Pietro Bertoglio

Glomus tumor of the shoulder: A case report and review of the literature

Glomus tumors are benign neoplasms that arise from neuromyoarterial glomus bodies, with clinical manifestations that include acute pain, cold intolerance and tenderness. Glomus tumors may occur anywhere in the skin, soft tissue or gastrointestinal tract, but are most frequently encountered in the nail bed of the hands. The present study reports the case of a 30-year-old female with a history of shoulder pain caused by a cystic neoformation. Following surgery, a microscopic examination revealed nests of small cells of a rounded and regular shape. The tumor cells exhibited positive expression for CD34 and smooth muscle actin. This study supports and confirms the fact that a glomus tumor is a benign neoplasm that may occur in multiple locations. Therefore, the significance of a histological and immunohistochemical approach for a correct characterization of this lesion is required.

Diaphragm and lung–preserving surgery with hyperthermic chemotherapy for malignant pleural mesothelioma: A 10-year experience

Background: The best surgical treatment for malignant pleural mesothelioma is still under a debate, but recent evidence points toward a less‐invasive approach to reduce morbidity and mortality. We reported our 10‐year experience of a limited surgical approach associated with hyperthermic intrathoracic chemotherapy (HITHOC). Material and Methods: Between 2005 and 2014, patients with epithelioid or biphasic malignant pleural mesothelioma were treated with lung–diaphragm–pericardium‐sparing pleurectomy associated with double‐drug HITHOC; at least 3 cycles of adjuvant chemotherapy were then administered. The primary outcome examined was the feasibility of the procedure, whereas secondary outcomes were overall survival and disease‐free interval. Results: Among 49 patients, 41 were male. Median age was 68 years (35‐76 years). Histology was epithelioid in 43 cases. Pathologic stage I, II, III, and IV occurred in 12, 14, 20, and 3 cases, respectively. No intraoperative complications or postoperative mortality occurred, whereas morbidity rate was 46.9%. Median hospital stay was 8 days (5‐45 days). Actuarial median overall survival was 22 months and a 1‐, 2‐, and 5‐year survival accounted for 79.6%, 45.7%, and 9.9%, respectively. Disease‐free survival after surgery was 62%, 37.5%, and 18.5% at 1, 2, and 5 years, respectively. Risk factors analysis for overall survival confirmed a significant role for early stages, epithelioid histology, and fibrinogen serum levels. Conclusions: Cytoreductive surgery associated with HITHOC and adjuvant chemotherapy appears feasible and safe, with no mortality and low morbidity. Preserving lung and diaphragmatic function might warrant an acceptable long‐term outcome.

The role of intracavitary therapies in the treatment of malignant pleural mesothelioma

Surgery is one of the steps of multimodality approach for the treatment of MPM. Due to anatomical features, microscopically radical (R0) resection is never possible and a Macroscopic Complete Resection (R1) is considered the target for mesothelioma surgeons. Recently, intracavitary therapies have been described with the aim of extending the loco-regional effect of surgery. Different agents might be administered intrapleurally: chemotherapy drugs are the most widely used, but also photodynamic therapy (PDT) showed to lead to satisfactory long-term outcomes; furthermore, immunotherapies and gene therapies have been also reported. Despite promising results, no high-quality evidences are currently available and controlled randomized trials are required to establish the exact role of intracavitary therapies and to standardize the technique.

Single lymph node metastasis 10 years after radical resection of a thymoma

From the Thoracic Surgery, and Pathological Anatomy, Department of Surgical, Medical andMolecular Pathology and Critical Area, University of Pisa, Pisa, Italy. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Nov 28, 2016; revisions received Feb 8, 2017; accepted for publication March 5, 2017; available ahead of print April 12, 2017. Address for reprints: Pietro Bertoglio, MD, U.O. Chirurgia Toracica, via paradisa 2, edificio 10, Ospedale Cisanello, 56124 Pisa (PI), Italy (E-mail: pietro.bertoglio@gmail.com). J Thorac Cardiovasc Surg 2017;154:e11-3 0022-5223/

Prognostic role of TPL2 in early‑stage non‑small cell lung cancer

36.00 Copyright 2017 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2017.03.036 Pietro Bertoglio, MD

Diagnosis and staging of locally advanced non-small cell lung cancer

Non-small cell lung cancer (NSCLC) accounts for ~70% of all lung cancer-associated mortalities worldwide. The serine/threonine protein kinase tumor progression locus 2 [TPL2/MAP3 kinase 8 (MAP3K8)] may impact oncogenic events; however the role of TPL2 in lung carcinogenesis remains unclear. The present study was focused on the potential prognostic role of TPL2 in 101 patients with early-stage NSCLC. Since TPL2 is a potential target of miR-21, the association between TPL2 and miR-21 expression was also examined. TPL2 and miR-21 mRNA expression was quantified using reverse transcription quantitative polymerase chain reaction (RT-qPCR). TPL2 protein levels were evaluated by immunohistochemistry (IHC). The present study identified that the mRNA expression of TPL2 was low in 52/101 (51%) cases and high in 49/101 (49%) cases. IHC analysis of TPL2 protein expression often demonstrated identical mRNA results. No statistically significant associations were observed between the mRNA expression of TPL2 and the predominant clinicopathological characteristics of the patients with NSCLC, as well as identifying no association between TPL2 and miR-21. TPL2 mRNA expression was significantly higher in patients with NSCLC with good prognosis (disease-free interval P=0.009; overall survival P=0.024), when compared with those of poor prognosis. Focusing on the difference in mRNA expression of TPL2 among the adenocarcinomas in affected patients, TPL2 was more highly expressed in lepidic adenocarcinomas compared with in the other subtypes (P=0.012). The present study is the first examination, to the best of our knowledge, of TPL2 in early-stage NSCLC in relation to miR-21, and in different adenocarcinoma subtypes. Future studies must clarify the mechanism by which TPL2 is involved in lung carcinogenesis due to its important translational implications.

Is left upper lobectomy always worthwhile for early stage lung cancer? A comparison between left upper lobectomy, trisegmentectomy, and lingulectomy

T4 non-small cell lung cancer (NSCLC) might include a wide range of clinical scenarios. In very selected cases a surgical treatment might be indicated, after careful staging and thorough functional evaluation. Performance status, cardiac and pulmonary function should be evaluated in detail, in a tailored fashion according to the planned surgical operation. Besides the anatomical lung unit (lobectomy or pneumonectomy), resection may involve several vital structures, including great vessels and some portion of the atria. Given the particular nature of T4, surgery is often a part of a multimodal approach. In case of induction therapies, pulmonary function should be re-assessed, to rule out any deterioration that could eventually jeopardize survival. Computed tomography (CT) scan and positron emission tomography (PET)-CT should be always performed to stage the disease, but in case of chest wall, airways or other mediastinal organs involvement, more detailed exams, such us Magnetic Resonance, echocardiography or CT angiography (CTA) and magnetic resonance angiography (MRA) should be carried out. Additionally, a careful investigation for possible mediastinal nodal involvement should be routinely performed, given the detrimental effect of nodal diffusion on survival in this subset of patients. Nowadays endobronchial ultrasound (EBUS), endoscopic (esophageal) ultrasound are reliable and semi-invasive tools that can be used as first step prior to more invasive surgical diagnostic procedures such as video assisted mediastinoscopy or even video-assisted mediastinoscopic lymph-adenectomy (VAMLA) and transcervical extended mediastinal lymphadenectomy (TEMLA). Bronchoscopy and EBUS can be safely used for yield diagnostic tissue in case of central tumors, while in case of peripheral masses, transthoracic biopsy is more sensitive.

N2 lung cancer is not all the same: an analysis of different prognostic groups†

Lobectomy is the gold standard treatment for resectable Non‐Small Cell Lung Cancer (NSCLC). We compared oncological outcomes of patients undergoing a “multi‐segmentectomy” (trisegmentectomy or lingulectomy) and left upper lobectomy for early stage (T1‐2, N0) NSCLC of the left upper lobe.

IgG4-related disease: a new challenging diagnosis mimicking lung cancer

OBJECTIVES The International Association for the Study of Lung Cancer (IASLC) recently proposed a change in the staging system for N2, based on the metastatic station number: N2a1 (a single metastatic station with no hilar involvement), N2a2 (a single metastatic station with hilar involvement) and N2b (multiple metastatic stations). The aim of our study was to validate the IASLC proposal in a cohort of patients with pathological N2 disease. METHODS All patients with pathological T1-T2 N2 non-small-cell lung cancer who were operated on between 2006 and 2010 in our department were enrolled. The patients had lobectomy, bilobectomy or pneumonectomy without induction therapy; patients with any type of extended resection were excluded. All patients had adjuvant treatment. The impact of the new IASLC proposal on the overall and disease-free survival rates was then analysed. RESULTS Ninety-three patients were selected. The median follow-up period and overall survival time were 92 and 28.8 months, respectively. According to the new IASLC proposal, we observed 22 cases of N2a1, 54 N2a2 and 17 N2b. Patients with N2a1 had a significantly better overall survival than those with N2a2 and N2b (P = 0.041); the difference between N2a2 and N2b was not significant (P = 0.19). Patients with N2a1 squamous cell carcinoma had a significantly better overall survival than those with other histological diagnoses (P = 0.046). The disease-free interval was longer in patients with N2a1 than those in other groups (P = 0.021). CONCLUSIONS Our experience partially validates the IASLC proposal; the introduction of quantitative criteria for N staging might improve stratification of patients and the assignment to the correct therapeutic path.

N1 small-cell lung cancer: where should thoracic surgeons dare?

IgG4-related disease (IgG4-RD) is a progressive inflammatory disease that might rarely involve only the lungs. We retrospectively reviewed the preoperative, clinical and surgical features of patients with a pathology highly suggestive or probable diagnosis of IgG4-RD without extra-thoracic involvement. Five patients were selected, 2 were operated on the right side. Positron emission tomography-computed tomography (PET-CT) showed an uptake in all the patients (median 5.5), and 2 patients had an uptake at the thoracic lymph nodes. Two diagnoses were made through a CT-guided needle biopsy, while 3 were determined based on a lung wedge resection. The levels of serum IgG4 were elevated (>1.35 g/dl) in all the patients. Two patients had a highly suggestive diagnosis of IgG4-RD, and 3 patients had a probable diagnosis of IgG4-RD. The differential diagnosis between IgG4-RD and lung malignancies based only on radiological features is challenging and often requires histological confirmation. A careful preoperative workup and a multidisciplinary approach to PET-positive nodules might help to avoid unnecessary major lung resections.