U. Cioffi

Synchronous isolated splenic metastasis from colon carcinoma.

&NA; We report the first case known to us of a synchronous isolated splenic metastasis from colon carcinoma in a 52‐year‐old woman operated on splenectomy, left colectomy, and ileal resection. The patient died of diffuse carcinomatosis 1 year after the operation. Splenectomy for isolated splenic metastasis from colon carcinoma is justified, and serum tumor markers are useful to detect metastases early during the follow‐up, as in our report.

Thermal ablation in the treatment of lung cancer: present and future.

Surgery is considered the best choice for stage I non-small cell lung cancer and also in treatment of selected patients with lung metastasis. However, surgery is often a high-risk procedure because of severe medical comorbidities affecting this cohort of patients. Thermal ablation (TA) has recently been proposed to achieve destruction of lung tumours whilst avoiding the use of general anaesthesia, thereby limiting the invasiveness of the procedure. For pulmonary malignancies, there are two methods of TA based on tissue heating: radio frequency ablation (RFA) and microwave ablation (MWA). Both are mini-invasive procedures, delivering energy to the tumour through single or multiple percutaneous needles introduced under guidance of computed tomography. The procedure may be performed under conscious sedation or general anaesthesia to avoid pain caused by needle insertion and tissue heating. Local efficacy is directly correlated to tumour target size: for RFA, tumours smaller than 2 cm can be completed ablated in 78-96% of cases; for MWA-according to the largest available study-95% of initial ablations are reported to be successful for tumours smaller than 5 cm. Very few series provide survival data beyond 3 years. For nodules smaller than 3 cm, the registered survival rate is higher: 50% at five years. The data collected in the last 10 years allow us to conclude that TA is an established alternative treatment for patients who cannot undergo surgery because of their compromised general condition. In the case of pulmonary metastasis, most authors agree to offer TA only if lesions are smaller than 5 cm.

Ultrasonographic evaluation of the cervical lymph nodes in preoperative staging of esophageal neoplasms

Abstract.Background: The detection of cervical lymph node metastases plays an important role in staging of patients affected by esophageal cancer to perform the best therapeutic approach.n Methods: We report our experience concerning the ultrasound evaluation of the cervical area in 174 patients with esophageal cancer. Ultrasonographic evaluation of the neck can be done with a 7.5- or 10 MHz transducer in all cases, with selective scanning of the lymph node chains of the internal jugular veins and supraclavicular regions. The short-to-long axis ratio (S/L) was a useful way to detect lymph node metastasis. Histopathologic diagnoses were obtained by sonographically guided fine-needle aspiration biopsy.n Results: At ultrasound examination, we found 18 (10.3%) patients with metastatic cervical nodes. Of these, 17 (94.4%) had metastatic cervical lymph nodes confirmed by cytology from fine-needle biopsy. Lymph node exceeding 5 mm in long axis and with an S/L over 0.5 showed a higher incidence of metastasis than those with an S/L under 0.5. Our experience shows a high incidence of lymph node metastases in patients with esophageal cancer localized to the thoracic supracarinal tract and in patients with cervical and lower esophageal cancer.n Conclusion: In the ultrasound evaluation of nodes, the most useful parameters are size of nodes, heterogeneity of internal echoes, morphology of the margins, and the deformation caused by compressive instrumental manipulation. These criteria, indicated by the Japanese Society for Esophageal Diseases, yield a high sensitivity and diagnostic specificity when the ultrasonographic studies are performed.

Ground glass opacity and T-factor in staging lung adenocarcinoma.

We have read with interest the paper by Murakawa et al. [1] about the role of ground glass opacity (GGO) on T-factor assessment of lung adenocarcinoma. According to the seventh edition of the TNM classification of the Union for International Cancer Control, the measurement of the diameter of the tumour must include GGO [2]. The GGO component of an adenocarcinoma reflects a non-invasive carcinoma in situ [3] and, including that component, the measurement of the T-factor could be overestimated. To investigate this hypothesis, the authors evaluated the effect of the GGO component of adenocarcinoma on the survival of patients T1–2, N0, M0. The data, supported by four different types of statistical analysis, showed that the recurrence-free survival was dependent on the solid component of the tumour, and that the GGO component has no impact on prognosis. They concluded by suggesting that the T-factor must be measured only on the solid component of the tumour, changing the current TNM classification. We must congratulate the authors for the idea, the complexity of the study and the accurate statistical analysis. However, some criticism can also be presented. The study includes, in the same group, T1–T2 patients (they have a different prognosis), and they are never divided when studying the GGO and solid component. Was the GGO component equally distributed between T1 and T2 tumours? It would be interesting as well, to have some information on the grading of the tumours that also have an impact on survival. The authors assert that the fluorodeoxyglucose-positron emission tomography (FDG-PET) scan was not considered because it was not available for all patients. However, nowadays, we cannot exclude FDG-PET scan results in evaluating lung cancer patients [4, 5] and, in this particular study, we are very curious about the uptake eventually present in GGO and its effect on patient survival. Lastly, it is not reported how the M parameter was studied before surgery, whether all patients were staged in the same way, and whether bone scan and brain evaluation were included. The TNM classification is the more diffuse and accepted staging system of lung cancer, and is commonly used to suggest therapies, compare patient data and make a prognosis. It is also well known that this staging system is not totally affordable. We must keep in mind that patients with very early stage lung cancer can survive for only a few months, while patients with advanced stage lung cancer survive for years despite their dramatic prognosis. This mainly means that lung cancer is a complex entity with a different biological behaviour, and many relevant factors are still unknown. TNM is currently the best way to stage lung cancer patients, but the clinical experience shows that it is not perfect. Any suggestion for improving TNM staging, such as that of Murakawa et al. is therefore welcome, but must be introduced only after a deeper evaluation.

Micrometastasis and skip metastasis as predictive factors in non-small-cell lung cancer staging

We have read with interest the article by Anami et al. [1], which focused on skip micrometastasis in left lung cancer. The authors report their retrospective experience with 19 patients who underwent bilateral thoracoscopic mediastinal nodal dissection (BMD) compared with 25 unilateral dissection (UMD). Considering that the unsatisfactory survival observed in Stage I, left-sided, non-small-cell lung cancer (NSCLC) is most likely related to a higher incidence of occult controlateral nodal involvement (N3), many authors have suggested complete clinical staging with right nodal biopsies. We routinely sample right paratracheal nodes in left upper NSCLC with mediastinoscopy since this allows us to turn the patient just once intraoperatively, avoiding the need for bilateral chest tubes. However, we congratulate the authors because there were no significant differences between the groups regardless of the bilateral approach used. The authors have reported on two topics already separately investigated, namely micrometastases and skip metastases, although uniquely focusing on the selective population with both N3 skip nodal involvement and micrometastases. We would like to highlight some points concerning their findings. First, only 1 of the 19 patients was upstaged at pathological examination, but molecular studies revealed that 11 of the 19 were affected by micrometastases, determining a further upstaging. The possibility of controlateral nodal involvement has been already demonstrated, with an incidence of 21–44%, concurring with the 8 of 19 cases. However, it is remarkable that in 7, there were skip micrometastases. This suggests that controlateral nodal involvement is rarely predicted by pN1/N2 and that its evaluation based on routine pathological investigation may lead to downstaging. Consequently, controlateral nodal biopsies should always be performed, and in particular molecular studies encouraged, leading to the result that bilateral surgical staging and resection should always be done at two different times. The other topic is the relevance of N3 skip metastasis to prognosis. There are contrasting opinions on the significance of N2 skip metastases on survival and no data on N3 skip micrometastases. However, it has been reported that patients staged as pN0/N1 with micrometastases have the same survival as pN2 [2, 3] and that micrometastases strongly correlate with prognosis [4]. Patients with BMD had better overall and disease-free survival than UMD, although not statistically significant. Nevertheless, patients with skip N3 micrometastases are all alive without disease recurrence, while 5 of 25 UMD died due to cancer relapse (pTNM of this last group is not reported). This suggests that BMD correlates with a better survival and that N3 skip micrometastases do not contraindicate surgery. Unfortunately, the authors did not report if N3 skip micrometastases involved one or multiple nodes [5] and if patients underwent adjuvant chemotherapy. These limitations and the small population of the study do not allow for conclusions to be drawn, however, their data encourage better investigation of some topics. Does N3 skip micrometastases detection guarantee a more efficient preoperative prognostic staging? Does an N3 micrometastatic finding contraindicate surgery or should nodal dissection be considered therapeutic? We congratulate the authors for this interesting paper giving the cue for further studies.

The oncological value of video-assisted thoracoscopic lobectomy for early-stage non-small cell lung cancer

Department of Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy* Corresponding author. Department of Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milan, Italy.Tel: +39-02-55035568; fax: +39-02-55034165; e-mail: ugo.cioffi@policlinico.mi.it (U. Cioffi).Received 22 January 2013; accepted 11 March 2013

Is video-assisted thoracic lobectomy safe and successful for locally advanced non–small cell lung cancer?

had sudden syncope. Neurologic examination showed paraplegia and weakness of the right hand. Computed tomography showed the presence of type A aortic dissection with supraaortic arch branch dissection. The left common carotid artery was occluded by the compression of thrombosed false lumen. Furthermore, infrarenal abdominal aorta was also occluded through compression by thrombosed false lumen. This patient underwent emergency total arch replacement and elephant trunk insertion under hypothermic circulatory arrest and selective cerebral perfusion. Five hours after surgery, the patient was extubated with a stable circulation; however, he reported right-sided weakness. Emergency computed tomography revealed that the left common carotid artery was still occluded and compressed by the false lumen as previously. The right

Video-assisted thoracic surgery is effective in systemic lymph node dissection

We read with interest the study by Palade et al. [1]. Their objective was to evaluate the possibility of achieving a nodal dissection by video-assisted surgery (VATS) as effectively as by open surgery. The background of the study is based on the European Society of Thoracic Surgeons 2006 guidelines [2] that recommend intraoperative systemic lymph node dissection for every surgically treated non-small-cell lung cancer (NSCLC). We agree with these indications, which are accepted by most authors; however, some others have recently reported interesting data supporting the possibility of performing a less-invasive nodal sampling in early-stage cases. Zhang et al. [3] have reported that, in T1aN0M0 patients, the number of nodal stations dissected and Station 7 dissection were both not statistically significant factors in determining prognosis. Moreover, Tsutani et al. [4] have reported the experience of a multicentre database showing that tumour size <0.8 cm and SUVmax <1.5 were significant predictive criteria of negative nodes, and concluded that in these cases, systemic lymphadenectomy for clinical Stage IA lung adenocarcinoma may be avoided, even in cases of T1b (2–3 cm) tumours. A question for the future is whether the necessity of a systemic lymph node dissection in early-stage NSCLC may become a topic for discussion again. Concerning the results of the authors, it should be underlined that both the number of the overall nodes and of those of each zone removed were equivalent in VATS and open procedures. It is also very remarkable that postoperative outcomes were significantly in favour of VATS. These results are consistent with data related to the oncological efficacy of VATS lobectomy compared with open lobectomy [5] and encourage a further increase in the procedures performed. Among the variables considered by the authors, only the mean intraoperative time was in favour of open surgery, with an advantage of half an hour. This was probably due to the difficult exposure of some anatomical regions like the subcarinal one. Palade’s study confirms our opinion on thoracoscopic lymphadenectomy. According to our experience, we think that, except for 4L, every nodal station can be reached and dissected by a thoracoscopic approach. Therefore, we assume that the efficacy of this technique is mostly related to the operating surgeon. Since the lack due to the learning curve in thoracoscopic surgery can be easily managed with an accurate training, it does not represent an absolute contraindication to VATS lymphadenectomy. Moreover, VATS may proffer many advantages in the hands of a surgeon skilled in thoracoscopy; the most interesting being that the camera presents an excellent visualization of the anatomical structures once correctly exposed. Concerning surgical technique, we agree with the authors who suggest the use of the harmonic scalpel, since this instrument was safe and successful in avoiding bleeding and lymphatic loss in our experience also. We conclude by congratulating Palade et al. on their prospective randomized trial.

Pneumomediastinum after a swimming race and dental extraction

A 16-year-old male competitive swimmer presented with dyspnea, chest pain, and right neck crepitus after a race. He had undergone an uncomplicated lower right third molar tooth extraction 2 days earlier. He had no known allergies. On examination, he was alert, wellperfused, and afebrile. The peritoneal signs were negative. A chest radiograph showed subcutaneous emphysema with pneumomediastinum. Computed tomography showed submandibular, neck, and mediastinal emphysema (Figure 1). Conservative therapy based on observation and prophylactic parenteral administration of antibiotics (clindamycin 450mg every 6 h and ceftriaxone 2 g daily for 10 days) was successfully adopted, and he was discharged after 3 days.

What Is the Best Treatment for Catamenial Pneumothorax

We read with interest the article by Seok and Lee1 presenting the case of a left-sided catamenial pneumothorax (CP) associated with diaphragmatic fenestrations. CP is considered a rare disease, but, as reported in a recent review, its incidence amounts to 25% of spontaneous pneumothorax in surgically treated women.2 It is more frequently located on the right side because, supposing that endometrial cells reach the thorax from the peritoneal space, the transportation occurs by a preferential clockwise peritoneal fluid current from the pelvis along the right paracolic gutter up to the subphrenic space. Cellswould implantmore easily on the right diaphragmatic leaf as they are stuck there by the falciform ligament3 and “piston effect” exerted by the liver,4whereas the soft and compressible viscera of the left upper quadrant cannot exert such activity. Despite the fact that CP has been known for five decades, its cause has not been defined. Thoracic endometriosis is frequently indicated as an implicated factor; however, the pathogenesis and mechanism that lead from thoracic endometriosis to pneumothorax are still unclear. In our surgical experience with CP, we have found patients with different abnormal findings. In fact, we treated patients with endometrial foci on parietal and diaphragmatic pleura without fenestrations on diaphragm, patients with fenestrations but without any pleural endometrial foci, and patients with pleural blebs. These findings suggest that there are different kinds of CP related to different and sometimes concomitant etiologies.5 Therefore, we agree with Seok and Lee1 about the thesis of a multifactorial model. Concerning CP treatment, the authors performed only surgical resection of the abnormal diaphragmatic lesions and excluded medical treatments because no endometrial fociwere found on the diaphragm. However, this could be due to surgery not performed during menses. In our opinion, surgical treatment should comprise, assessing each time, blebs resection and/or diaphragmatic repair and/or endometrial foci coagulation, depending on the abnormal findings at thoracoscopy. However, we think that, regardless of thoracoscopic findings, mechanical pleurodesis should always be performed because pleurodesis is the most important factor to avoid pneumothorax relapse. We also think that medical treatment with gonadotropinreleasing hormone agonist should always be administered for 6 months after surgery, despite its temporary collateral effects.2 This strategy allows to control endometriosis and reduces the risk of a new pneumothorax until pleurodesis is obtained. Summarizing, in case of CP we prefer to combine surgical and medical treatment. We always perform thoracoscopic pleurodesis associated with the repair of every diaphragmatic, pleural, or parenchymal abnormal findings. Then, a temporary hormonal treatment is undertaken to achieve an effective pleurodesis.