Sara Tenconi

Intra pulmonary migration of a Kirschner wire after glenohumeral fixation.

A 79-year-old asymptomatic woman underwent arthrodesiswith a double K-wire insertion for a posttraumatic invet-erate right glenohumeral dislocation. After removal of thefirst K-wire, chest X-ray showed intrathoracic migration ofthe foreign body, and the CT scan confirmed the pulmonarypenetration of the device within the right upper lobe withintraparenchymal surrounding hematoma (Fig. 1).Although the vital parameters were substantially within therange, the patient underwent urgent surgery. A combinedapproach was attempted: the K-wire was mobilized fromthe glenoid cavity to resect the distal hook and, at the sametime, a right lateral thoracotomy was performed to removesafely the device deeply slipped into the lung and suture theparenchyma (Fig. 2). The postoperative course wasuneventful, and the patient was discharged on the eighthpostoperative day.Improper uses or positioning of K-wires are widelydescribed in the literature and may expose patients toinsidious but potentially life-threatening complications [1];therefore, regular radiological follow-up may be advisablein patients with foreign body at risk of dislodgement intovital structures.

Mediastinal Castleman’s disease mimicking thoracic paravertebral schwannoma

A 51-year-old female underwent resection of a solid lesion in the posterior mediastinum, preoperatively interpreted at imaging as thoracic schwannoma, requiring double sequential surgical procedure to be resected. The histologic examination of the resected mass diagnosed a hyaline-vascular Castlemans disease.

Diagnostic pitfalls in the preoperative 18F-FDG PET/CT evaluation of a case of giant malignant solitary fibrous tumor of the pleura

Solitary fibrous tumor of the pleura (SFTP) is an uncommon entity, generally with an indolent behavior. Nevertheless, some malignant forms have been rarely reported. These, often have an aggressive biological behavior with pathological findings of invasiveness. The preoperative diagnosis and evaluation of the grade of malignancy are extremely challenging. Herein we report a case of a 64-year-old man who presented with a left giant intra-thoracic mass imaged with fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG/PET-CT) and sampled via fine-needle aspiration biopsy (FNAB). Imaging and FNAB findings showed suspicion of a benign form of SFTP. Surgical radical resection of the giant mass was performed. The definitive histological diagnosis showed a malignant SFTP. Based on this report, we take the opportunity to briefly discuss the insidious pitfalls concerning the radiological and (18)F-FDG/PET-CT features as well as cyto/histological findings in the pre-operative diagnostic work-up examination of this rare entity.

Extended pleurectomy decortication for malignant pleural mesothelioma in the elderly: the need for an inclusive yet selective approach

OBJECTIVES The median age at diagnosis of patients with pleural mesothelioma in the UK is 73 years. Recent series have shown the feasibility of extended pleurectomy decortication in the elderly, but with continuing debate about the efficacy of this treatment, we reviewed our experience to identify more detailed selection criteria. METHODS We reviewed prospectively collected data on all patients from 1999 to 2016 undergoing extended pleurectomy decortication. We compared clinical and pathological outcomes and survival data from patients 70 years and older (≥70 years) with those younger than 70 years (<70 years). RESULTS Eighty-two of the 300 (27.3%) patients were ≥70 years of age at the time of surgery. More patients in the elderly group required intensive care postoperatively (6.2 vs 16.7%, P = 0.01) and developed atrial fibrillation (14.4 vs 24.4%, P = 0.05). There was no intergroup difference in length of hospital stay or in in-hospital, 30-day or 90-day mortality. Elderly patients were less likely to receive neoadjuvant (<70 years 21.2%, ≥70 years 11.0%; P = 0.045) or adjuvant chemotherapy (<70 years 45.4%, ≥70 years 29.3%; P = 0.04). Median overall survival was similar: <70 years 14.0 months, ≥70 years 10.3 months; P = 0.29. However, in node-positive patients, survival was poorer in the elderly (13.0 vs 9.1 months, P = 0.05), particularly in those with non-epithelioid tumours (3.8 vs 6.7 months, P = 0.04). On multivariable analysis, age was not a significant prognostic factor, although lack of adjuvant therapy (P = 0.001) and admission to the intensive care unit (P < 0.001) remained poor prognostic factors. CONCLUSIONS Although age in isolation should not be an exclusion criterion for extended pleurectomy decortication for mesothelioma, in the elderly, a more rigorous preoperative evaluation of nodal disease and an additional assessment of fitness for adjuvant chemotherapy are recommended.

Long-term survival and symptomatic relief in lower lobe lung volume reduction surgery†

OBJECTIVES Lung volume reduction surgery (LVRS) has been demonstrated to provide symptomatic relief and improve lung function in patients with end-stage emphysema. The National Emphysema Treatment Trial specifically noted functional benefits in patients with predominantly upper lobe emphysema and demonstrated improvement in quality-of-life parameters, in patients with non-upper lobe emphysema and a low-baseline exercise capacity. We aimed to investigate whether physiological and health status benefits correlated with lower lobe LVRS. METHODS A retrospective analysis was performed from our prospectively collected patient database. A total of 36 patients with severe, non-upper lobe predominant emphysema underwent lower lobe LVRS in our institution, over a 20-year period. The assessments consisted of measurements of body mass index, pulmonary function tests and health-related quality of life using the Short Form 36-item questionnaires. RESULTS Forced expiratory volume in 1 s was seen to improve 3 months [coefficient of time = 1.55 (0.88, 2.21); P < 0.0001] after the procedure, maintained until the first 6 months [0.48 (0.12, 0.85); P = 0.010], decline over the second half of the first year and gradually return to preoperative levels after 2 years, while residual volume to total lung capacity (%) ratio was seen to follow a similar pattern with significant decrease from baseline after 3 months [coefficient of time = -1.76 (-2.75, -0.76); P = 0.001] and 6 months [-1.05 (-1.51, -0.59); P < 0.0001]. Quality-of-life improvements were mainly noted in physical components. CONCLUSIONS Contrary to a widely held misconception following the National Emphysema Treatment Trial that lower lobe lung volume reduction does not offer significant benefits to patients with non-upper lobe predominant emphysema, we feel justified in offering lower lobe LVRS in these patients when they meet the same selection criteria as upper lobe LVRS.

Surgery as part of radical treatment for malignant pleural mesothelioma

Purpose of review To review the latest developments in surgery for malignant pleural mesothelioma both in patient selection, surgical technique, and strategy. Recent findings The International Association for the Study of Lung Cancer mesothelioma staging project has produced data to inform the 8th tumour node metastasis revision. The difficulty in clinical N staging and clinical T staging are highlighted and the importance of tumour volume is recognized. New imaging techniques can be utilized to assess tumour volume. The transition from extrapleural pneumonectomy to lung-sparing pleurectomy/decortication has extended the role of cancer-directed surgery into a more elderly population. More aggressive multimodality regimes, including induction radiotherapy are available to a selected population and adjuvant radiotherapy and chemotherapy are feasible in the elderly majority. Additional chemotherapy should not be delayed in those with poorer prognosis node positive, nonepithelioid disease. Summary Radical surgery for malignant pleural mesothelioma can achieve significant survival when targeted in those with the best prognosis by careful staging. It can be made more accessible by lung preservation without compromising outcome. It should be part of multimodality therapy.

Correction to Massive right hemothorax as the source of hemorrhagic shock after laparoscopic cholecystectomy - case report of a rare intraoperative complication [Patient Safety in Surgery 5 (2011) 12]

After publication of this work [1], it was noticed that first and second names of co-authors of the article were reported in the wrong order with the exception of the corresponding author. The correct author list is listed in this article. Competing interests The authors declare that they have no competing interests. Reference 1. Cristian, et al: Massive right hemothorax as the source of hemorrhagic shock after laparoscopic cholecystectomy – case report of a rare intraoperative complication. as the source of hemorrhagic shock after laparoscopic cholecystectomy-case report of a rare intraoperative complication.

Surgery in Small-Cell Lung Cancer: Past, Present and Future

Small-Cell Lung Carcinoma (SCLC) represents about 15% of all lung cancers diagnosed worldwide. Although its incidence is diminished in the last decades, SCLC continues to represent an almost fatal disease due to its propensity to local relapse and distant metastasis, despite initial responsiveness to therapies. Biological behaviour of SCLC has therefore lead to consider it as a systemic disease per se not amenable of surgical resection: the Veterans Administration Lung Study Group (VALSG) two-stage classification was in fact based on field irradiation criteria and has been applied to SCLC for long-time. The introduction of TNM staging system, the common recurrences of local disease despite initial complete response after chemo-radiation therapy, the lack of a valid maintenance therapy after remission or a second-line therapy after relapse renewed interest in surgery in a multimodal treatment setting. However, the second prospective randomized trial in 1994, did not confirm any significant advantage of surgery compared to chemo-radiation therapy and several retrospective studies published in the same years failed to provide strong evidences of surgerys benefits. Lack of homogeneity in design of clinical trials, which are mostly dated, patients selection and other confounding factors made results of metaanalysis too much inconsistent to be added to guidelines; for these reasons, nowadays, surgery is recommended only in small peripheral nodules without nodal involvement (proven by invasive preoperative staging). Advances in comprehension of biological pathways underlying carcinogenesis in SCLC are the next steps that could deeply modify the approach to disease (patients selection and prognostic stratification, chemosensitivity and treatment modality) beyond the mere histology. Molecular profile should lead to identify subsets of tumours with more favourable prognosis, especially in terms of systemic control of disease, which is actually a major issue in SCLC; these subsets could be overlapped to NSCLC regarding to natural history of disease, making their treatment similar, including indication to surgery. The aim of this review is to analyze literature to deduce which has been, is actually and could be the role of surgery on overall survival and pattern of recurrence of patients affected by SCLC.

Short and Long Term Results of Major Lung Resections in Very Elderly People

Consequently, a growing number of very elderly people, aged 80 or more, are presenting with a resectable lung tumour. The increased prevalence of cardiovascular and pulmonary comorbidity and consequently poor performance status often make patients unfit to surgery, which remains the treatment of choice for early stages Non-Small Cell Lung Cancer (NSCLC) [1, 2]. Increasing age is often associated with lower likelihood of treatment and more liberal use of radiation therapy than of surgery [3].