Maria Letizia Vita

Thirty-Five–Year Follow-Up Analysis of Clinical and Pathologic Outcomes of Thymoma Surgery

BACKGROUND The impact of myasthenia gravis on patients with thymoma is still controversial when perioperative and long-term outcomes are analyzed. With the unique opportunity of a 35-year follow-up in a single institution, thymomatous myasthenia gravis cohort, we investigated the influence of early and long-term clinical predictors. METHODS We reviewed a surgical series of 317 (1972 to 2007) patients with thymoma: clinical and pathologic features were analyzed as prognostic factors matched against the short- and long-term survival and recurrence rates. RESULTS Male to female ratio was 153:164; median age, 49 years. Myasthenia gravis coexisted in 276 patients (87.1%). Thymomas were classified according to the Masaoka (42.0% stage I, 32.2% stage II, 21.5% stage III, and 4.4% stage IV) and the World Health Organization (3.5% type A, 9.5% type AB, 19.2% type B1, 57.7% type B2, 8.2% type B3, and 1.9% thymic carcinoma) staging systems. The resection was complete in 295 patients (93.1%). Operative mortality and morbidity were respectively 1.6% and 7.6%. No differences were recorded in postoperative outcome stratifying for myasthenia gravis or comorbidities. Mean follow-up was 144.7 +/- 104.4 months. The overall 5-, 10-, 20-, and 30-year survival rates were 89.9%, 84.1%, 73%, and 58.6%, respectively. The completeness of resection (p < 0.001), the Masaoka staging (p = 0.010), and the World Health Organization classification (p < 0.001) all significantly influenced the long-term survival (univariate analysis). Only completeness of resection was significantly correlated with a better prognosis (p < 0.001) in multivariate analysis. Masaoka staging (p < 0.001) and World Health Organization classification (p < 0.001) significantly correlated with the disease-free survival in the univariate and multivariate analyses as significant prognostic factors (Masaoka, p < 0.001; World Health Organization, p = 0.011). Myasthenia gravis patients showed a better prognosis in terms of long-term survival (p = 0.046) and disease-free survival (p = 0.012) in the univariate analysis. CONCLUSIONS We confirm the evidence that the clinical staging and the histologic classification influence long-term survival. The presence of myasthenia gravis was not significantly related to operative outcome, but prolongs both long-term survival and disease-free survival.

Usefulness of Whole-Body Fluorine-18-Fluorodeoxyglucose Positron Emission Tomography in Patients with Neurofibromatosis Type 1: A Systematic Review

Aim. To systematically review the role of positron emission tomography (PET) with fluorine-18-fluorodeoxyglucose (FDG) in patients with neurofibromatosis type 1 (NF1). Methods. A comprehensive literature search of published studies regarding FDG-PET and PET/CT in patients with NF1 was performed. No beginning date limit and language restriction were used; the search was updated until December 2011. Only those studies or subsets in studies including whole-body FDG-PET or PET/CT scans performed in patients with NF1 were included. Results. We identified 12 studies including 352 NF1 patients. Qualitative evaluation was performed in about half of the studies and semiquantitative analysis, mainly based on different values of SUV cutoff, in the others. Most of the studies evaluated the role of FDG-PET for differentiating benign from malignant peripheral nerve sheath tumors (MPNSTs). Malignant lesions were detected with a sensitivity ranging between 100% and 89%, but with lower specificity, ranging between 100% and 72%. Moreover, FDG-PET seems to be an important imaging modality for predicting the progression to MPNST and the outcome in patients with MPNST. Two studies evaluated the role of FDG-PET in pediatric patients with NF1. Conclusions. FDG-PET and PET/CT are useful methods to identify malignant change in neurogenic tumors in NF1 and to discriminate malignant from benign neurogenic lesions.

Bronchial carcinoid tumors causing Cushing's syndrome: an insidious disease.

M IS C E L LA N E O U S 7. Scottish Intercollegiate Guidelines Network (2003) Dyspepsia: a national clinical guideline. Available from: http://www.sign. ac.uk/pdf/sign68.pdf. 8. Talley NJ, Vakil N. The practice parameters committee of the American College of Gastroenterology. Guidelines for the management of dyspepsia. Am J Gastroenterol 2005;100: 2324–37. 9. American Gastroenterological Association. American Gastroenterological Association Technical Review on the Evaluation of Dyspepsia. Gastroenterology 2005;129:1756–80.

Giant air-inflated hydatid cyst of the lung mimicking massive pneumothorax

A 68-year-old Caucasian man was admitted to our emergency department with a 6-month history of progressive dyspnoea, tachycardia, chronic cough and purulent sputum production. The patients medical history was notable for hepatic echinococcosis diagnosed in 2002. Physical examination revealed no chest wall movement, a hyper-resonant sound on percussion, absent tactile fremitus and no audible breath sound in the right hemithorax. A slight tracheal deviation towards the left could also be felt on palpation …

Multiple giant bullae of the lung mimicking massive pneumothorax in a patient with osteogenesis imperfecta

A 60-year-old Caucasian man was admitted to our emergency department with progressive dyspnoea, chronic cough and general asthenia. Physical examination revealed lack of left chest wall motion and absent breath sounds over the left hemithorax. Vital signs were stable with a heart rate of 90 bpm, blood pressure of 120/70 mm Hg, respiratory rate of 20 breaths per minute and oxygen saturation by pulse oximetry of 95% while breathing room air. The patient reported being an active smoker with …

Looking for a standardized approach in the surgical treatment of hyperhidrosis.

We read with great interest the article by Hida et al. [1] reporting on comparison between postoperative effects of sympathotomy by cutting or clamping at T3 on palmar sweating, compensatory sweating, and also on patient satisfaction. Large series have shown a high success rate after endoscopic thoracic sympathectomy (ETS) [2, 3], with improvement in quality of life of patients, but all these results are hardly comparable due to heterogeneous patient populations, different surgical procedures, and more importantly, the variety of qualitative/quantitative scales for definition of symptoms, results and side effects such as compensatory hyperhidrosis. Accordingly, we wish to submit our reflections to the attention of the authors and the community to state the importance of using standardized preoperative and postoperative questionnaires to objectify the improvements of these patients. In the study by Hida et al. [1], the authors proposed the use of two different scales to grade postoperative palmar sweating and patients’ satisfaction. However, recently, the Society of Thoracic Surgeons through Cerfolio and co-workers [4] recommended the use of standardized questionnaires and proposed an example of a data collection sheet that was formulated by De Campos and associates [5]. In the expert consensus, it had also been established that the ETS is the treatment of choice for patients with hyperhidrosis, and that the interruption of the sympathetic chain can be achieved by cauterizing, cutting, or clipping but the use of a rib-oriented nomenclature is required because of anatomical variations in the position of ganglia. In our practice, we are successfully using a version of De Campos’ questionnaire partially implemented by us that is administered to patients preoperatively, postoperatively, and at 1 month, 6 months, and 1 year after surgery, as recommended by the expert consensus [4]. However, long-term follow-up studies providing repeated and standardized questionnaires are needed for systematic assessments of patients’ symptoms and quality of life, before and after surgery, to help us develop a common evidence-based clinical practice.

N2 Nodal Involvement in Multiple Primary Lung Cancer: Really an Exclusion Criterion?

Correspondence Only six patients without previous AFib were given antiarrhythmic drugs (AADs), and interaction between AADs and CPAP did not infl uence the incidence of AFib during follow-up among them ( P 5 1) (our unpublished data, 2013). CPAP did not add any clinical benefi t to AADs in patients with previous AFib documentation ( P 5 .53, unpublished data). Compliance and duration of CPAP use was not higher in patients who did not have AFib during follow-up, and lack of “antiarrhythmic” effi cacy of CPAP in patients with previous AFib cannot be attributed to a lower use of this therapy in this subgroup. A prior history of AFib is the strongest risk factor for recurrent AFib after AF ablation. 4 It would appear by our results that other acknowledged variables (left atrial size, hypertension, ejection fraction, atrial stretching biomarkers, BMI, etc) are not as predictive. Again, this study was not designed to assess for risk factors of AFib, but to determine the impact of an intervention (CPAP) on a reduction of AFib after AF ablation (from 46% to 6% of cases, P 5 .025). We may conclude that documentation of AF sets for the identifi cation of a subset of patients in whom underlying OSA is highly likely. This fact has notable implications in terms of cardiovascular morbidity and mortality. 5 This also appears to include a lower incidence of AFib after CPAP initiation if this arrhythmia has never been documented. 1 Further investigation will be needed to assess the etiopathogenic relationship between OSA and AF and the physiologic changes induced by CPAP that prevent AFib in some patients with AF.

Single center experience on talc poudrage morbidity: focus on high talc dosage.

Malignant pleural effusion (MPE) is a common clinical problem of concern for most of the pneumologists and thoracic surgeons. A general consensus regarding the use of talc poudrage in treatment of MPE exists, but only few studies analyzed in detail talc insufflation related pulmonary morbidity. In particular, ARDS talc-related is caused by physical and chemical effects of the small talc particles (50% particle size <15 μm) and its occurrence is independent from the underlying disease, the quantity of talc used or the technique of talc instillation. In our series we observed 3 cases only (0.75%) of talc-related lung injury. This data strongly confirm the low rate of talc-related lung injury after talc poudrage in treatment of MPE regardless the amount of talc insufflated.