Improving the efficiency of identifying malignant pulmonary nodules before surgery via a combination of artificial intelligence CT image recognition and serum autoantibodies.

OBJECTIVE: To construct a new pulmonary nodule diagnostic model with high diagnostic efficiency, non-invasive and simple to measure. METHODS: This study included 424 patients with radioactive pulmonary nodules who underwent preoperative 7-autoantibody (7-AAB) panel testing, CT-based AI diagnosis, and pathological diagnosis by surgical resection. The patients were randomly divided into a training set (n = 212) and a validation set (n = 212). The nomogram was developed through forward stepwise logistic regression based on the predictive factors identified by univariate and multivariate analyses in the training set and was verified internally in the verification set. RESULTS: A diagnostic nomogram was constructed based on the statistically significant variables of age as well as CT-based AI diagnostic, 7-AAB panel, and CEA test results. In the validation set, the sensitivity, specificity, positive predictive value, and AUC were 82.29%, 90.48%, 97.24%, and 0.899 (95%[CI], 0.851-0.936), respectively. The nomogram showed significantly higher sensitivity than the 7-AAB panel test result (82.29% vs. 35.88%, p < 0.001) and CEA (82.29% vs. 18.82%, p < 0.001); it also had a significantly higher specificity than AI diagnosis (90.48% vs. 69.04%, p = 0.022). For lesions with a diameter of ≤ 2 cm, the specificity of the Nomogram was higher than that of the AI diagnostic system (90.00% vs. 67.50%, p = 0.022). CONCLUSIONS: Based on the combination of a 7-AAB panel, an AI diagnostic system, and other clinical features, our Nomogram demonstrated good diagnostic performance in distinguishing lung nodules, especially those with ≤ 2 cm diameters. KEY POINTS: • A novel diagnostic model of lung nodules was constructed by combining high-specific tumor markers with a high-sensitivity artificial intelligence diagnostic system. • The diagnostic model has good diagnostic performance in distinguishing malignant and benign pulmonary nodules, especially for nodules smaller than 2 cm. • The diagnostic model can assist the clinical decision-making of pulmonary nodules, with the advantages of high diagnostic efficiency, noninvasive, and simple measurement.

Extension of lymph node dissection in the surgical treatment of esophageal and gastroesophageal junction cancer: seven questions and answers.

The role of two- or three-field nodal dissection in the surgical treatment of esophageal and gastroesophageal junction cancer in the minimally invasive era is still controversial. This review aims to clarify the extension of nodal dissection in esophageal and gastroesophageal junctional cancer. A basic evidence-based analysis was designed, and seven research questions were formulated and answered with a narrative review. Reports with little or no data, single cases, small series and review articles were not included. Three-field lymph node dissection improves staging accuracy, enhances locoregional disease control and might improve survival in the group of patients with cervical and upper mediastinal metastatic lymph nodal involvement from middle and proximal-third esophageal cancer.

The second modification of a dedicated staging system for lung metastases.

The topic of pulmonary metastases has long been of high interest and ongoing controversy. There is a group of patients with pulmonary metastases who may benefit from curative resection. It remains unclear which among them will benefit from surgery in terms of survival. This work updates a previously proposed classification system for pulmonary metastases, similar in its essence to the tumor, nodes, metastasis (TNM) classification used for primary tumors and named pmTNM classification, where 'pm' stands for 'pulmonary metastasis'. The objective is to allow future studies to explore predictive and survival prognostic factors for pulmonary metastases and separate patients who will benefit from lung metastasectomy from those who will not. The secondary aim is to provide a classification system that will allow physicians, oncologists and surgeons to speak the same language in comparing their data and assessing the results of treatment of lung metastases.

Precision surgery in lung metastasectomy.

The value of pulmonary metastasis (PM) resection in the context of controlled primary tumor sites was shown to improve survival of patients if complete resection could be achieved. The surgeon's approach can be modulated by various parameters pertaining to safety margins including local growth properties, size, spread and location of PMs. Lymph node dissection and assessment is recommended although its impact on survival remains unclear. Thoracoscopic surgery combined to thin slice chest CT scans has shown results comparable to thoracotomy in patients with few PMs. The management of PMs should therefore be discussed on an individual, interdisciplinary basis to offer the best possible oncological and surgical results as well as to maximize long term patient survival rates.

Mood disorders and outcomes in lung cancer patients undergoing surgery: a brief summery.

Cancer is a leading cause of death worldwide. Literature reports depression and anxiety are the most common psychiatric symptoms in cancer patients. Notably, lung cancer is associated with major depressive disorder in 5-13% of cases. The present article aims to give an overview regarding the impact of mood disorders on the outcomes of patients affected by lung cancer. Our review showed that pharmacological treatment and psychotherapy can be useful to improve the quality of life of patients with lung cancer. Moreover, the treatment of depression and anxiety can be associated with a reduced mortality. In conclusion, it is important to consider psychiatric care as important as other adjuvant oncologic therapies in patients with cancer.

Precision treatment of post pneumonectomy unilateral laryngeal paralysis due to cancer.

Aim: The aim of this study is to assess the efficacy of external laryngeal medialization acquired through a Gore-Tex implant in a 45 patients affected by unilateral vocal fold paralysis in abduction after pneumonectomy. Method: The cohort of patients was made up of 30 male (73.1%) and 11 female patients (26.9%) with an average age of 66.7 years in a range between 46 and 78 years. Results: The results were analyzed with the objective and subjective analysis of voicing and swallowing. In 95.2% of cases, voice and swallow improvement with statistically significant evidences. Conclusion: We can conclude that Gore-Tex implantation is a simple, reproducible and minimally invasive procedure for management of selected cases of vocal fold unilateral paralysis in the abductory position.

Adenoid cystic carcinoma of trachea: long-term disease control after endoscopic surgery and radiotherapy.

Aim: Adenoid cystic carcinoma is a rare tumor of head and neck region and its development in the thoracic region is even less frequent. This implies the absence of guidelines for therapeutic management and a consequent case-by-case approach. The role of radiotherapy is not yet clearly defined, but intensity-modulated radiotherapy allows for improved organ-at-risk sparing. Materials & methods: We have collected the cases of four patients treated at our institutions by the means of intensity-modulated radiotherapy, after endoscopic resection. Results & conclusion: Patients treated achieved long-term disease control of about 5 years, with a minimal acute toxicity. Longer follow-up is needed to drain conclusion on the impact of this treatment on overall survival.

Fibulin-3 immunoexpression in malignant mesothelioma due to fluoro-edenite: a preliminary report.

An increased standardized incidence and mortality rate were reported due to malignant mesothelioma (MM) in Biancavilla. Environmental investigations showed the presence of an asbestiform fiber: fluoro-edenite (FE). MM develops with a latency of 20-60 years from exposure and specific and sensitive biomarkers are urgently needed. For this purpose, we evaluated Fibulin-3 (Fb-3) immunoexpression in human cases of MM related to FE exposure and its prognostic role. Immunohistochemical analysis of Fb-3 was carried out in eight MM patients resident in Biancavilla and the analysis showed evidence of environmental exposure to FE fibers. Six MM cases (3 epithelioid and 3 biphasic) showed a high immunoexpression of Fb-3 in neoplastic cells with nuclear and cytoplasmic localization. One epithelioid and one biphasic subtype did not show Fb-3 immunostaining. The results demonstrate the implication of Fb-3 in MM due to FE exposure and may possibly suggest its potential role as a diagnostic and prognostic marker.

2016 Annual report from the Italian VATS Group.

This report highlights the results of the Italian video-assisted thoracoscopic surgery (VATS) Group, launched in mid 2013, which now has a website and an established database with over 4000 VATS lobectomy cases recruited from 67 thoracic surgery units across Italy. The year 2016 has been crucial for the following steps: inclusion of a dedicated biostatistician and a 'Survey Analysis & Data Quality Check'; the First Consensus Meeting with statements consequently adopted as Recommendations for the Italian Thoracic Surgery Society and published in a peer-reviewed journal; two papers published under the logo Italian VATS Group and seven abstracts accepted at annual international meetings (European Society of Thoracic Surgeons, European Association of Cardio-Thoracic Surgeons, European Lung Cancer Conference and European Respiratory Society); the institution of a Master Course on VATS lobectomy; the partnership with AME Publishing Company.

Single-institution experience of intensity-modulated radiotherapy for malignant pleural mesothelioma at University of Catania.

AIM: The multimodal approach to malignant pleural mesothelioma is gradually becoming the standard of care for this disease in patients with good performance status. Materials & methods: We report our experience concerning eight cases treated with the use of static step-and-shoot intensity-modulated radiotherapy to the whole pleural cavity, in patients already undergoing surgical and/or antiblastic therapy. Results & conclusion: Results at a median follow-up of 16 months showed a median survival from the initial treatment of 29 months, with lung toxicity of grade II reported only in two patients.

Occupational exposure to fluoro-edenite and prevalence of anti-nuclear autoantibodies.

An environmental contamination due to an asbestiform mineral fiber, fluoro-edenite (FE), caused a significantly increased mortality rate for malignant mesothelioma in Biancavilla, Italy. Exposure to fluoro-edenite has been associated with inflammatory processes as an early response to inhaled fibers. The aim was to explore prevalence of anti-nuclear autoantibodies (ANA) in a group of construction workers residing and working in the contaminated area. Prevalences for samples positive to ANA were 60% (n = 9) and 13% (n = 2), for exposed and nonexposed, respectively (p-value <0.05), the odds ratio was 9.75 (95% CI: 1.59-59.69). The significance of elevated ANAs in subjects exposed to fibers is unknown; additional studies may provide a better opportunity to establish a correlation between autoimmunity and environmental exposure.

Combined taxane-based chemotherapy and intensity-modulated radiotherapy with simultaneous integrated boost for gastroesophageal junction adenocarcinoma.

We describe our experience, gained over the past 3 years, in the treatment of gastroesophageal junction adenocarcinoma, whose incidence has been increasing in recent years. In our series, we present the results to a follow-up of about 2 years for a total of 18 patients, treated with a particularly intensive combination treatment. It consists of neoadjuvant induction chemotherapy with the protocol docetaxel-cisplatin-5-fluorouracil for four cycles, before a concomitant chemoradiotherapy treatment. During combined phase, patients received an intensity-modulated radiotherapy and a weekly cisplatin. We will present the data to a long follow-up time and we will discuss the literature, the integration with thoracoabdominal surgery and other specific issues of this pathology.

Video-assisted thoracic lobectomy for lung cancer in Italy: the 'VATS Group' Project.

As part of the third Mediterranean Symposium in Thoracic Surgical Oncology, we introduce the Italian VATS Group ( http://vatsgroup.org/sito/index.php ). This national collaborative initiative was established in 2013 and started to recruit patients in January 2014; as of July 2016, 3680 patients have been enrolled in the database. Three different video-assisted thoracic surgery approaches have been predominantly used by Italian thoracic surgery centers, 71% of them preferentially adopting a multi-portal approach, with a 20% recorded morbidity. The majority of the cases were stage I adenocarcinomas of the lung. Conversion to open surgery occurred in 9% of the cases. The study suggests video-assisted thoracic surgery lobectomy as a 'gold standard' for the surgical treatment of early-stage lung cancer in Italy.

Lung cancer invading a single left pulmonary vein requiring extended pneumonectomy.

Unilateral single left pulmonary vein is a congenital anomaly of the pulmonary venous system. Surgical treatment is not commonly required for this anatomical variant except in rare circumstances. No previous cases of lung cancer involving the intrapericardial portion of a single left pulmonary vein have been published in the peer-reviewed literature. We describe the case of a 69-year-old man with lung cancer invading single left pulmonary vein, which required intrapericardial pneumonectomy and partial resection of the left atrium.

Awake uniportal video-assisted thoracic surgery for complications after pneumonectomy.

Since 1998, we started a clinical program for awake video-assisted thoracic surgery in our unit using four-step local anesthesia and sedation. Throughout the years, we experienced several difficult cases, three of them had complications postpneumonectomy. The aim of this paper is to report these three cases.

Safety of video-assisted thoracic surgery lobectomy for non-small-cell lung cancer in a low-volume unit.

Several studies have demonstrated that for complex surgical procedures, surgeons who treat more patients have better outcomes than their lower-volume counterparts. The aim of this paper is to review the experience with video-assisted thoracic surgery (VATS) lobectomies in our small thoracic unit (group A), to understand whether our short-term results were different to the outcomes obtained by the same surgeon previously working in a high-volume unit (group B). 37 patients underwent VATS lobectomy. Hospital stay was on average 4.5 days (group A) versus 4.1 days (group B). Operative time and the number of 'frozen sections' were higher in group A. Hospital mortality was 0. VATS lobectomies are a safe approach in a low-volume unit formed by a single surgeon with a previous high-volume experience.

Early effects of fluoro-edenite: correlation between IL-18 serum levels and pleural and parenchymal abnormalities.

Fluoro-edenite (FE) is a natural mineral asbestos-like fibrous species first isolated in Biancavilla, Sicily. In order to clarify potential involvement of IL-18 in the pathogenesis of FE-induced chest abnormalities, we analyzed IL-18 serum levels in FE-exposed workers (FEEW) and correlated them with pleural and parenchymal abnormalities. A total of 21 FEEWs, residing in Biancavilla for >30 years, with a working seniority of 17 ± 6.1 years were examined. High-resolution computed tomography scans revealed low grade of fibrosis in 8 (38%) FEEWs, and pleural plaques (PPs) in 13 (62%) FEEWs. The mean IL-18 level was 203.13 ± 90.43 pg/ml. Pearson correlation showed a significant association (p < 0.0001) between IL-18 and PPs and parenchymal abnormality scores. Data suggest a potential role of IL-18 in the pathogenesis of these diseases.

Intensity-modulated radiotherapy for relapsed malignant pleural mesothelioma.

The use of novel radiotherapy techniques is widely increasing, allowing clinicians to treat diseases that were previously difficult to treat with radiation therapy. Malignant pleural mesothelioma is a clear example of this clinical challenge. We describe our first experience with intensity-modulated radiotherapy technique which was used to treat a 73-year-old patient with multiple relapsing malignant pleural mesothelioma. Intensity-modulated radiation therapy has allowed to respect the QUANTEC (quantitative analyses of normal tissue effects in the clinic) dose constraints, patient has experienced a 14 months progression-free time, without relevant subacute or late lung toxicity.