Silvia Ceccarelli

Mediastinitis and sternal prosthesis infection successfully treated by minimally invasive omental flap transposition.

Purulent mediastinitis is a possible serious complication after mediastinal surgery. We report the case of a localized sternal plasmocytoma treated by sternectomy and prosthetic repair, who needed a second surgery for a fistulizing mediastinitis. Five months earlier, in another Hospital, the patient underwent sternal resection and reconstruction with a “sandwich” prosthesis (Methyl-methacrylate and Marlex mesh). Suppurative mediastinitis occurred and septic shock resolution was observed after the spontaneous opening of a mediastinal cutaneous fistula. After referring to our Unit the patient underwent extensive local and systemic preparation and nutritional support; the infected prosthesis was then removed and the gap filled by a laparoscopically-prepared omental flap. Adequate preoperative management, removal of any infected material and minimally invasive omental flap transposition allowed the successful treatment of this life-threatening condition.

Malignant Giant Solitary Fibrous Tumor of the Pleura Metastatic to the Thyroid Gland

Purpose Solitary fibrous tumor (SFT) of the pleura is a rare mesenchymal neoplasm arising from mesenchymal cells in the areolar tissue subjacent to the mesothelial-lined pleura and accounting for less than 5% of primary pleural tumors. SFTs are generally benign and asymptomatic, with 10-year survival rates of up to 98%. Unfortunately, approximately 10% have malignant potential, leading to local recurrence after radical surgery and/or metastatic spread. Of note, giant pleural SFT, which consists of a tumor occupying at least 40% of the affected hemithorax, is even less common with only anecdotal cases reported in the medical literature. Methods We describe a unique case of giant SFT of the pleura that metastasized to the thyroid gland 1 year after complete resection, focusing on its clinical and pathological features of presentation. Results En bloc resection remains the mainstay of therapy with curative intent. Patients with large tumors may undergo preoperative angiography with percutaneous embolization of the tumor, which allows to reduce perioperative bleeding. In case of local recurrence, surgery still remains the best treatment option. However, surgery can also be considered in patients with isolated metastatic spread. Conclusions Every suspected and proven SFT of the pleura should undergo surgical resection, as clinical and radiological criteria cannot accurately distinguish benign from malignant forms. Moreover, the peculiar histological features of SFT should not be neglected when planning clinicoradiological follow-up. Additionally, suspicious clinical findings during follow-up should always be thoroughly investigated in order to exclude or confirm the diagnosis of recurrent disease.

The association between the use of powered staplers and the decreased postoperative complications following VATS lobectomy

In the May 2018 issue of Adv Ther , Miller et al. (1), reported on the influence of powered and tissue specific endoscopic stapling technology on clinical and economic results of VATS lobectomy procedures. This was a real world, non-randomized study, based on data extracted from the Premier Healthcare Database.

Thoracotomy versus VATS: short term outcomes from a large randomized controlled trial

In the February 2018 issue of Annals of Thoracic Surgery, the results of the “Thoracoscopic Surgery Versus Thoracotomy For Lung Cancer: Short Term Outcomes Of A Randomized Trial” by Hao Long et al . were published (1). The aim of this non-inferiority, phase 3, multicenter randomized controlled trial both for short-term and oncologic outcome, was “to confirm that VATS lobectomy is non-inferior to open surgery for the treatment of early-stage NSCLC”. The results of this study merit the attention of thoracic surgeons for several reasons.

Could thymomectomy be a reasonable option for non-myasthenic thymoma patients?

Background Complete resection is the mainstay of treatment for thymoma, but few studies have investigated the extent of resection on normal thymus. Extended thymectomy is considered the treatment of choice for myasthenic patients with thymoma, while the optimal therapy for non-myasthenic patients is still a matter of debate. The aim of this retrospective study was to compare extended thymectomy vs. thymomectomy in non-myasthenic thymoma patients for (I) oncological outcome, (II) multicentric thymoma occurrence and (III) postoperative myasthenia gravis (MG) development. Methods A retrospective comparative study was conducted on 92 non-myasthenic patients with completely resected thymoma, according to the extent of resection: extended thymectomy (70 patients) vs. R0-mediastinal thymomectomy (22 patients). Clinical and pathological characteristics, oncological outcome and postoperative MG occurrence were compared between the two study groups. Results We did not observe any significant differences in gender, age, symptomology, preoperative chemotherapy, histology, tumour size, adjuvant therapy or complications. There were no recorded postoperative mortalities. Stage distribution was different between the two groups: similar percentages of early stage thymoma for both groups were present, but there was a prevalence of stage III for extended thymectomy and stage IV for thymomectomy (P<0.01). At a median follow-up of 77.4 months (range 1-255 months), no statistically significant differences were recorded in local recurrence (P=0.396), thymoma related deaths (P=0.504), multicentric thymoma occurrence (P=0.742) and postoperative MG development (P=0.343). A high preoperative anti-acetylcholine receptor antibodies (ARAb) serum titer assay was statistically correlated with postoperative MG occurrence (r=0.49, P<0.05). Conclusions Thymomectomy appears to be a valid treatment option for non-myasthenic thymoma patients, as this procedure was associated to the same 5-year oncological results, compared to extended thymectomy, for both stage I-II small thymomas and patients with giant unilateral masses, as well as advanced diseases. Moreover, thymomectomy was not associated to an increased rate of postoperative MG.