Tommaso Claudio Mineo

Solitary secretory plasmacytoma of the lung in a 14‐year‐old boy

A case of solitary plasmacytoma of the lung in a 14‐year‐old boy is reported. The diagnosis was made after a lobectomy was performed for the presence of a mass in the right lung. Two aspects of this case are of particular interest: the young age of the patient and the disappearance after 2 months of the M‐protein of the IgG‐k type which was present in the serum.

PHA and ConA lymphocyte response in normal, hyperplastic and neoplastic human thymus: Morphologic and functional correlations

In the present work the in vitro response to PHA and ConA was determined for thymus lymphocytes from normal, hyperplastic, and neoplastic conditions as well as for peripheral blood lymphocytes from normal control donors. Our investigation has revealed these results: (1) lymphocytes from normal thymus are less responsive to both mitogens than lymphocytes from peripheral blood and abnormal thymus. (2) Lymphocytes from thymic benign lymphoid hyperplasia show an increased response only to PHA regardless of the extent of hyperplasia. (3) Lymphocytes from thymic neoplasia display an increased response to both mitogens regardless of the histologic pattern of the tumor studied. (4) Thymic lymphocytes from patients with myasthenia gravis have a mitogenic response higher than that from thymic lymphocytes from nonmyasthenic subjects. (5) In patients with myasthenia gravis, lymphocytes from neoplastic thymus show a response to PHA higher than that observed for lymphocytes from hyperplastic thymus. It seems clear that two conditions maximally enhance mitogenic response of thymus lymphocytes: thymomas and myasthenia.

Awake thoracoscopic treatment of spontaneous pneumothorax

Spontaneous Pneumothorax (SP) is a relatively common condition defined as the presence of air in the pleural space associated with lung collapse. On an etiologic basis, pneumothorax is classified as spontaneous, traumatic and iatrogenic. The term spontaneous indicates that no mechanical injury is recognized as the causative mechanism whereas secondary SP occurs as an acute complication of an underlying lung disease. The principal goal of treatment is to evacuate air from the pleural space and achieve lung reexpansion. Simple chest drainage is often employed as first line treatment, whereas bullectomy performed by Video-Assisted Thoracic Surgery (VATS) is widely adopted for treatment of recurrent SP. Pleurodesis by pleurectomy or talc insufflation is also commonly associated to bullectomy to reduce risks of recurrence. VATS is usually carried out through general anesthesia and one lung ventilation, although use of this type of anesthesia can be associated with several adverse effects. Recently, VATS management of SP has been performed with satisfactory results by local anesthesia in spontaneously ventilating patients. In particular, we have began a clinical investigational program entailing VATS bullectomy and pleurectomy performed through sole Thoracic Epidural Anesthesia (TEA) in fully awake patients. In this chapter we describe technical features and results of this novel surgical approach.

Awake Non-Resectional Lung Volume Reduction Surgery

Lung Volume Reduction Surgery (LVRS) is now a well established procedure, which can considerably improve dyspnea, pulmonary function, exercise capacity, quality of life and survival in selected patients with severe emphysema, particularly when the upper lung lobes are predominantly involved. The standard operation entails unilateral or bilateral, staple non-anatomical resection of the most emphysematous lung tissue, carried out by median sternotomy or thoracoscopic approaches through general anesthesia and single-lung ventilation (resectional LVRS). Operative mortality and morbidity of resectional LVRS have been higher than those observed following the majority of other thoracic surgery procedures. It seems reasonable to assume that, in anatomically and physiologically fragile subjects such as candidates to LVRS, determinants of operative mortality and morbidity may include not only the surgical trauma deriving from resection of emphysematous lung tissue, but also general anesthesia. We have developed a non-resectional LVRS method that can be carried out through sole thoracic epidural anesthesia in fully awake patients. This technique has proved to offer lower morbidity and clinical benefits that paralleled those of resectional LVRS.

A curious rarity of the thymus gland: the microscopic thymoma

In 1976, Rosai & Levine (1) opened a novel and interesting niche in the variegated field of the morphology of thymus gland in myasthenia gravis (MG). These authors firstly described a microscopic lesion having the histological features of a thymoma, occasionally observed in thymus gland removed during cardiac operations.

Value of nonintubated thoracoscopic biopsy for mediastinal masses

Background: The development and success of the nonintubated anesthesia video-assisted thoracoscopic surgery (VATS) biopsy has progressively replaced cervical mediastinoscopy, anterior mediastinotomy, and computed tomography (CT)-guided needle biopsy in the diagnosis of mediastinal masses. In this paper we have evaluated the value of this approach comparing traditional multiportal VATS in thoracic epidural anesthesia with the more recent uniportal approach under intercostal bloc. n Methods: Since October 2001 to August 2017, 213 consecutive patients underwent nonintubated biopsies of mediastinal masses. Until July 2006, the approach was multiportal in thoracic epidural anesthesia (n=68) and afterwards uniportal under intercostals bloc (n=145). Positron emission tomography (PET) was routinely performed since 2006 and allowed targeted biopsies. n Results: We had no perioperative mortality. Complication rate was lower, yet not significantly, in uniportal group (17.6% vs. 15.3%). Uniportal VATS required significantly shorter in-operatory room stay, operative time and recovery room stay with lesser economical costs. Furthermore, the approach was significantly less painful at 7 days with a better patient acceptance score at one month. One-hundred and seven patients were managed under outpatient regimen. Seventeen patients had a redo VATS biopsy. Diagnostic accuracy was improved by the use of PET. n Conclusions: Nonintubated VATS biopsy proved safe and reliable. Uniportal approach under intercostal bloc allowed shortening the operatory room utilization, reducing chronic postoperative pain and morbidity, permitting the majority of the operation to be accomplished in outpatient regimen thus ultimately reducing the economical costs.

Awake thoracoscopic sympathectomy

Video-Assisted Thoracic Surgery (VATS) sympathectomy is a safe and effective procedure for treatment of facial, palmar and axillary hyperhidrosis. It can be more rarely used in other conditions. Awake thoracic surgery with epidural anesthesia and spontaneous ventilation has been employed to perform many surgical procedures including VATS sympathectomy. This chapter describes the anatomy of the nerve with the most frequent abnormalities, the indications and contraindication for both sympathectomy and awake surgery, the method for awake anesthesia, a detailed step-by-step description of the surgical technique and postoperative management as well as an analysis of benefits and potential side-effects of awake VATS sympathectomy. Patient selection, choice of the level of sympathectomy and adequate information about anesthesia and side effects of the operation are extremely important for the good result of the procedure. Awake VATS sympathectomy may be considered a globally minimally invasive approach combining avoidance of general anesthesia-related adverse effects with maximum patient satisfaction.

Awake resection of solitary pulmonary nodules

The term Solitary Pulmonary Nodule (SPN) refers to a newly developed lung nodular lesion of unknown origin and up to 3 cm in diameter, which is completely surrounded by normal parenchyma without atelectasis or adenopathy. Video-Assisted Thoracic Surgery (VATS) has been increasingly advocated as an ideal approach for management of peripheral SPN due the satisfactory results and negligible morbidity rates reported with this minimal invasive surgical option. General anesthesia with one-lung ventilation has been considered mandatory to accomplish a safe operation by VATS. However, this type of anesthesia should not be considered strictly necessary to accomplish simple pulmonary resection and can be associated with several adverse effects that can increase the procedure-related morbidity with a potential negative impact on hospital stay and overall costs. We have employed VATS performed through sole thoracic epidural anesthesia in awake patients to resect undetermined lung nodules, solitary metastases and non-small-cell lung cancer in high-risk patients. Early results have been encouraging although the pros and cons of awake VATS pulmonary resections still need to be fully elucidated.

Awake Thoracoscopic Biopsy of Anterior Mediastinal Masses

Anterior mediastinal masses can develop due to a number of conditions, most of which require prompt pathologic diagnosis to initiate appropriate treatment. Diagnosis can be achieved by surgical and non-surgical methods but Video-Assisted Thoracic Surgery (VATS) through general anesthesia is frequently preferred due to its minimal invasiveness and optimal diagnostic yield. One limitation of VATS includes the need for general anesthesia and one-lung ventilation, which can induce life-threatening adverse effects, particularly in patients with bulky masses In order to reduce general anesthesia-related operative risks, we employed a VATS biopsy approach performed by just thoracic epidural or local anesthesia in fully awake, spontaneously ventilating patients. This surgical method allows a wide visual control of mediastinal compartments, an accurate assessment of the disease extension and achievement of multiple biopsy specimens from different sites of the mass, eventually resulting in excellent diagnostic yield. In addition, adequate surgical management of associated intrathoracic conditions including drainage of pleural-pericardial effusions or pleuralpulmonary biopsy is possible when necessary. We believe that this novel and globally less invasive surgical option might thus be included within the framework of the most reliable methods currently available to achieve a rapid diagnosis and adequate surgical management in patients with undetermined anterior mediastinal masses.

Video-Assisted Thoracoscopic Access to the Mediastinum

Video-assisted Thoracic Surgery (VATS) is now routinely employed as a reliable diagnostic method for undetermined mediastinal masses and lymphadenopathy. It can also prove useful for lung and esophageal cancer staging due to the possibility of a comprehensive assessment of the pleural cavity, lung and mediastinum. Therapeutic VATS has been successfully applied to thymectomy, excision of small encapsulated anterior mediastinal tumours and posterior neurogenic tumours, management of benign esophageal conditions, pericardiectomy and pericardioscopy. Furthermore, VATS has also been employed in combination with laparotomy and cervicotomy to perform esophagectomy for esophageal cancer.