The challenging management of a giant intrathoracic desmoid tumour: a case report.

Desmoid tumours are rare, locally aggressive neoplasms exhibiting high tendency for recurrence, even after complete resection. Only 1 in 5 of them originates from the chest wall, usually measuring less than 10 cm at diagnosis. Herein, we report the case of a woman presenting with symptoms of gradual lung compression by a giant desmoid tumour occupying the entire hemithorax. She underwent complete surgical resection of the tumour and chest wall reconstruction. She had disease recurrence 15 months later and currently remains under regular follow-up. The management of intrathoracic desmoid tumours is challenging because they are usually not diagnosed until they become large enough to cause compression symptoms. While medical management is the primary modality of treatment, surgery could be considered in selected cases where significant symptoms arise, and the functional status is impaired secondary to the tumour. Adjuvant radiotherapy to minimise the risk of local recurrence should also be considered.

Metastatic mandibular ameloblastoma of the lung ten years after primary resection: A rare case report.

Ameloblastoma is a rare odontogenic neoplasm of the jaw. It usually behaves as a benign, slow growing tumour of the oral cavity with a high recurrence rate, especially when it is inadequately resected. A small proportion of ameloblastomas metastasize to distant organs, with lungs representing the most common site of metastatic spread. In this report, we present the case of a middle-aged man with two pulmonary nodules and a history of mandibular ameloblastoma excised 10 years prior to this radiological finding. Following resection and histopathological analysis of the lung lesion, a diagnosis of metastatic ameloblastoma was confirmed. No local recurrence of the primary tumour was identified. At 1-year follow-up, the patient had no evidence of local or metastatic disease.

Cystic fibrohistiocytic tumour of the lung presenting with recurrent pneumothoraces: a case report.

Cystic fibrohistiocytic tumour of the lung is a very rare pathological entity that occurs either as a primary pulmonary neoplasm or as a metastasis from skin lesions called cellular fibrous histiocytomas. Herein, we present the case of a 19-year old man with a history of recurrent pneumothoraces who was managed surgically and was eventually diagnosed with cystic fibrohistiocytic tumour of the lung. Clinicians should include this disease in the differential diagnosis of pulmonary cystic lesions and be aware of its association with cellular fibrous histiocytoma. Reporting of more cases is warranted to further elucidate the natural course of the disease and optimise its management.

Right Coronary Artery and Left Anterior Descending Artery Occlusion after Aortic Valve Replacement.

Coronary artery stenosis is a potentially life-threatening complication after heart valve surgery. The details are presented of a patient with unobstructed coronary arteries, who underwent routine aortic valve replacement and developed dissection of the right coronary artery (RCA) on the third postoperative day, and occlusion of the left anterior descending (LAD) artery one month after surgery. This complication required prompt clinical recognition and diagnosis by repeat coronary angiography, and a rapid intervention with coronary artery bypass grafting or with angioplasty and stenting.

Clinical outcomes of the robot-assisted Ivor Lewis procedure for adenocarcinoma of the esophagogastric junction with semi-instrument overlap intrathoracic anastomosis.

Background: The main difficulty of minimally invasive Ivor Lewis (IL) procedure for adenocarcinoma of the esophagogastric junction (AEGJ) is the intrathoracic esophagogastric anastomosis (IEA). We aimed to assess the safety and feasibility of the IL procedure with the da Vinci surgical system for treatment of AEGJ with semi-mechanical intrathoracic IEA. Methods: The cohort included 72 patients with AEGJ who received treatment at the Department of Minimally Invasive Esophagus Surgery of the Tianjin Medical University Cancer Institute and Hospital from August 2020 to March 2023. Of these 72 patients, 17 received neoadjuvant chemo-immunotherapy. The robot-assisted minimally invasive IL procedure was performed using a linear stapler for overlap side-to-side intrathoracic anastomosis and the stapler defect was closed with double full-layer continuous sutures by robotic hand-sewn (semi-mechanical) IEA. Results: Of the 72 AEGJ patients, 2 were converted to exploration, 7 were converted to laparotomy and thoracotomy for circular-stapled intrathoracic anastomosis, and 6 were converted to thoracotomy for circular-stapled anastomosis, which included 2 cases of extensive pleural adhesion and 4 cases of overlap anastomosis failure, whereas 57 underwent the robot-assisted minimally invasive IL procedure with semi-mechanical IEA. Among the 9 patients converted to laparotomy, the laparotomy rate was closely related to the Siewert classification (P<0.005) and preoperative use of neoadjuvant therapy (P<0.05). Among the 57 patients who underwent the robot-assisted minimally invasive IL procedure with semi-mechanical IEA, there were 2 cases of anastomotic leakages (2/57, 3.5%), no case of anastomotic stricture, 5 cases of postoperative pneumonia (5/57, 8.77%), 2 cases of intensive care unit admission (2/57, 3.5%), and 1 case of readmission within 30 days (1/57, 1.75%). None of the patients died within 30 days after surgery. Conclusions: The robot-assisted minimally invasive IL procedure with semi-mechanical IEA is both safe and feasible for AEGJ. However, caution is advised for patients with Siewert type III AEGJ and those who have already received preoperative neoadjuvant therapy.

Mediastinal Teratoma Mimicking Neurofibroma in CT-Guided Biopsy in a Patient With Neurofibromatosis Type 1.

Teratomas are a type of germ cell tumor that may contain several different types of tissue. Neurofibroma is a benign peripheral nerve sheath tumor with the plexiform type being pathognomonic for neurofibromatosis type 1. We report a case of a 33-year-old woman with a background of Neurofibromatosis type 1 who presented with left-sided chest pain and shortness of breath. She was diagnosed with a large mediastinal mass which was confirmed from a CT-guided biopsy as neurofibroma. Following a multidisciplinary team discussion, she underwent mediastinal mass resection and the final histopathology report revealed mediastinal mature teratoma.

Comparisons of prognosis prediction accuracy between modified and unmodified versions of 8th edition ypTNM.

Background: The prognostic value of the existing 8th edition post-neoadjuvant treatment (ypTNM) appears to be limited, and necessary reassessment and modification should be carried out as needed. This study aimed to compare the prognosis prediction accuracy of modified and unmodified versions of the 8th edition ypTNM. Methods: Esophageal cancer patients who had received neoadjuvant therapy from the Surveillance, Epidemiology, and End Results (SEER) database were included in this observational longitudinal study. The median follow-up time was 26 months. All-cause mortality was the outcome variable. Demographic and clinical variables were collected as covariates. Kaplan-Meier (log-rank test) and Cox proportional hazards models were conducted for developing modified ypTNM staging. The concordance index (C-index) was calculated to analyze the discriminative ability of modified ypTNM staging. Results: Overall, 3,595 patients met inclusion criteria. The 8th edition staging was not able to significantly discriminate between patients with ypT1- and ypT2-, ypT3- and ypT4-, ypN2- and ypN3- disease, respectively. Using the modified staging, we found that patients with ypT0-2 [hazard ratio (HR) =1.232; 95% confidence interval (CI): 1.053-1.441] and ypT3-4 (HR =1.257; 95% CI: 1.136-1.390) with grade III + IV had a significant risk of death compared to those with grade I + II. As was the case for the ypN0 (HR =1.295; 95% CI: 1.073-1.562) group with middle and upper tumor locations compared to those with low tumor location. The modified staging possessed better homogeneity in terms of the chi-square likelihood ratio (143.443 vs. 102.044), Akaike information criterion (AIC) (32,683.716 vs. 32,719.115), and Schwarz's Bayesian criterion (SBC) (32,723.496 vs. 32,741.847), as well as better discriminatory ability (C-index of 0.577 vs. 0.560, P=0.045) compared to the 8th edition staging. Conclusions: Although the modified ypTNM staging system we created by incorporating tumor grade and location to the original T and N displayed certain prognosis prediction accuracy compared with the 8th edition ypTNM staging, a larger sample size and prospective studies are needed to explore.

Vacuum Bell: Is It a Useful Innovative Device for Pectus Excavatum Correction?

Pectus Excavatum (PE) or "funnel chest," the most common deformity of the anterior chest wall characterized by sternal depression, can be repaired via either operative or non-invasive techniques. Vacuum Bell (VB) device is the most widespread of the latter one which can be applied either intraoperatively or as monotherapy. The present narrative review examines the efficacy of that innovative method. A thorough search of the literature resulted in 13 English-written articles concerning VB therapy from its first description to February 2019. The studies included patients with mild to moderate PE, mainly evaluated via Haller-Index and/or sternum depth prior to and following treatment. Concerning depth-improvement, 37-90% showed amelioration while 10-40% of them an excellent correction to normal. In 42%, Haller-Index also improved with a median decrease of 0.3 after VB application. A correlation was attempted to be found between the efficacy of VB and factors such as the frequency and duration of VB application, patient age, gender, PE severity and type, and differential pressure of the suction cup. Complications may be frequent yet mild and temporary. Intraoperatively, VB widows Minimally Invasive Repair of Pectus Excavatum (MIRPE) operation a safer procedure with greater results. VB as conservative treatment is an effective and well-tolerated alternative therapeutic option for selected patients with PE who meet specific criteria. It also constitutes a device of significant efficacy, appropriate for intraoperative use during MIRPE procedure.

Lung Decortication With Argon Plasma Energy for the Treatment of Chronic Pleural Empyema.

Lung decortication for the treatment of chronic pleural empyema remains a technically challenging procedure that is associated with bleeding and air leak. The recent advent of pure argon plasma has provided thoracic surgeons with an electrically neutral energy source for dissection and coagulation of pulmonary tissue with minimal depth of necrosis. In this article, we describe the technique of lung decortication with argon plasma energy (PlasmaJet, Plasma Surgical, Roswell, GA, USA) for the treatment of chronic pleural empyema. With appropriate application, the PlasmaJet can facilitate the removal of fibrous cortex with satisfactory hemostasis and aerostasis. Argon plasma energy can potentially be a useful adjunct in lung decortication. Controlled trials are needed to determine its role in the surgical management of advanced pleural empyema.

Facilitating robotic thymectomy in patients with pectus excavatum deformity.

Robotic procedures in the anterior mediastinum can be challenging in the existence of pectus excavatum deformity due to the limited intrathoracic working space caused by sternal depression. We propose that the temporary application of a vacuum bell device during the procedure can correct the deformity and thus, facilitate robotic approach similarly to the standard procedure.

Video-thoracoscopic left cardiac sympathetic denervation for long-QT syndrome.

BACKGROUND: Congenital long-QT syndrome represents the most common cardiac channelopathy and manifests as potentially lethal ventricular arrhythmias. Prevention strategies include beta-blockade pharmacotherapy, implantable cardioverter-defibrillators, and left cardiac sympathetic denervation, which can increase the threshold for ventricular fibrillation. Herein, we report our experience with video-assisted thoracoscopic left cardiac sympathetic denervation. METHODS: We performed a retrospective review of the electronic medical records of all patients with congenital long-QT syndrome who underwent video-assisted thoracoscopic left cardiac sympathetic denervation at our institution. RESULTS: From September 2009 to May 2016, 6 patients with a mean age of 30.5 years (range 20-47 years) underwent video-assisted thoracoscopic left cardiac sympathetic denervation for medically refractory long-QT syndrome. All patients had an uneventful recovery and were discharged 1-3 days after the operation. At a median follow-up of 14 months (range 12-60 months), 4 patients had no cardiac events while 2 experienced 1 episode of arrhythmic syncope and 1 episode of appropriate implantable cardioverter-defibrillator shock. Following surgery, the mean annual cardiac events in the study cohort decreased from 2.13 to 0.33 (p = 0.004) and the mean corrected QT interval reduced from 560 ms to 491 ms (p = 0.006). CONCLUSIONS: Video-assisted thoracoscopic left cardiac sympathetic denervation is a safe and effective therapy in patients with congenital long-QT syndrome who continue to suffer from recurrent life-threatening arrhythmias or frequent implantable cardioverter-defibrillator discharges despite maximum tolerated doses of beta blockers.

Small lymphocytic lymphoma and lung malignancy coincidence in a male patient: a case report and literature review.

Lung carcinoma management secondary to chronic lymphocytic leukemia could be quite challenging. We report a case of a 60-year-old male with several co-morbidities, who presented with shortness of breath and persistent cough. A chest imaging showed a right pleural effusion and complete white-out of the right chest cavity. A computed tomography scan revealed consolidation of the right upper lobe with a 6-cm lesion in hilum with complete occlusion of right lobe bronchus. The patient underwent a video-assisted thoracoscopic surgery, drainage of pleural effusion and pleural and lung biopsy. Talc pleurodesis as well as a flexible bronchoscopy of the endobronchial lesion was performed. Histopathological examination showed a small B-cell lymphoma of the right pleura and an invasive non-small cell carcinoma of the right lung. Dual neoplasms are challenging in terms of diagnosing, and they usually require a multidisciplinary team for the right treatment strategy, including surgery and chemotherapy.

Pectus excavatum and scoliosis: a review about the patient's surgical management.

Although Nuss procedure is performed with satisfactory results, there has been a controversy in the literature regarding the effect of a Nuss procedure on the spine. This review article aims to perform an updated overview of the literature about the effect of pectus excavatum correction at the spine and the management of patients with both pectus excavatum and scoliosis. Although acquired scoliosis has been rarely reported after a Nuss procedure, studies show that the Nuss procedure can have a beneficial effect in mild coexisting scoliosis especially when it is performed during the adolescence. The management of cases presented with both pectus excavatum and scoliosis depends on the severity of pre-operative scoliosis and demands detailed evaluation of the spine pre and postoperatively. In the rare condition of post-operative scoliosis following a Nuss procedure, the removal of the metallic bar and conservative measures may have satisfactory results on the spine.

The insidious presentation and challenging management of esophageal perforation following diagnostic and therapeutic interventions.

Diagnostic and therapeutic interventions on the esophagus or adjacent organs are responsible for nearly half of all esophageal perforations. If not recognized at the time of the injury, iatrogenic esophageal perforations can present insidiously and lead to delay in diagnosis, thereby increasing morbidity and mortality. Acute clinical awareness is vital for prompt diagnosis, which is usually confirmed with contrast esophagography and contrast-enhanced computed tomography. After establishment of diagnosis, treatment should be promptly initiated and include fluid-volume resuscitation, cessation of oral intake, nasogastric tube insertion, broad-spectrum antibiotics and analgesia. Primary repair, when feasible, is the treatment of choice. Additional procedures beyond primary repair, such as relief of concomitant obstruction, may be necessary if there is underlying esophageal pathology. Drainage alone can be performed for perforations of the cervical esophagus that cannot be visualized. Esophageal T-tube placement or exclusion and diversion techniques are appropriate in clinically unstable patients and in cases where primary repair is precluded either due to preexisting esophageal disease or extensive esophageal damage. Esophagectomy should be performed in patients with malignancy, end-stage benign esophageal disease or extensive esophageal damage that precludes repair. Endoscopic techniques, including stenting, clipping or vacuum therapy, can be used in select cases. Finally, nonoperative management should be reserved for patients with contained esophageal perforations, limited extraluminal soilage and no evidence of systemic inflammation.

Carcinoma of unknown primary abuts left clavicle: Case report and review of the literature.

INTRODUCTION: Carcinoma of unknown primary is a well-recognized clinical syndrome which accounts for the 3-5% of all the malignancies. Patients with carcinoma of unknown primary usually present with late stage disease without having identified the primary source of the tumour despite an extensive diagnostic work-up. PRESENTATION OF CASE: A 60 years old male presented to the clinic complaining of a neck mass to the left lateral neck. Patient's history was unremarkable without evidence of any malignant disease. Clinical and radiological examination revealed a cystic mass extending from the lower one third of the neck to the left clavicle causing periostal reaction. Mass biopsy and PET-CT was unspecific for the primary origin of the mass. However in the context of tumour immunohistochemistry, HPV status, neck location and basaloid cell differentiation, the tumour mass was considered as carcinoma of unknown primary with possible oropharyngeal primary location. The patient underwent surgical resection of the mass, left clavicle and the first rib. One year after the operation the patient is disease free. DISCUSSION: Although CUP usually presents with cervical lyphadenopathy, in our case there was no evidence of lymph node tissue infiltration in the neck region. Surgical resection of the mass showed that the location was extending within the cervical soft tissues and upper thorax. Taking into consideration the absence of lymphadenopathy this is an uncommon location of carcinoma of unknown primary in the neck. CONCLUSION: This is an uncommon location of CUP with possible implications in survival and management.

A critical appraisal of open- and closed-chest models of experimental myocardial ischemia.

Myocardial ischemia is one of the most extensively studied topics in modern cardiovascular research. Early investigators first reported experimental myocardial ischemia (EMI) in 1862. The open-chest (surgical) approach is a well-developed model of EMI that enables researchers to directly access and observe the heart. With this approach, EMI is generally induced by surgical ligation of a coronary artery. A drawback of the open-chest model is the need for major surgery, which can result in local and systemic side effects. Alternative closed-chest models of EMI have been developed; most of these models involve endovascular catheterization with coronary artery embolization or thrombosis. Closed-chest techniques eliminate the need for invasive surgery, and the resultant model is more physiologically similar to clinical myocardial ischemia than is EMI produced by artery ligation. The authors present a review of open- and closed-chest models of EMI and discuss the advantages and disadvantages of each approach.

Is systematic lymph node dissection mandatory or is sampling adequate in patients with stage I non-small-cell lung cancer?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: Is systematic lymph node dissection (SLND) mandatory or is sampling adequate in stage I non-small-cell lung cancer (NSCLC)? Two hundred and eleven papers were identified, of which 12 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and the results of these papers are tabulated. There are 7 retrospective cohort reviews, 3 meta-analyses and 2 randomized controlled clinical trials (RCTs) to answer the clinical question. Four of the 7 retrospective studies demonstrated that the total number of resected lymph nodes and the number of lymph node stations sampled affected the accuracy of staging in patients with early-stage NSCLC and had an impact on overall survival and disease-free survival. Two RCTs, 1 meta-analysis and 1 cohort study revealed no significant benefit in overall survival and disease-free survival in patients undergoing SLND. One meta-analysis, which contained only 1 RCT, revealed significantly better 3- and 5-year survival with SLND. One further meta-analysis revealed improved survival with SLND in cohort studies but no significant difference in the 4 RCTs included. Two further studies identified specific subgroups of patients in whom LN sampling could be justified and SLND avoided. We conclude that there is no significant difference in the recurrence rate when performing either SLND or LN sampling in patients with stage I NSCLC. While retrospective cohort studies implied survival benefit with SLND, this was not borne out in RCTs and meta-analyses. However, there may be a potential survival benefit for patients who are upstaged by SLND identifying mediastinal nodal involvement.

Biologic Agents in the Treatment of Multicentric Castleman Disease.

Multicentric Castleman disease (MCD) causes an extensive range of systematic symptoms and can be life-threatening if not treated promptly and appropriately. The pathophysiology of the disease remains unclear; however, interleukin 6 (IL-6) pathway and human herpesvirus 8 infection appear to play an important role. As a result, the treatment of MCD remains complex and often insufficient, although a plethora of therapeutic approaches have been used. Between these, biological agents in the form of monoclonal antibodies against specific pathogenic processes of the disease have improved survival rates significantly. In the present study, we review the clinical results of rituximab, which targets B lymphocytes, siltuximab and tocilizumab, which target the IL-6 pathway, bortezomib, which is a selective proteasome inhibitor, and anakinra, which is an interleukin 1 receptor antagonist. The introduction of these biological agents in the treatment of MCD appears to be promising in the first studies performed. However, more clinical trials are required to assess the efficacy and safety of each agent and to form therapeutic strategies that will be widely accepted.

The role of surgical resection in Unicentric Castleman's disease: a systematic review.

INTRODUCTION: Castleman's disease is a rare benign lymphoproliferative disorder of unknown etiology. The disease occurs in two clinical forms with different prognoses, treatments and symptoms: a unicentric form (UCD), which is solitary, localized, and a multicentric form characterized by generalized lymphadenopathy and systemic symptoms. This article aims to review the current literature to consolidate the evidence surrounding the curative potential of surgical treatment to the unicentric type. MATERIAL AND METHODS: A systematic review of English-language literature was performed and databases (Medline, Pubmed, the Cochrane Database and grey literature) were searched to identify articles pertaining to the treatment of unicentric form of Castleman's disease. Each article was critiqued by two authors using a structured appraisal tool, and stratified according to the level of evidence. RESULTS: After application of inclusion criteria, 14 studies were included. There were no prospective randomized control studies identified. One meta-analysis including 278 patients with UCD reported that resective surgery is safe and should be considered the gold standard for treatment. Seven retrospective studies enhance this standpoint. Radiotherapy (RT) has been used in six studies with controversial results. CONCLUSIONS: We conclude that surgical resection appears to be the most effective treatment for Unicentric Castleman's Disease of the thoracic cavity. Radiotherapy can also achieve clinical response and cure in selected patients.

Surgical approach in oligometastatic non-small cell lung cancer.

The vast majority of lung cancer (80%) are non-small cell lung cancer (NSCLC) presenting in huge proportion of patients in a metastatic stage at the time of diagnosis with an overall survival (OS) of only 6 months. Standard treatment at this stage involves systemic platinum based chemotherapy improving the OS for only few months. For the vast majority of patients disease progression occurs and cure cannot achieved. An exception to this general rule is represented by patients with a limited number of metastasis (approximately 7% of patients with metastatic NSCLC): in 1995 Hellman and Weichselbaum introduced the term "oligometastatic" for a selected group of patients with metastatic disease. Several retrospective studies have been published and documented an improved outcome in patients managed surgically. The purpose of this narrative review is to gather all relevant information and present the various clinicopathological and generic aspects of diagnosis, management strategies and prognostic factors in patients with oligometastatic NSCLC. The key for long term survival includes radical treatment of the primary NSCLC, single organ site with either synchronous or metachronous presentation, a disease free interval to be as long as possible and the absence of intrathoracic lymph node spread (N0). A more accurate staging with combination of FDG-PET and CT scan can have on impact on the survival rates due to an increased accuracy in mediastinal staging and in the diagnosis of distant metastasis. No randomized data but only retrospective series are available to date to address this topic: in the future, additional prospective studies will be necessary to provide robust evidence to support the surgical resection as treatment of oligometastatic NSCLC.