Vittorio Aprile

Long-term results of percutaneous radiofrequency ablation of pulmonary metastases: a single institution experience

OBJECTIVES Surgical resection of pulmonary metastases is considered as a therapeutic procedure in selected cases. However, many patients are unable to tolerate surgical intervention due to comorbidities and/or poor pulmonary reserve, also related to repeated parenchymal resections. Considering this scenario, we decided to investigate the role of radiofrequency ablation (RFA). METHODS The outcomes of all patients that underwent RFA for lung metastases, during the period 2003-2013, were analysed. The primary end-points were overall survival (OS) and local progression-free survival (LPFS). Secondary end-point was the analysis of possible risk factors affecting OS and LPFS. RESULTS Ninety-nine RFAs were performed on 61 patients (38 men, 23 women, median age of 74 years). Fourteen patients were treated for two or more lesions, for a total of 86 lesions. Twelve lesions were treated up to three times. The median lesion diameter was 2 cm. The majority of patients were affected by lung metastases from colorectal cancer (47.5%). All procedures were successfully completed. One death occurred, whereas the morbidity rate was 11% (8% pneumothorax requiring chest drainage). At a median follow-up of 28 months, the 1-, 3-, 5-year OS (LPFS) rates were 94.8% (86.3%), 49.0% (70.3%) and 44.5% (68.3%), respectively. No significant correlation was found, using univariate and multivariate analysis, between OS and age, gender, histology of primary cancer (colon versus others), type of approach (computed tomography versus ultrasonography guidance), number of treated lesions (1 vs >1), disease-free interval (from primary tumour to first lung metastases) (1-35 vs >35 months), previous lung resections (yes versus no), whereas a tendency towards better OS was observed, by applying univariate analysis, for a lesion of <3 cm (P = 0.051) and for the presence of local disease 1 month after treatment (P = 0.056), however, without a statistically significant difference. With regard to LPFS, lesion dimensions (P = 0.005) and the presence of local disease 1 month after treatment (P < 0.001) were found to be significant risk factors, in both univariate and multivariate analyses. CONCLUSIONS RFA appears as a feasible and safe procedure, with an acceptable morbidity, offering the possibility to safely repeat the treatment on the same lesion. RFA can be considered a valid option for the local control of lung metastases, in patients not eligible for surgery, especially those with lesions smaller than 3 cm.

Diaphragm and lung–preserving surgery with hyperthermic chemotherapy for malignant pleural mesothelioma: A 10-year experience

Background: The best surgical treatment for malignant pleural mesothelioma is still under a debate, but recent evidence points toward a less‐invasive approach to reduce morbidity and mortality. We reported our 10‐year experience of a limited surgical approach associated with hyperthermic intrathoracic chemotherapy (HITHOC). Material and Methods: Between 2005 and 2014, patients with epithelioid or biphasic malignant pleural mesothelioma were treated with lung–diaphragm–pericardium‐sparing pleurectomy associated with double‐drug HITHOC; at least 3 cycles of adjuvant chemotherapy were then administered. The primary outcome examined was the feasibility of the procedure, whereas secondary outcomes were overall survival and disease‐free interval. Results: Among 49 patients, 41 were male. Median age was 68 years (35‐76 years). Histology was epithelioid in 43 cases. Pathologic stage I, II, III, and IV occurred in 12, 14, 20, and 3 cases, respectively. No intraoperative complications or postoperative mortality occurred, whereas morbidity rate was 46.9%. Median hospital stay was 8 days (5‐45 days). Actuarial median overall survival was 22 months and a 1‐, 2‐, and 5‐year survival accounted for 79.6%, 45.7%, and 9.9%, respectively. Disease‐free survival after surgery was 62%, 37.5%, and 18.5% at 1, 2, and 5 years, respectively. Risk factors analysis for overall survival confirmed a significant role for early stages, epithelioid histology, and fibrinogen serum levels. Conclusions: Cytoreductive surgery associated with HITHOC and adjuvant chemotherapy appears feasible and safe, with no mortality and low morbidity. Preserving lung and diaphragmatic function might warrant an acceptable long‐term outcome.

The role of intracavitary therapies in the treatment of malignant pleural mesothelioma

Surgery is one of the steps of multimodality approach for the treatment of MPM. Due to anatomical features, microscopically radical (R0) resection is never possible and a Macroscopic Complete Resection (R1) is considered the target for mesothelioma surgeons. Recently, intracavitary therapies have been described with the aim of extending the loco-regional effect of surgery. Different agents might be administered intrapleurally: chemotherapy drugs are the most widely used, but also photodynamic therapy (PDT) showed to lead to satisfactory long-term outcomes; furthermore, immunotherapies and gene therapies have been also reported. Despite promising results, no high-quality evidences are currently available and controlled randomized trials are required to establish the exact role of intracavitary therapies and to standardize the technique.

Single lymph node metastasis 10 years after radical resection of a thymoma

From the Thoracic Surgery, and Pathological Anatomy, Department of Surgical, Medical andMolecular Pathology and Critical Area, University of Pisa, Pisa, Italy. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Nov 28, 2016; revisions received Feb 8, 2017; accepted for publication March 5, 2017; available ahead of print April 12, 2017. Address for reprints: Pietro Bertoglio, MD, U.O. Chirurgia Toracica, via paradisa 2, edificio 10, Ospedale Cisanello, 56124 Pisa (PI), Italy (E-mail: pietro.bertoglio@gmail.com). J Thorac Cardiovasc Surg 2017;154:e11-3 0022-5223/

Nodal upstaging evaluation in NSCLC patients treated by robotic lobectomy

36.00 Copyright 2017 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2017.03.036 Pietro Bertoglio, MD

Is left upper lobectomy always worthwhile for early stage lung cancer? A comparison between left upper lobectomy, trisegmentectomy, and lingulectomy

BackgroundOpen pulmonary resection is considered the gold standard treatment of early-stage non-small cell lung cancer (NSCLC). However, in the last decades, the use of minimal-invasive techniques has given promising results. Survival in lung cancer, after surgery, depends on the number of pathological nodes (pN), thus lymph nodal upstaging can be considered a surrogate for surgical quality of the procedure. Several studies have demonstrated a lower rate of upstaging in video-assisted thoracic surgery than in open surgery, suggesting an approach-related difference in lymphadenectomy. Features of robotic technique could consent a lymph nodal dissection similar to open surgery. The aim of the study is to compare nodal upstaging between thoracotomy and robotic approaches to evaluate the oncologic radicality.MethodsBetween January 2013 and December 2016, 212 consecutive cN0 NSCLC patients underwent lobectomy and lymphadenectomy (N1 + N2 stations) by either thoracotomy (Open Group) or robotic surgery (Robotic Group).ResultsLobectomy and lymphadenectomy were performed in 106 cN0–cN1 NSCLC patients by robotic surgery and in 106 cN0–cN1 NSCLC patients by open surgery. A mean of 14.42 ± 6.99 lymph nodes was removed in the Robotic Group (RG) and a mean of 14.32 ± 7.34 nodes in the Open Group (OG). Nodal upstaging was observed in 22 (20.75%) RG patients and in 19 OG (17.92%) patients.ConclusionsRobotic lobectomy for clinical N0–N1 NSCLC appears to be equivalent to thoracotomy in terms of efficacy of lymph node dissection and nodal upstaging. Given that the nodal upstaging is a surrogate of quality of surgery, we can consider robotic lobectomy an appropriate procedure which ensures similar result to the open approach.

N2 lung cancer is not all the same: an analysis of different prognostic groups†

Lobectomy is the gold standard treatment for resectable Non‐Small Cell Lung Cancer (NSCLC). We compared oncological outcomes of patients undergoing a “multi‐segmentectomy” (trisegmentectomy or lingulectomy) and left upper lobectomy for early stage (T1‐2, N0) NSCLC of the left upper lobe.

Recurrent Spontaneous Pneumothorax Hiding a Rare Pulmonary Tumor in a 4-Year-Old Girl

OBJECTIVES The International Association for the Study of Lung Cancer (IASLC) recently proposed a change in the staging system for N2, based on the metastatic station number: N2a1 (a single metastatic station with no hilar involvement), N2a2 (a single metastatic station with hilar involvement) and N2b (multiple metastatic stations). The aim of our study was to validate the IASLC proposal in a cohort of patients with pathological N2 disease. METHODS All patients with pathological T1-T2 N2 non-small-cell lung cancer who were operated on between 2006 and 2010 in our department were enrolled. The patients had lobectomy, bilobectomy or pneumonectomy without induction therapy; patients with any type of extended resection were excluded. All patients had adjuvant treatment. The impact of the new IASLC proposal on the overall and disease-free survival rates was then analysed. RESULTS Ninety-three patients were selected. The median follow-up period and overall survival time were 92 and 28.8 months, respectively. According to the new IASLC proposal, we observed 22 cases of N2a1, 54 N2a2 and 17 N2b. Patients with N2a1 had a significantly better overall survival than those with N2a2 and N2b (P = 0.041); the difference between N2a2 and N2b was not significant (P = 0.19). Patients with N2a1 squamous cell carcinoma had a significantly better overall survival than those with other histological diagnoses (P = 0.046). The disease-free interval was longer in patients with N2a1 than those in other groups (P = 0.021). CONCLUSIONS Our experience partially validates the IASLC proposal; the introduction of quantitative criteria for N staging might improve stratification of patients and the assignment to the correct therapeutic path.

Nerve sparing surgery in advanced stage thymomas

four-year-old, white female child was referred to the Aemergency department for slight chest pain, cough, and a history of low-grade fever in the previous days. Chest radiography showed a hypertensive right pneumothorax associated with complete atelectasis of the lung. A chest tube was positioned with complete resolution of pneumothorax, and the patient was discharged after 5 days. Ten days later, the patient was seen again in the emergency department with cough and dyspnea. Chest radiography revealed a new episode of right hypertensive pneumothorax (Fig 1), and a chest tube was forthwith