.4 months, respectively. Cancer-specific actuarial survival was 89% at 1 year, 59% at 3 years, and 40% at 5 years. Conclusions: Radiofrequency ablation treatment of early-stage NSCLC seems to be a effective minimally invasive therapy even in the long-term period, particularly for stage Ia tumors.

The multimodality treatment of thymic carcinoma.

OBJECTIVES Thymic carcinoma is a rare neoplasm more invasive and with a poorer prognosis than ordinary thymoma. Complete curative resection is sometimes not possible, but good response rates to chemotherapy are reported in literature. We report our experience with seven cases of thymic carcinoma, who took part to a multimodality treatment including neoadjuvant chemotherapy, surgery and post-operative radiotherapy in our center. METHODS Since June 1989, seven previously untreated patients were enrolled. The primary chemotherapy consisted of three courses of cisplatin (P; 75 mg/m(2) i.v., day 1), epidoxorubicin (E; 100 mg/m(2) i.v., day 1) and etoposide (VP16; 120 mg/m(2) i.v., days 1, 3 and 5), every 3 weeks. Surgery was performed following complete hematological recovery. After surgery, all patients underwent radiation therapy to the tumor areas, operatively marked with clips, at doses of 45 (complete resection) or 60 Gy (incomplete resection). RESULTS The pre-operative diagnosis of thymic carcinoma was performed in four cases by a mediastinotomy, and in the remaining cases, by an ultrasound-guided (n=2) or a computed tompography-guided (n=1) fine needle aspiration. All patients responded (one completely) to the chemotherapy regimen. Surgical resection was complete in four cases (histological examination negative in one case). Three patients are still alive and well (62-136 months from the diagnosis), two are alive with relapse at 16 and 85 months, one patient died at 86 months from another cause, and one patient died at 18 months from local relapse and lung metastases. CONCLUSIONS A pre-operative shrinkage of the thymic carcinoma by means of neoadjuvant multi-drug chemotherapy may improve the resectability, and therefore, the survival rate. Our experience, although preliminary, is encouraging and merits additional study in a multicenter trial with a sufficient number of patients to draw definitive conclusions.

Combined Nd-YAG laser/HDR brachytherapy versus Nd-YAG laser only in malignant central airway involvement: a prospective randomized study

BACKGROUND Laser debulking and prosthetic stents are useful modalities in the palliative treatment of initial inoperable or recurrent lung cancer. Recently, endobrochial brachytherapy was introduced to extend the duration of palliation and reduce the number of endoscopic treatments. This trial compares Nd-YAG laser alone and associated to high dose rated (HDR)-brachytherapy. PATIENTS AND METHODS From 1995 to 1998, 29 consecutive patients, with non-small cell lung cancer (NSCLC) and central airway involvement, were randomized in two groups: group 1 (15 patients) received Nd-YAG laser only; group 2 (14 patients) underwent a combined Nd-YAG laser/ HDR brachytherapy treatment. RESULTS There was no mortality or morbidity related to the treatment. The period free from symptoms was 2.8 months for group 1 and increased to 8.5 months in group 2 (P<0.05). The diseases progression free period grew from 2.2 months of group 1 to 7.5 months of group 2 (P<0.05) and the number of further endoscopic treatment reduced from 15 to 3 (P<0.05). CONCLUSION The results confirm the potential of brachytherapy to prolong relief from symptoms, lessen disease progression and reduce costs of treatment. A detailed analysis is presented of both groups.

Radiofrequency Ablation of Lung Malignancies: Where Do We Stand?

Percutaneous radiofrequency (RF) ablation is a minimally invasive technique used to treat solid tumors. Because of its ability to produce large volumes of coagulation necrosis in a controlled fashion, this technique has gained acceptance as a viable therapeutic option for unresectable liver malignancies. Recently, investigation has been focused on the clinical application of RF ablation in the treatment of lung malignancies. In theory, lung tumors are well suited to RF ablation because the surrounding air in adjacent normal parenchyma provides an insulating effect, thus facilitating energy concentration within the tumor tissue. Experimental studies in rabbits have confirmed that lung RF ablation can be safely and effectively performed via a percutaneous, transthoracic approach, and have prompted the start of clinical investigation. Pilot clinical studies have shown that RF ablation enables successful treatment of relatively small lung malignancies with a high rate of complete response and acceptable morbidity, and have suggested that the technique could represent a viable alternate or complementary treatment method for patients with non-small cell lung cancer or lung metastases of favorable histotypes who are not candidates for surgical resection. This article gives an overview of lung RF ablation, discussing experimental animal findings, rationale for clinical application, technique and methodology, clinical results, and complications.

Acute major airway injuries: clinical features and management

OBJECTIVE Patients with an acute major airway injury are coming at our attention with increasing frequency. Despite of its nature, post-traumatic or iatrogenic, these lesions may be life-threatening. An early diagnosis and a prompt treatment reduce morbidity and mortality. MATERIALS AND METHODS In the last 10 years, on a total of 55 patients treated in our institution for benign lesions of the major airway, 20 were with an acute injury; eleven females and nine males with a mean age of 58 years (range of 24--92). Twelve lesions were iatrogenic (orotracheal intubation) and eight were post-traumatic (three blunt traumas, five penetrating traumas). The cervical trachea was involved in 13 cases (one associated to an incomplete esophageal transection and two associated to laryngeal injuries), the thoracic trachea in six cases (four extended to the right mainstem one and to the left). Sixteen patients underwent immediate surgical repair (13 direct sutures of the tear and three complex restorations of the airway): 11 by cervicotomy and five by thoracotomy. In six cases the suture of a posterior tracheal wall tear was achieved through a new approach which provides for a small collar incision and a longitudinal tracheotomy. RESULTS All the patients were discharged healed with a normal patency of the airway. At a mean follow up of 49 months (range of 9--122) endoscopy showed a perfect healing process of the lesions. One patient, treated in a conservative fashion, required endoscopic laser Nd-YAG removal of a granuloma. CONCLUSION Early diagnosis and surgical repair are the goals to persecute to achieve the best outcomes in this potentially lethal lesions. The surgical approach should be the thoracotomy if the trauma involves the 1/3 inferior trachea and/or a mainstem, the cervicotomy in the case it was injured the 2/3 superior trachea and the larynx. Posterior tracheal wall tears may be repaired via the new transcervical/transtracheal technique. The conservative treatment should be reserved to those patients with minimal signs and symptoms, and with an adequate patency of the airways.

Surgical treatment of non-small cell lung cancer in octogenarians

As the European population ages, surgeons are regularly faced with octogenarians with resectable early stage non-small cell lung cancer (NSCLC). We compared our experience with those reported in the literature to comprehend the feasibility, outcomes and lessons learned regarding surgical treatment. We reviewed octogenarians who underwent lung resection for NSCLC in the past nine years in our Department. The purpose of this paper is to retrospectively analyse postoperative surgical and oncological outcomes of our series, trying to find possible correlations between mortality, morbidity, survival and preoperative oncological and functional assessment, surgical approach and extent of resection. Eighty-two patients (M/F = 63/19), with a mean age 81.0 years (range 80-87 years) underwent lung resection for NSCLC: 63 lobectomies, one inferior bilobectomy, three segmentectomies, and 15 wedge resections. There were two perioperative deaths (2.4%). The overall complication rate was 30.0%, with a major complication rate of 2.5%. Actuarial cancer-related survival rates at one, three and five years were 90%, 44% and 36%, respectively, with a statistically-significant correlation with pathological stage. Octogenarians may benefit from surgical treatment of NSCLC with an acceptable morbidity and mortality rate, if an accurate preoperative selection is pursued.

Robotic extended thymectomy for early-stage thymomas

OBJECTIVES The aim of this study was to report a single referral centre experience in robotic extended thymectomy for clinical early-stage thymomas, evaluating its safety, feasibility and efficacy, with special regard to oncological outcomes. METHODS Between April 2002 and February 2011, we retrospectively selected all those patients who underwent robotic thymectomy for clinical early-stage thymomas. Operative time, morbidity, mortality, duration of hospitalization and overall and disease-free survival were analysed. RESULTS There were 14 patients (8 males, 6 females) with a mean age of 65.2 years (range 23-81). One patient suffered from myasthenia gravis. The WHO classifications were: A in two cases, AB in four cases, B1 in three cases, B2 in two cases and B3 in three cases. The Masaoka stages were: I in seven cases, IIA in four cases, IIB in two cases and III in one case. The mean operative time was 139 min. No intra-operative complication or death occurred. Conversion to open surgery was required in two cases. Minor complications occurred in two patients (14.2%) due to pleural effusion. The mean hospitalization was 4.0 days. Five patients underwent adjuvant radiotherapy. All patients were alive with no disease recurrence, with a median follow-up of 14.5 months (range 1-98). CONCLUSIONS Robotic thymectomy is a safe and feasible technique, with a short operative time and low morbidity. Even on a small series with short follow-up, robotic extended thymectomy for thymoma appeared to be an effective treatment for early-stage thymomas.

Ten-year experience of mediastinal robotic surgery in a single referral centre

OBJECTIVE The aim of this study was to report a single referral centre experience in the exeresis of mediastinal lesions with robotic surgical system. The outcomes of all patients were retrospectively investigated with special regard to myasthenic and thymomatous patients. METHODS From February 2001 to December 2010, 69 patients (30 males, 39 females), with a mean age of 55.4 years (range 20-81), underwent robotic surgery for treatment of mediastinal lesions. There were 39 thymectomies, 13 paravertebral neurogenic tumour removals, 9 pleuropericardial cyst removals, 3 teratoma excisions, 4 lymphonodal removals and 1 enterogenous cyst excision. Operative time, conversion rate, morbidity and mortality were analysed. RESULTS There were no intra-operative complications, and no mortality. The mean operative time was 124.3 min (range 45-240). Conversion to open surgery occurred in three cases (4.3%). All post-operative complications (7.2%) were conservatively treated. The mean post-operative stay was 4.3 days (range 3-10). For the myasthenic patients (mean follow-up of 18 months), the Myasthenia Gravis Foundation of America change in status resulted improved in 18 (90%) patients and unchanged in 2 (10%) patients. In cases of thymoma, the pathological analysis revealed Masaoka stage I (seven cases), IIA (three cases), IIB (two cases) and III (one case). No disease recurrence occurred at a mean follow-up of 16 months. CONCLUSIONS Our experience suggests that the surgical system was safe in performing mediastinal mass resection, with low morbidity and conversion rate. The robotic system proved useful, especially in a tiny space such as the mediastinum, and appeared to be an effective treatment for myasthenia gravis and for early-stage thymoma.

Video robotic lobectomy

Video-assisted thoracoscopic surgery (VATS) is beneficial to the patient but challenging for the surgeon. Recently, robots have been introduced into surgical procedures in an attempt to facilitate surgical performance. The da Vinci™ Robotic System (Intuitive Surgical, Inc, CA, USA) is one of these robots. It consists of a console and a surgical cart supporting three articulated robotic arms. The surgeon sits at the console where he manipulates the joystick handles while observing the operating field through binoculars that provide a three-dimensional image. Improved ergonomic conditions and instrument mobility at the level of distal articulation seem beneficial in thoracic procedures. After a period of technical development and training we used the robotic systems to treat patients with various thoracic diseases. We focused our efforts on the development of this technique in thoracic surgery particularly to perform video robotic lobectomy (VRL).