Marco Alloisio

Gene expression signature of non-involved lung tissue associated with survival in lung adenocarcinoma patients

Lung adenocarcinoma patients of similar clinical stage and undergoing the same treatments often have marked interindividual variations in prognosis. These clinical discrepancies may be due to the genetic background modulating an individuals predisposition to fighting cancer. Herein, we hypothesized that the lung microenvironment, as reflected by its expression profile, may affect lung adenocarcinoma patients survival. The transcriptome of non-involved lung tissue, excised from a discovery series of 204 lung adenocarcinoma patients, was evaluated using whole-genome expression microarrays (with probes corresponding to 28 688 well-annotated coding sequences). Genes associated with survival status at 60 months were identified by Cox regression analysis (adjusted for gender, age and clinical stage) and retested in a validation series of 78 additional cases. RNA-Seq analysis from non-involved lung tissue of 12 patients was performed to characterize the different isoforms of candidate genes. Ten genes for which the loge-transformed hazard ratios expressed the same direction of effect in the discovery (P < 1.0 × 10(-3)) and validation series comprised the gene expression signature associated with survival: CNTNAP1, PKNOX1, FAM156A, FRMD8, GALNTL1, TXNDC12, SNTB1, PPP3R1, SNX10 and SERPINH1. RNA sequencing highlighted the complex expression pattern of these genes in non-involved lung tissue from different patients and permitted the detection of a read-through gene fusion between PPP3R1 and the flanking gene (CNRIP1) as well as a novel isoform of CNTNAP1. Our findings support the hypothesis that individual genetic characteristics, evidenced by the expression pattern of non-involved tissue, influence the outcome of lung adenocarcinoma patients.

Robotic approach in case of thymoma involving the left anonymous vein: a case report

The robotic system has several technical advantages over the manual video thoracoscopic approach. It offers a high definition three-dimensional view and robotic arms are more comfortable to use, because they allow more precise, flexible, and intuitive movements. This case report describes a locally advanced thymoma in a 75-year-old male patient, excised through a robotic-assisted thymectomy with atypical resection of the infiltrated left upper lobe, the preservation of the left phrenic nerve and partial resection of the left anonymous vein involved, without necessity of reconstruction. Clinical staging was thymoma T3 B1-2, while the postoperative histological classification and radiation was thymoma T3, B3, Masaoka-Koga stage IIB. The postoperative course was uneventful and the patient was discharged in second postoperative day. This case remarks that robotic devices are of great help in the intraoperative recognition and precise management of infiltrated structure, like important vessels and nerves, avoiding conversion to an open approach, which until now was the main surgical indication in these situations.

Surgical approach to giant thymoma: is the hemi-clamshell incision the best option?

We read with interest the article by Gotte and Bilfinger titled “Resection of giant right-sided thymoma using a lateral thoracotomy approach followed by median sternotomy for completion thymectomy”. As the authors have pointed out, the most commonly used approach for thymomas is a median sternotomy, but they decided to perform a lateral thoracotomy because of the size and location of the tumor in the right chest cavity. The mass was successfully resected, and a median sternotomy was performed in a separate setting for completion thymectomy. The second surgical procedure was necessary because the thymus gland could not be resected due to limited exposure of the right lateral thoracotomy [1]. A median sternotomy is the most common approach for anterior mediastinal tumors, due to the good exposure of the pericardium, thymus gland and main vessels. However, by a sternotomy, diaphragm, posterior chest wall, and lower lobes are not exposed as well as by a posterolateral thoracotomy, and surgical treatment of mediastinal tumors extensively involving hemithorax is limited. Various approaches to the chest have been described: posterior, lateral, and anterior approaches are effective surgical options, and the choice of which incision to perform depends on the tumor site and involved structures. Posterior and lateral approaches provide adequate exposure of the chest cavity, but they are not suitable for en bloc resection of a thymoma and the thymus gland, or for resection of other malignancies involving the anterior cervicothoracic junction. For such tumors invading the thoracic inlet, an L-shaped transcervical approach has been described, although the main disadvantage of this technique is the lack of access to the pulmonary vessels which can require a separate posterolateral thoracotomy to perform a major pulmonary resection [2, 3]. The hemi-clamshell (or trap-door) incision provides simultaneous effective exposure of the mediastinum, the involved hemithorax and the anterior cervicothoracic junction, and access to the pulmonary hilum is excellent [4 –6]. The surgical technique