Rendina Ea

Thymoma and thymic carcinoma

Thymoma and thymic carcinoma are an extremely heterogeneous group of neoplastic lesions with an exceedingly wide spectrum of morphologic appearances. They show different presentations with a variable and unpredictable evolution ranging from an indolent non-invasive attitude to a highly infiltrative and metastasising one. Prognosis can be predicted on the basis of a number of variables, mainly staging, the WHO histological pattern and diameter of the tumour. Complete surgical resection is certainly the gold standard to achieve cure. However, especially in patients with lesions at advanced stage, complete resection may be difficult and recurrence often occurs; at these stages, disease-free long-term survival may be difficult to be accomplished. Chemo- and radiotherapy protocols have been designed to complete surgical treatment and improve results in inoperable patients as well, based on the reported sensitivity of thymic tumours to these treatment modalities. The integration of clinical staging and histology, with the new histogenetic morphological classification, has contributed to design multimodality treatment protocols that help to improve prognosis. Induction therapy can now be applied before surgery in patients with tumours considered inoperable, improving resectability and outcome without adding morbidity and mortality to the surgical procedure. This newly developed approach helps to reduce the recurrence rate and to ameliorate disease-free survival. New therapies are now being evaluated as for many other tumours; however, they still need confirmation in prospective randomised studies. In the future, integrated treatment modality should be incorporated in a standardised approach that goes from a careful assessment of histology, staging and lymph node status, and a constructive and non-empirical co-operation between medical and radiation oncologists, pathologists and thoracic surgeons.

Technique to reduce air leaks after pulmonary lobectomy

OBJECTIVEnPatients undergoing pulmonary resections often present postoperative air leaks of varying magnitude and duration; this complication is more frequent with incomplete or absent interlobar fissures. Small leaks close spontaneously within 5-7 days; larger leaks may persist longer and could be associated with increased morbidity and prolonged hospitalization. We evaluated the role of different techniques to complete interlobar fissures before pulmonary lobectomy to prevent postoperative air leaks and reduce hospital stay and costs.nnnMETHODSnA total of 30 patients undergoing pulmonary lobectomy for lung cancer and presenting incomplete interlobar fissures that needed to be opened both anteriorly and posteriorly were randomized into three groups. In Group I, fissures were created with a GIA stapler and buttressed with bovine pericardial sleeves. In Group II, we used TA 55 staplers alone; in Group III we used the old fashion cautery, clamps and silk ties. The three groups were homogeneous for age, type of pulmonary resection and stage of the tumor. The duration of postoperative air leaks and hospital stay were compared with the one-way variance analysis.nnnRESULTSnPostoperative air leaks for Groups I, II and III persisted for 2 +/- 0.94, 5.3 +/- 2 and 5.3 +/- 1.7 days, respectively. Mean hospital stay was 4.4 +/- 0.96, 7.8 +/- 2.14 and 7.2 +/- 1.5, respectively. The difference between groups in terms of duration of postoperative air leaks and hospital stay was statistically significant (P = 0.0001).nnnCONCLUSIONSnThe use of GIA staplers and pericardial sleeves to complete interlobar fissures for pulmonary lobectomy significantly reduces the duration of postoperative air leaks and hospital stay; no complications were associated with this technique.

Parenchymal sparing operations for bronchogenic carcinoma

By the end of the 1950s, the principles of tracheobronchial and pulmonary artery (PA) reconstruction had been established, and their successful clinical application had taken place. It was not until very recently, however, that these techniques aroused widespread interest among thoracic surgeons as a means to achieve complete cancer resection while preserving functioning lung parenchyma. At the present time, sleeve resection of the bronchus and/or PA has a definite role in the surgical management of lung cancer. Growing interest in this field is evidenced by an increasing number of technical variations intended to adapt the basic technique to the different anatomical settings. Also pitfalls, complications, and their prevention and treatment are being extensively described. Last but not least, functional and oncological long-term results, comparing favorably with those of more extended resections, are being reported by many groups. This demonstrates that sleeve lobectomy is no longer reserved only for particularly skillful surgeons. Sleeve lobectomy has achieved its rightful position among the techniques commonly used in thoracic surgery after 40 years of improving understanding and alternating enthusiasm and legitimate doubts.

Video-assisted thoracoscopic treatment of giant bullae associated with emphysema

OBJECTIVEnSurgical treatment of bullous emphysema has received renewed attention because of recent advances in minimally invasive techniques. We describe our experience in the thoracoscopic management of patients with bullous emphysema over the last 5 years.nnnMETHODSnTwenty-five patients (24 male, one female) with a mean age of 57 years with giant bullae associated with various degree of underlying emphysema, were operated on thoracoscopically at our Institution. The severity of the emphysema was classified according to the criteria of the American Thoracic Society: five patients were in stage I (FEV 1 > 50%), eight patients were in stage II (FEV1 35 to 49%) and 12 patients were in stage III (FEV1 < 35%). Nine patients underwent operation to treat complications related to bullae, 12 presented dyspnoea and four were asymptomatic. We performed 23 unilateral and two bilateral staged thoracoscopic procedures.nnnRESULTSnNo intraoperative complications developed. Mean operative time was 107+/-25 min. No patient dead. Mean post-operative chest tube duration was 8+/-4.13 days and mean post-operative hospital stay was 11+/-5.76 days. The most frequent post-operative complication was air-leakage that in 12 patients lasted more than 7 days. Pulmonary function tests were obtained 3-6 months after the operation and statistical comparison between pre-operative and post-operative data was performed using Students paired t-test. We observed best results in I and II stage patients, but also stage III patients experienced clinical improvement and better quality of life.nnnCONCLUSIONSnOur experience supports the safety and effectiveness of video-assisted thoracoscopy for the treatment of giant bullae. Minimally invasive approach is fully justified especially in the group of patients with severe impairment of lung function.

Intrathoracic lobe of the liver: case report and review of the literature

A case of a heterotopic intrathoracic lobe of the liver connected through a normal diaphragm to the main organ by a vascular and biliary pedicle is described. Eight similar cases reported in the literature are reviewed and a comparative evaluation is undertaken to elucidate the correct clinical diagnosis and the indications for operative exploration. Because the occurrence of ectopic supradiaphragmatic hepatic tissue should be considered, it is believed that the preoperative evaluation of a solid, smooth lump in the diaphragmatic region should include gallium liver scans prior to invasive procedures.

Left atrial size predicts the onset of atrial fibrillation after major pulmonary resections

OBJECTIVESnAtrial fibrillation (AF) is a frequent complication after pulmonary resections. Notwithstanding prevention and early treatment it may show a negative impact on the outcome. We assessed the role of echocardiographic variables to predict the onset of this complication.nnnMETHODSnOne-hundred and thirty-four patients were prospectively evaluated: 72 (53.7%) (Group I) underwent lobectomy or pneumonectomy; 62 (46.3%) receiving minor thoracic procedures were included in Group II. Previous AF was the only exclusion criteria. All patients preoperatively underwent bidimensional echocardiography. Demographics, type of resection, histology, staging, diagnosis of chronic obstructive pulmonary disease , induction chemotherapy, smoking history, magnesium levels, other cardiologic diseases, electrocardiographic and echocardiographic findings (atrial and ventricular diameters, left atrial area, left ventricular ejection fraction and diastolic dysfunction) were assessed.nnnRESULTSnPreoperative variables did not show any statistically significant difference between the groups. In 21 patients (15.7%) AF was observed 3.7 ± 1.8 days after surgery. All AF episodes occurred in Group I. Three patients (2.2%) with AF died during the postoperative course. The left atrial diameter and area were significantly enlarged in patients with AF (P = 0.001 and P < 0.0002); 18 AF episodes (86%) occurred in patients with atrial enlargement. At univariate analysis low postoperative magnesium levels, LV diastolic dysfunction, left atrial antero-posterior diameter >40 mm, left atrial area above 20 mm(2) and extended resections were statistically significant. At multivariate analysis only left atrial area enlargement was an independent predictive prognostic factor for postoperative AF.nnnCONCLUSIONSnEchocardiographic left atrial size evaluation may be useful to predict the onset of postoperative AF in patients undergoing lobectomy and pneumonectomy.

Preoperative chemotherapy and immunochemotherapy for locally advanced stage IIIA and IIIB non small cell lung cancer: preliminary results

From January 1991 to November 1993, 110 patients with histologically confirmed stage IIIA and IIIB non-small cell lung cancer (NSCLC), were seen at our Institution. Our study was designed to evaluate whether redirection to surgery of otherwise unresectable patients may be obtained by preoperative therapy. Forty-nine patients were considered eligible for neoadjuvant treatment. Thirty-two (Group I) were treated with two or three cycles of cisplatin, vinblastine and mitomycin C and 17 (Group II) received two cycles of cisplatin, VP16, alpha 1 timosine and interferon. The overall response rate was 81.2% for Group I and 88.7% for Group II. Downstaging was predictive of resectability (P < 0.05). Forty-one patients (83.6%) underwent thoracotomy with 37 (75.5%) radical resections. Conservative techniques (bronchovascular reconstruction) (22 cases) were preferred over pneumonectomy (2 cases). The resectability rate was 84% for Group I and 87% for Group II (P = NS). Treatment-related complications were minor, with no deaths. Postoperative complications occurred in two cases in each group (7.4% and 14.3%). There was no histologic evidence of tumor in three patients. Two-year survival was 75% for Group I and 55% for Group II (P = NS). To date 35 patients who had complete resection are alive, and free of disease. We conclude that preoperative chemotherapy produces high response and resectability rates in both stage IIIA and IIIB unresectable NSCLC; radical resection using a conservative technique is possible in patients who are otherwise unresectable; no local recurrence occurred after radical resection; no significant differences were demonstrated between the two protocols.

Surgery for T4 lung cancer invading the thoracic aorta: Do we push the limits?

Few investigators have described en bloc resection of non‐small cell lung cancer (NSCLC) invading the aorta.

Evaluation of Renal Function in Patients Undergoing Lung Transplantation

BACKGROUNDnAcute kidney injury and chronic kidney failure are serious complications after lung transplantation. Glomerular filtration rate (GFR) is the primary indicator of renal function. Several equations have been proposed to evaluate the estimated GFR (eGFR). We compared three different equations to determine which has the better correlation with the development of acute and chronic renal failure in lung recipients.nnnMETHODSnTwenty-two patients with a mean age of 54.4 ± 8.5 years underwent lung transplantation from 2010 to 2015. Thirteen (59%) had pulmonary fibrosis, 7 (32%) emphysema, 1 (4.5%) bronchiectasis, and 1 (4.5%) lymphangioleiomyomatosis. In all patients, eGFR was measured preoperatively using Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD), and Leveys Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. In 20 patients (90%) eGFR was calculated at 1, 3, and 6 months.nnnRESULTSnAccording to CKD-EPI and MDRD, eight patients (36.3%) had preoperative reduction in eGFR, whereas 6 patients (27.2%) had preoperative reduction according to the CG (Pxa0= .04). The mean values were higher for the CG (103.2 vs. 102 vs. 94.4). Five patients (22.7%) developed perioperative acute renal failure requesting a dialysis treatment; four of these showed a preoperative eGFR to the highest CG (Pxa0= .05). At 1xa0and 6 months after lung transplantation, the CG, MDRD and CKD-EPI eGFR values were, respectively, 86.6, 84.1 and 76.6 mL/min/1.73m2 and 75.8, 72.7, and 72.3 mL/min/1.73m2. CKD-EPI eGFR values are more predictable than the other equations of AKI.nnnCONCLUSIONSnPreoperative assessment of eGFR using the MDRD and CKD-EPI seems to correlate better than the CG to the prediction of acute renal failure, whereas for the chronic form the three equations seem equivalent.

382 Is primary surgery for N2 non small cell lung cancer (NSCLC) still justified

37.0%, 47.1% in resected cases. Especially, improvement in resected cases was marked. Analysis of resected cases resulted in increase of cases detected by mass survey, cases of early stage, cases of adenocarcinoma of peripheral type, and cases of female. The proportions of stage I lung cancer in cases detected by mass survey were increasing as 36.7%, 47.3%, 49.0%, 52.0% in group A to D, so mass survey seemed to contribute to early detection of lung cancer. It was also important that accurate diagnosis of staging became possible by the progress of diagnostic technology such as CT and MRI. In conclusion, the result of treatment for lung cancer in the Natronal Chest Hospitals in Japan have been improving because of increase of early cases detected by mass survey. However, the proportion of cases found by mass survey is less than 30% even lately, and it is a problem left in the future that more than half of lung cancer patients are still discovered through their subjective symptoms. We conclude that N2 NSCLC can be effectively treated by primary surgery if radical resection can be performed. We believe that CT-negative patients can procede to resection without further invasive staging. Mediastinoscopy may screen out unsuspected N2 disease and shift the patient to neoadjuvant treatment. The latter can however hardly offer the 40% 5 year survival rate which we have obtained by primary surgery. CT-positive patients should not be denied primary surgery if the primary tumor and the N2 lymphnodes are resectable. Invasive staging (mediastinoscopy, thoracoscopy) and careful screening of clinical N2 may markedly reduce non radical procedures. Nevertheless, when the resection is deemed radical, primary surgery can offer good long term survival.