Lung Metastasectomy: Where Do We Stand? Results from an Italian Multicentric Prospective Database.

Background/Objectives: The surgical resection of pulmonary metastases is considered a therapeutic option in selected cases. In light of this, we present the results from a national multicenter prospective registry of lung metastasectomy. Methods: This retrospective analysis involves data collected prospectively and consecutively in a national multicentric Italian database, including patients who underwent lung metastasectomy. The primary endpoints were the analysis of morbidity and overall survival (OS), with secondary endpoints focusing on the analysis of potential risk factors affecting both morbidity and OS. Results: A total 470 lung procedures were performed (4 pneumonectomies, 46 lobectomies/bilobectomies, 13 segmentectomies and 407 wedge resections) on 461 patients (258 men and 203 women, mean age of 63.1 years). The majority of patients had metastases from colorectal cancer (45.8%). In most cases (63.6%), patients had only one lung metastasis. A minimally invasive approach was chosen in 143 cases (30.4%). The mean operative time was 118 min, with no reported deaths. Morbidity most frequently consisted of prolonged air leaking and bleeding, but no re-intervention was required. Statistical analysis revealed that morbidity was significantly affected by operative time and pulmonary comorbidities, while OS was significantly affected by disease-free interval (DFI) > 24 months (p = 0.005), epithelial histology (p = 0.001) and colorectal histology (p = 0.004) during univariate analysis. No significant correlation was found between OS and age, gender, surgical approach, surgical extent, surgical device, the number of resected metastases, lesion diameter, the site of lesions and nodal involvement. Multivariate analysis of OS confirmed that only epithelial histology and DFI were risk-factors, with p-values of 0.041 and 0.031, respectively. Conclusions: Lung metastasectomy appears to be a safe procedure, with acceptable morbidity, even with a minimally invasive approach. However, it remains a local treatment of a systemic disease. Therefore, careful attention should be paid to selecting patients who could truly benefit from surgical intervention.

Factors Associated with Early Discharge after Thoracoscopic Lobectomy: Results from the Italian VATS Group Registry.

Objective. There are limited data for estimating the risk of early discharge following thoracoscopic lobectomy. The objective was to identify the factors associated with a short length of stay and verify the influence of these variables in uncomplicated patients. Methods. We reviewed all lobectomies reported to the Italian VATS Group between January 2014 and January 2020. Patients and perioperative characteristics were divided into two subgroups based on whether or not they met the target duration of stay (≤ or >4 days). The association between preoperative and intraoperative variables and postoperative length of stay (LOS) ≤4 days was assessed using a stepwise multivariable logistic regression analysis to identify factors independently associated with LOS and factors related to LOS in uncomplicated cases. Results. Among 10,240 cases who underwent thoracoscopic lobectomy, 37.6% had a hospital stay ≤4 days. Variables associated with LOS included age, hospital surgical volume, Diffusion Lung CO % (81 [69−94] vs. 85 [73−98]), Forced Expiratory Volume (FEV1) % (92 [79−106] vs. 96 [82−109]), operative time (180 [141−230] vs. 160 [125−195]), uniportal approach (571 [9%] vs. 713 [18.5%]), bioenergy sealer use, and pain control through intercostal block or opioids (p < 0.001). Except for FEV1 and blood loss, all other factors emerged significantly associated with LOS when the analysis was limited to uncomplicated patients. Conclusions. Demographic, clinical, and surgical variables are associated with early discharge after thoracoscopic lobectomy. This study indicates that these characteristics are associated with early discharge. This result can be used in association with clinical judgment to identify appropriate patients for fast-track protocols.

A unique case of a typical carcinoid of the middle mediastinum: en bloc surgical resection on cardiopulmonary bypass.

We report a unique case of a 67-year-old man with a typical carcinoid of the middle mediastinum that adhered tightly to the pericardium, the posterior part of the ascending aorta and the pulmonary trunk, that was radically resected with the patient on cardiopulmonary bypass by clamping, sectioning and suturing the ascending aorta.

Clinical staging of malignant pleural mesothelioma: current perspectives.

Malignant pleural mesothelioma (MPM) is a disease with limited therapeutic options, the management of which is still controversial. Diagnosis is usually made by thoracoscopy, which allows multiple biopsies with histological subtyping and is indicated for staging purposes in surgical candidates. The recommended and recently updated classification for clinical use is the TNM staging system established by the International Mesothelioma Interest Group and the International Association for the Study of Lung Cancer, which is based mainly on surgical and pathological variables, as well as on cross-sectional imaging. Contrast-enhanced computed tomography is the primary imaging procedure. Currently, the most used measurement system for MPM is the modified Response Evaluation Criteria in Solid Tumors (RECIST) method, which is based on unidimensional measurements of tumor thickness perpendicular to the chest wall or mediastinum. Magnetic resonance imaging and functional imaging with 18F-fluoro-2-deoxy-D-glucose positron-emission tomography can provide additional staging information in selected cases, although the usefulness of this method is limited in patients undergoing pleurodesis. Molecular reclassification of MPM and gene expression or miRNA prognostic models have the potential to improve prognostication and patient selection for a proper treatment algorithm; however, they await prospective validation to be introduced in clinical practice.

Multicentre external validation of the BIMC model for solid solitary pulmonary nodule malignancy prediction.

OBJECTIVES: To provide multicentre external validation of the Bayesian Inference Malignancy Calculator (BIMC) model by assessing diagnostic accuracy in a cohort of solitary pulmonary nodules (SPNs) collected in a clinic-based setting. To assess model impact on SPN decision analysis and to compare findings with those obtained via the Mayo Clinic model. METHODS: Clinical and imaging data were retrospectively collected from 200 patients from three centres. Accuracy was assessed by means of receiver-operating characteristic (ROC) areas under the curve (AUCs). Decision analysis was performed by adopting both the American College of Chest Physicians (ACCP) and the British Thoracic Society (BTS) risk thresholds. RESULTS: ROC analysis showed an AUC of 0.880 (95 % CI, 0.832-0.928) for the BIMC model and of 0.604 (95 % CI, 0.524-0.683) for the Mayo Clinic model. Difference was 0.276 (95 % CI, 0.190-0.363, P < 0.0001). Decision analysis showed a slightly reduced number of false-negative and false-positive results when using ACCP risk thresholds. CONCLUSIONS: The BIMC model proved to be an accurate tool when characterising SPNs. In a clinical setting it can distinguish malignancies from benign nodules with minimal errors by adopting current ACCP or BTS risk thresholds and guiding lesion-tailored diagnostic and interventional procedures during the work-up. KEY POINTS: • The BIMC model can accurately discriminate malignancies in the clinical setting • The BIMC model showed ROC AUC of 0.880 in this multicentre study • The BIMC model compares favourably with the Mayo Clinic model.

Radical surgery in an unusual case of thymoma with intraluminal growth into the superior vena cava and right atrium.

We report a very rare case of malignant invasive thymoma with intraluminal growth through the thymic veins into the superior vena cava (SVC), with intracardiac right atrium extension. A 44-year old female with SVC syndrome underwent a radical thymectomy with pericardiectomy and complete removal of the endovascular and endocardiac neoplastic thrombus by a longitudinal incision starting from the atrium and extending along the SVC. The left anonymous vein was sacrificed, and the SVC and atrium were repaired with a continuous 5-0 Prolene suture. The hospital stay was uneventful. Postoperatively, the patient received adjuvant chemoradiotherapy (three cycles of cisplatin, doxorubicin and cyclophosphamide and subsequent mediastinal irradiation with 50 Gy). Nine months after surgery, no recurrences were seen and the patient is still well. This thymoma presentation with intravascular growth without direct vascular wall infiltration, although very rare, is possible and the management may be challenging. In our case, a primary radical operation was considered mandatory due to the clinical symptoms and the risk of neoplastic embolization. The collection of other similar cases could better clarify the role of adjuvant therapy.

Risk is not our business: safety of thoracic surgery in patients using antiplatelet therapy.

American Heart Association recommendations have changed preoperative management of patients with antiplatelet therapy (APT). We assessed safety and outcomes of surgery in patients who were receiving APT. A prospective study of patients operated on while receiving APT was matched with those with no APT (ratio 1:4), using the propensity score method. Logistic regression analysis was used to identify covariates among imbalanced baseline patient variables. Both χ(2) test and Fisher's test were used to calculate the probability value for the comparison of dichotomous variables. Between January 2008 and December 2010, 38 patients who received APT at the time of surgery were matched with 141 patients who had not received APT. APT indications were a history of myocardial infarction, coronary artery by-pass graft and/or valve replacement (19), coronary artery stent (11) and severe peripheral vascular disease (8). None of the patients required re-operation for bleeding. Two patients received blood transfusions. The amount of chest tube drainage was not statistically significantly different. There were no statistically significant differences between the outcomes for the operative time, length of hospital stay, estimated blood loss or morbidity. The results show that thoracic surgical procedures can safely be performed in patients receiving APT at the time of surgery, with no increased risk of bleeding or morbidity and no differences in the operative time and the length of hospital stay.

Usefulness of 18-F FDG PET/CT in the pre-treatment evaluation of thymic epithelial neoplasms.

BACKGROUND: To assess the usefulness of (18)fluorine-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) for differentiating the grade of malignancy of thymic epithelial neoplasm, and to determine whether (18)F-FDG PET/CT can have a role in pretreatment evaluation and possibly modify treatment strategy. MATERIALS AND METHODS: The data of 26 consecutive patients (14 males and 12 females) diagnosed with a thymic epithelial neoplasm were prospectively collected and analyzed retrospectively. All patients underwent standard clinical assessment and (18)F-FDG PET/CT. The patients were divided into two subgroups according to a simplified histologic classification: low-risk thymoma (types A, AB and B1) and high-risk thymoma (types B2, B3 and C). The maximum standardized uptake value (SUV(max)) of the tumor, the mean SUV of mediastinum, and the tumor/mediastinum (T/M) ratio (ratio of peak SUV of the tumor to mean SUV of mediastinum) were compared to determine whether the two subgroups (low-risk versus high-risk tumors) could be distinguished by (18)F-FDG PET/CT, and to test for possible correlations between (18)F-FDG uptake and disease stage. RESULTS: There was a strong statistical correlation between SUV(max) and patient subgroup and between SUV(max) and disease stage, and an even stronger correlation between SUV(max) and patient subgroup and the T/M ratio; a T/M ratio of 2.75 emerged as the cut-off value for differentiating between low-risk and high-risk thymomas. CONCLUSIONS: (18)F-FDG PET/CT can be used a "metabolic biopsy" to divide thymic epithelial neoplasm into two subgroups of high and low risk and is useful in pretreatment staging.

'Six sigma approach' - an objective strategy in digital assessment of postoperative air leaks: a prospective randomised study.

OBJECTIVE: Until now, only way to report air leaks (ALs) has been with an analogue score in an inherently subjective manner. The Six Sigma quality improvement methodology is a data-driven approach applicable to evaluate the quality of the quantification method of repetitive procedures. We applied the Six Sigma concept to improve the process of AL evaluation. METHODS: A digital device for AL measurement (Drentech PALM, Redax S.r.l., Mirandola (MO), Italy) was applied to 49 consecutive patients, who underwent pulmonary intervention, compared with a similar population with classical chest drainage. Data recorded were postoperative AL, chest-tube removal days, number of chest roentgenograms, hospital length of stay; device setup time, average time rating AL and patient satisfaction. Bivariable comparisons were made using the Mann-Whitney test, the χ² test and Fisher's exact test. Analysis of quality was conducted using the Six Sigma methodology. RESULTS: There were no significant differences regarding AL (p=0.075), although not statistically significant; there was a reduction of postoperative chest X-rays (four vs five) and of hospital length of stay (6.5 vs 7.1 days); and a marginally significant difference was found between chest-tube removal days (p=0.056). There were significant differences regarding device setup time (p=0.001), average time rating AL (p=0.001), inter-observer variability (p=0.001) and patient satisfaction (p=0.002). Six Sigma analyses revealed accurate assessment of AL. CONCLUSIONS: Continuous digital measurement of AL reduces degree of variability of AL score, gives more assurance for tube removal, and reports AL without the apprehension of observer error. Efficiency and effectiveness improved with the use of a digital device. We have noted that the AL curves depict actually sealing of AL. The clinical importance of AL curves requires further study.

Letter to the editor. Re:. Initial experience with a synthetic sealant PleuraSeal™ after pulmonary resections: a prospective study with retrospective case matched controls.

A response to Dango S, Lin R, Hennings E, Passlick B. Initial experience with a synthetic sealant PleuraSeal™ after pulmonary resections: a prospective study with retrospective case matched controls. Journal of Cardiothoracic Surgery 2010, 5:50.