Nizar Asadi

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.

Three-dimensional surgical simulation-guided navigation in thoracic surgery: a new approach to improve results in chest wall resection and reconstruction for malignant diseases

OBJECTIVES Oncological surgery of the chest wall should be performed to achieve free margins of at least 2 cm for metastasis or 4 cm for primary tumours. When the lesion is not visible or palpable, difficulty in identification may lead to a larger incision and a resection wider than is necessary. METHODS We report three cases of non-palpable metastatic chest wall lesions in which the preoperative surgical planning and the intraoperative identification of the tumour, and thus the subsequent chest wall reconstruction, was supported using computer-based surgery. RESULTS The application of high-resolution three-dimensional imaging technology and navigational systems is used in preoperative surgical planning to provide virtual simulations of a patients skeletal changes and new soft tissue profile. Intraoperatively, a mobile navigation probe was used to identify the lesion, matching surgical landmarks and the preoperative computed tomography imaging, achieving the radical resection of the tumour with correct but not excessive surgical margins. Two patients underwent partial sternectomy followed by sternal allograft reconstruction. The third patient underwent chest wall resection followed by reconstruction using titanium bars and vicryl mesh. In all cases, the postoperative period was uneventful. After a follow-up period of 13.9 and 8 months, respectively, all patients are disease free, without complications. CONCLUSIONS Application of navigation technology in thoracic surgery should be encouraged because it is easy to use and requires a limited learning curve.

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.

Thoracoscopic resection of a giant mediastinal parathyroid cyst

Parathyroid cysts are a rare situation, unusually in the mediastinum. The preoperative diagnosis could be more difficult in some atypical topographies and imaging characteristics in particular in case of huge mediastinal cyst. In the following years traditionally, in case of intrathoracic parathyroid cysts, sternotomy or thoracotomy have been the preferred approaches. We report a case of an older patient with a huge mediastinal parathyroid cyst removed successfully using videothoracoscopy.

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.

Transthoracic ultrasound planning in the treatment of second and third stage of empyema.

Background The management of empyema is still debated. Videoassisted thoracoscopic surgery (VATS) has revolutionized surgical management of patients with empyema. Currently thoracoscopic approach probably is the best choice in the management of second or third stage of empyema, particularly in those patients with chronic empyema and poor performance status. Multioculated empyemas generally make thoracoscopic procedure difficult therefore open procedures would be preferable. We evaluate the effectiveness of transthoracic ultrasound (TUS) in the planning of the best thoracoscopic approach in treatment of chronic empyema.

Sternal allograft transplantation for anterior chest wall reconstruction

Background Reconstruction of the chest wall after an anterior chest wall resection remains a difficult and controversial issue, therefore a correct reconstruction of these large resections is fundamental to avoid secondary complications. Different materials have been used to reconstruct the sternum, but none of them are considered the gold standard procedure. We propose a new technique using sternal-allograft to reconstruct the anterior chest wall after sternal resection.

Successful treatment of parapneumonic empyema after H1N1 infection in a heart transplant recipient

Pandemic influenza A H1N1 virus is likely to cause severe disease in patients who have received solid organs transplants. In these patients pneumonia is the most frequent clinical feature. Parapneumonic empyema (PPE) may represent the evolution of secondary bacterial respiratory infections. To our knowledge this is the first reported case of PPE during H1N1 influenza A in an adult heart transplanted patient. The patient was treated successfully with surgical empyemectomy and lung decortication, broad-spectrum antibiotics and oseltamivir. Eradication of influenza was obtained in the fifth postoperative day.