The Overweight Paradox: Impact of Body Mass Index on Patients Undergoing VATS Lobectomy or Segmentectomy.

The aim of this study was to assess the impact of BMI on perioperative outcomes in patients undergoing VATS lobectomy or segmentectomy. Data from 5088 patients undergoing VATS lobectomy or segmentectomy, included in the VATS Group Italian Registry, were collected. BMI (kg/m2) was categorized according to the WHO classes: underweight, normal, overweight, obese. The effects of BMI on outcomes (complications, 30-days mortality, DFS and OS) were evaluated with a linear regression model, and with a logistic regression model for binary endpoints. In overweight and obese patients, operative time increased with BMI value. Operating room time increased by 5.54 minutes (S.E. = 1.57) in overweight patients, and 33.12 minutes (S.E. = 10.26) in obese patients (P < 0.001). Compared to the other BMI classes, overweight patients were at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications. In the overweight range, a BMI increase from 25 to 29.9 did not significantly affect the length of stay, nor the risk of any complications, except for renal complications (OR: 1.55; 95% CI: 1.07-2.24; P = 0.03), and it reduced the risk of prolonged air leak (OR: 0.8; 95% CI: 0.71-0.90; P < 0.001). 30-days mortality is higher in the underweight group compared to the others. We did not find any significant difference in DFS and OS. According to our results, obesity increases operating room time for VATS major lung resection. Overweight patients are at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications following VATS resections. The risk of most postoperative complications progressively increases as the BMI deviates from the point at the lowest risk, towards both extremes of BMI values. Thirty days mortality is higher in the underweight group, with no differences in DFS and OS.

Plates versus struts versus an extracortical rib fixation in flail chest patients: Two-center experience.

PURPOSES: Notwithstanding advances in medical and surgical management of flail chest, its morbidity and mortality rates are still high. Aim of this study is to compare three approaches for parietal thoracic stabilization by analyzing both early and long-term patient outcomes. METHODS: A retrospective study from January 2006 to January 2018 involving sixty-five surgical flail chest (25 plates,11 struts and 29 wires fixations) was conducted. A mean Abbreviated Injury Scale (AIS) was 2.38±0.82 and a mean Injury Severity Score (ISS) was 32.02±8.21. RESULTS: Struts and plates stabilizations compared with wires fixation showed an immediate restoring of the partial pressure of oxygen (90.56 mmHg vs 91.90 mmHg vs 89.23 mmHg, p = 0.021), the carbon-dioxide levels (36.00 mmHg vs 35.03 mmHg vs 38.98 mmHg, p = 0.000) and the oxygen-blood saturation (97.71% vs 98.21% vs 92.12%, p = 0.000) in the early postoperative period. Furthermore, struts and plates ensured a better recovery of daily activities up to the 3rdmonth (QoL=1.0: p<0.001 in lateral flail chest and p<0.02 in anterior and antero-lateral flail chest). At the 12thmonth no difference in QoL was found between the different approaches. CONCLUSIONS: Plate and strut fixation revealed a lower rate of postoperative morbidity and mortality. Wires stabilization was characterized for a reduction of operative time.

Pleurectomy-decortication in malignant pleural mesothelioma: are different surgical techniques associated with different outcomes? Results from a multicentre study.

OBJECTIVES: The potential benefit of surgery for malignant pleural mesothelioma (MPM), especially concerning pleurectomy/decortication (P/D), is unclear from the literature. The aim of this study was to evaluate the outcome after multimodality treatment of MPM involving different types of P/D and to analyse the prognostic factors. METHODS: We reviewed 314 patients affected by MPM who were operated on in 11 Italian centres from 1 January 2007 to 11 October 2014. RESULTS: The characteristics of the population were male/female ratio: 3.7/1, and median age at operation was 67.8 years. The epithelioid histotype was observed in 79.9% of patients; neoadjuvant chemotherapy was given to 57% of patients and Stage III disease was found following a pathological analysis in 62.3% of cases. A total of 162 (51.6%) patients underwent extended P/D (EP/D); 115 (36.6%) patients had P/D and 37 (11.8%) received only a partial pleurectomy. Adjuvant radiotherapy was delivered in 39.2% of patients. Median overall survival time after surgery was 23.0 [95% confidence interval (CI): 19.6-29.1] months. On multivariable (Cox) analysis, pathological Stage III-IV [ P = 0.004, hazard ratio (HR):1.34; 95% CI: 1.09-1.64], EP/D and P/D ( P = 0.006, HR for EP/D: 0.46; 95% CI: 0.29-0.74; HR for P/D: 0.52; 95% CI: 0.31-0.87), left-sided disease ( P = 0.01, HR: 1.52; 95% CI: 1.09-2.12) and pathological status T4 ( P = 0.0003, HR: 1.38; 95% CI: 1.14-1.66) were found to be independent significant predictors of overall survival. CONCLUSIONS: Whether the P/D is extended or not, it shows similarly good outcomes in terms of early results and survival rate. In contrast, a partial pleurectomy, which leaves gross tumour behind, has no impact on survival.

Pulmonary metastasectomy in elderly colorectal cancer patients: a retrospective single center study.

Colorectal cancer (CRC) is one of the most common malignancies worldwide and the lung is one of the most frequent sites for CRC metastasis. The geriatric population is increasing, but clinical decision making is often influenced by the effect of aging. For this reason, the elderly population does not often receive potentially curative cancer treatments as offered to younger ones. From January 2000 to March 2016, 21 elderly patients (older than 75 years) underwent pulmonary resections for colorectal cancer pulmonary metastases. A postoperative morbidity rate of 23.8 % and a 30-day mortality rate of 4.8 % were reported. A cumulative overall survival of 34.19 ± 23.51 months (95 % CI 23.71-50.28) and a disease-free interval of 24.62 ± 23.79 months (95 % CI 6.44-39.56) were observed. By considering only R0 surgically resected patients, the 1-, 3- and 5-year OS were 94.1, 59.5 and 21.2 % with a mean overall survival and disease-free interval of 51.10 ± 7.82 and 42.75 ± 9.35, respectively. Concerning risk factors, an important correlation between the number of pulmonary metastases, surgical radicality and overall survival was reported (p = 0.030 and p = 0.005, respectively). In summary, according to our series, pulmonary metastasectomy in selected elderly CRC oligometastatic patients seems to be safe and effective.

Oligometastatic non-small cell lung cancer (NSCLC): adrenal metastases. Experience in a single institution.

Though the actual incidence of an adrenal oligometastasis is between 1.5 and 3.5 %, secondary adrenal neoplasms occur in less than 10 % patients with non-small cell lung cancer (NSCLC). According to 7° ed. TNM staging system, the presence of an adrenal metastasis (M1b disease) configures stage IV, which is usually associated with poor prognosis. We evaluated if metastasectomy in selected patients with oligometastatic disease improves overall survival. A 15-year retrospective study concerning patients with NSCLC was performed and an oligometastatic disease was found in 1.61 % of the patients. 18 adrenalectomies were performed. Clustering the population according to different therapeutic strategies, a benefit in terms of survival was found in patients who underwent adrenalectomy. A statistical relevance was found, indeed, between adrenalectomy (p < 0.01), metachronous disease (p < 0.01), the presence of a homolateral disease (p < 0.05) and overall survival. Adrenalectomy should be offered in selected patients with oligometastatic disease.

Osteopontin is not a specific marker in malignant pleural mesothelioma.

BACKGROUND AND AIMS: Osteopontin (OPN) is an integrin-binding protein recently shown to be related to tumorigenesis, progression and metastasis in different experimental models of malignancy. Malignant pleural mesothelioma (MPM) is a fatal disease in which the prognosis remains very poor and the knowledge of predictive factors for outcome is insufficient. The identification of new molecules involved in cancer initiation and development is a fundamental step for improving the curability of this kind of tumor. The purpose of this study is to define the role of OPN in the diagnosis of MPM by determining its prognostic and diagnostic value. METHODS: A group of 24 surgically staged MPM subjects was compared with a group of 31 subjects with nonmalignant pulmonary diseases, and with 37 healthy controls. Tumor tissue was analyzed for OPN by immunohistochemical tests, and plasma OPN levels were measured by an enzyme-linked immunosorbent assay. RESULTS: Plasma OPN levels were not significantly higher in either of the patient groups compared with the control group. Immunohistochemical analysis revealed OPN staining of tumor cells in 21 of 24 MPMs. Receiver operating characteristic curve/area under the curve (ROC/AUC) analysis comparing the plasma OPN levels in the healthy group with those of MPM patients showed 40% sensitivity and 100% specificity at a cutoff value of 60.8 ng of OPN per milliliter (AUC 0.6). CONCLUSION: Plasma OPN levels do not discriminate between chronic inflammatory and malignant lung diseases and staining intensity in MPM specimens does not correlate with OPN plasma levels.

Sternectomy and sternum reconstruction for infection after cardiac surgery.

Sternum infection after cardiac surgery represents a severe complication with a high mortality rate. Therapeutic possibilities consist in "open packing" with specific antibiotic irrigation or in "en-block" resection. We report a case of sternum reconstruction using a titanium patch covered with bone-powder.

Frequent mutations in the neurotrophic tyrosine receptor kinase gene family in large cell neuroendocrine carcinoma of the lung.

The neurotrophic tyrosine receptor kinase (NTRK) family is potentially implicated in tumorigenesis and progression of several neoplastic diseases, including lung cancer. We investigated a large number of pulmonary neuroendocrine tumors (PNETs) and non-small cell lung carcinomas (NSCLCs) without morphological evidence of neuroendocrine differentiation for mutations in the NTRK gene family. A total of 538 primary lung carcinomas, including 17 typical carcinoids (TCs), 10 atypical carcinoids (ACs), 39 small cell lung carcinomas (SCLCs), 29 large cell neuroendocrine carcinomas (LCNECs), and 443 NSCLCs were evaluated by single-strand conformation polymorphism (SSCP) and sequencing of the tyrosine kinase domain (TKD) of NTRK1, NTRK2, and NTRK3. The NTRK1 gene was never found to be mutated. A total of 10 somatic mutations were detected in NTRK2 and NTRK3, mostly located in the activating and catalytic loops. NTRK mutations were seen in 9 (10%) out of 95 PNETs but in 0 out of 443 NSCLCs investigated. No mutations were observed in TCs, ACs, and SCLCs. Interestingly, all the mutations were restricted to the LCNEC histotype, in which they accounted for 31% of cases. A mutational analysis, performed after microdissection of LCNECs combined with adenocarcinoma (ADC), showed that only neuroendocrine areas were positive, suggesting that NTRK mutations are involved in the genesis of the neuroendocrine component of combined LCNECs. Our data indicate that somatic mutations in the TKD of NTRK genes are frequent in LCNECs. Such mutational events could represent an important step in the cancerogenesis of these tumors and may have potential implications for the selection of patients for targeted therapy.

Giant posterior mediastinal liposarcoma invading the esophagus: a case report.

Giant liposarcoma is an unusual variant of mediastinal tumors. The case of a 73-year-old woman is reported. She presented with a posterior mediastinal tumor invading the third middle tract of the thoracic esophagus and the adventitia of the descending aorta, close to the posterior pericardium; a neoplastic thrombus 2cm in size was located in the upper left pulmonary vein. The tumor was completely excised by left thoracotomy, in extracorporeal circulation. The postoperative course was uneventful and the patient received adjuvant chemotherapy. She is currently alive after 8 months, disease-free. The natural history, pathology, and prognosis of the disease are reviewed and management of such lesions is discussed.

[The role of surgery in the treatment of malignant pleural mesothelioma]. / Il ruolo della chirurgia nel trattamento del mesotelioma pleurico maligno.

The role of surgery in the treatment of diffuse pleural malignant mesothelioma is controversial. The procedures proposed to date are extrapleural pneumonectomy, pleurectomy, and thoracoscopy. External radiation or intraoperative implantation of radioisotopes, chemotherapy and intrapleural treatment with various different agents are also considered as adjuvant therapy. Patient selection, postoperative morbidity and mortality and survival rates are discussed. Our personal series of 72 diffuse pleural malignant mesotheliomas is described: 29 had a palliative operation while 43 underwent radical surgery consisting in 24 extrapleural pneumonectomies and 19 pleurectomies.

[Intralobar pulmonary sequestration: a case report]. / Sequestrazione polmonare intralobare: a proposito di un caso.

The authors report a case of intralobar pulmonary sequestration diagnosed accidentally in a 64-year-old woman. The patient subsequently underwent surgery. The authors were prompted by this fairly rare case to describe and discuss its anatomopathological, clinical, diagnostic and therapeutic aspects.

Pneumonectomy for lung cancer: technical and general aspects.

The current role and technical aspects of pneumonectomy for the treatment of lung cancer are evaluated based on the personal experience and on the review of the international literature. Over a four-year period 669 operations for lung cancer were performed. Fifty-nine were pneumonectomies 11 of which were completion pneumonectomies and 7 tracheal sleeve right pneumonectomies 5 of which performed with the anesthesiological tube always kept in trachea. Overall postoperative mortality was about 10% for pneumonectomy, and about 16,6 % for completion pneumonectomy with a median survival rate of 21 and 26 months respectively. In agreement with reports of the international literature, it is confirmed that pneumonectomy is a high-risk thoracic surgical procedure and an accurate cardiovascular and respiratory evaluation is very important for patient selection.