1000 Robotic-assisted lobectomies for primary lung cancer: 16 years single center experience.

OBJECTIVE: This study aimed at describing our high-volume single center experience in robotic-assisted thoracic surgery (RATS) to evaluate short outcome and feasibility of the technique, the adequacy of oncological results, and the learning curve. METHODS: We retrospectively analyzed data from 1000 consecutive patients who underwent lobectomy and systematic lymphadenectomy for primary lung cancer using RATS approach between May 2007 and May 2023. RESULTS: Nine-hundred ninety-seven patients (99.7 %) underwent lobectomy, whereas 3 (0.03 %) patients bilobectomy. Conversion rate to open surgery was 3.7 %. Minor complications occurred in 213 (21.3 %) patients, major complications in 29 patients (2.9 %). The 30-day and 90-day operative mortality was 0 % and 0.1 %, respectively. The median number of N1 + N2 stations resected was 5 (range 0-9), with a median number of 17 of N1 + N2 lymph nodes resected (range 0-55). The oncological outcome was evaluated only on the subgroup of patients (n = 895) with non-small cell lung cancer. Pathological lymph node upstaging from cN0 to pN1/pN2 was evident in 147 patients (17.3 %): 9 % from cN0 to pN1 and 7.1 % from cN0 to pN2. With a median follow-up of 3.9, 5-year OS and DFS were respectively 89.3 % and 83.6 % for stage I, 74 % and 66.5 % for stage II, and 61 % and 36.4 % for stage IIIA. CONCLUSIONS: Better vision and excellent instrument maneuverability of the robotic surgical system allowed excellent results in terms of early, adequate oncological outcome comparable to open surgery literature data, and acceptable learning curve. ULTRAMINI ABSTRACT: 1000 consecutive patients who underwent lobectomy and systematic lymphadenectomy for primary lung cancer using RATS approach have been analyzed with the aim to describe our high-volume single center experience, and to evaluate short outcome and feasibility of the technique, the adequacy of oncological results, and the learning curve.

Pneumonectomy for broncho-pulmonary carcinoids: a single centre analysis of surgical approaches and patient outcomes.

Background: Pneumonectomy is a radical surgical procedure associated with significant morbidity and mortality. Its application in the context of pulmonary neuroendocrine tumours, including carcinoid tumours, requires meticulous preoperative planning and intraoperative precision. This study aims to assess the safety and efficacy of pneumonectomy in the management of these rare and challenging neoplasms. Methods: A retrospective analysis of patients who underwent pneumonectomy for pulmonary carcinoid tumours at our institution over a specified period was conducted. Data regarding patient demographics, tumour characteristics, surgical techniques, intraoperative complications, perioperative management, and long-term outcomes were collected and analysed. Results: Between March 2001 and October 2022, 21 patients (7 male, 14 female) with carcinoid tumours underwent pneumonectomy on a total of 459 surgical operations for carcinoid. Preoperative bronchoscopic procedures were conducted in 90.4% of cases, leading to histological diagnoses for most. The median hospital stay was eight days, with no reported perioperative deaths. Median follow-up after surgery was 73 months, with a five-year overall survival of 65.4 months. Recurrences occurred in 28.6% of cases, primarily in atypical carcinoids. Conclusion: Despite the rarity of bronchial carcinoids, pneumonectomy is effective for low-grade malignancies, demonstrating positive short-and long-term outcomes. Radical lymph node dissection is fundamental in pathological staging and overall survival.

How General and Inflammatory Status Impacts on the Prognosis of Patients Affected by Lung Cancer: State of the Art.

Pulmonary cancer is often associated with systemic inflammation and poor nutritional status and these two aspects are strongly correlated and related to the scarce infiltration of a tumor by immune cells. We reviewed all English literature reviews from 2000 to 2024 from PubMed, Scopus and Google Scholar, including original articles, review articles, and metanalyses. We excluded non-English language articles and case reports/case series. Generally speaking, nutritional and inflammatory status largely affect medium and long-term prognosis in lung cancer patients. A correct stratification of patients could improve their preoperative general functional nutritional and inflammatory status, minimizing, therefore, possible treatment complications and improving long-term prognosis.

Anastomosis Complications after Bronchoplasty: Incidence, Risk Factors, and Treatment Options Reported by a Referral Cancer Center.

BACKGROUND: Sleeve lobectomy with bronchoplasty is a safe surgical technique for the management of lung cancer and endobronchial localization of extrapulmonary cancers. However, anastomotic complications can occur, and treatment strategies are not standardized. METHODS: Data from 280 patients subjected to bronchoplasty were retrospectively analyzed, focusing on surgical techniques, anastomotic complications, and their management. Multivariate analysis was performed, and Kaplan-Meier curves were used to determine survival. RESULTS: Ninety percent of 280 surgeries were for lung cancer. Anastomotic complications occurred in 6.42% of patients: late stenosis in 3.92% and broncho-pleural fistula in 1.78%. The median survival was 65.90 months (95% CI = 41.76-90.97), with no difference (p = 0.375) for patients with (51.28 months) or without (71.03 months) anastomotic complications. Mortality at 30 days was higher with anastomotic complications (16.7% vs. 3%, p = 0.014). Multivariable analysis confirmed pathological stage (N+) as a risk factor for anastomotic complications (p = 0.016). Our mortality (3.93%) and morbidity rate (41.78%) corresponded to recent series results. CONCLUSIONS: In our experience, surgery is preferred to avoid life-threatening complications in bronchopleural fistulas. Bronchoscopic balloon dilatation is preferred for benign strictures. The nodal stage is related to complications (p = 0.0014), reflecting the aggressiveness of surgery, which requires extended radical lymphadenectomy.

The Role of Surgery in Primary Chest Wall Tumors: Over 20 Years' Experience in Resection and Reconstruction.

BACKGROUND: Primary chest wall tumors comprise a heterogeneous group of neoplasms arising from soft tissues and bones. While surgical excision is the standard of care for benign tumors, the management of malignant tumors requires multimodal treatment. We conducted a predictive analysis of outcome, recurrence-free and overall survival. METHODS: We retrospectively reviewed the clinical and pathological records of all patients treated in our center between 1998 and 2020. RESULTS: 53 patients (15-85 years) were treated in our department. The average tumor diameter was 65 ± 35 mm (10-160 mm). Negative margins were obtained in 48 patients (90.6%), whereas in the remaining 5, R1 resection was accomplished. Median overall survival was 63,03 months (1-282 months). Overall survival was 90% at 1 year, 78% at 2 years, and 61% at 5 years. Our analysis identified tumor diameter, postoperative complications, and high grade of malignancy as factors that can influence prognosis. CONCLUSIONS: The treatment of primary chest wall tumors remains a very challenging process. Different histological types preclude definition of an unequivocal approach. Complete resection with healthy margins remains a definitive cornerstone in the treatment of these cancers as part of a more comprehensive approach.

A Practical Assessment of the Postoperative Management in Lung Cancer Surgery.

Postoperative management after major and minor thoracic surgeries is crucial for patient recovery and can be challenging. Major thoracic surgeries, such as extensive pulmonary resections, especially in patients with poor health status, may require intensive surveillance, particularly during the first 24-72 h after surgery. Moreover, thanks to the demographic development and medical progress in perioperative medicine, more patients with comorbidities undergoing thoracic procedures require proper management in the postoperative period to improve prognosis and decrease hospital stay. Here, we summarize the main thoracic postoperative complications in order to clarify how to prevent them through a series of standardized procedures.

Minimally Invasive Anatomical Segmentectomy versus Lobectomy in Stage IA Non-Small Cell Lung Cancer: A Systematic Review and Meta-Analysis.

OBJECTIVE: A systematic review and meta-analysis was performed to assess potential differences in perioperative outcomes and disease-free survival (DFS) and overall survival (OS) of patients with pathological stage IA non-small cell lung cancer (NSCLC) who underwent minimally invasive anatomical segmentectomy or lobectomy. METHODS: This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search of EMBASE (through Ovid), MEDLINE (via PubMed), and Cochrane CENTRAL was conducted. Two researchers independently reviewed each eligible study that included patients with stage IA NSCLC who underwent minimally invasive anatomical segmentectomy and lobectomy and compared perioperative and/or survival outcomes of patients. RESULTS: A total of 887 publications were identified. Of these, 10 articles met our eligibility criteria. A significantly higher number of lymph nodes were harvested in lobectomies. The two groups did not significantly differ in postoperative complication rates, DFS, and OS. Patients who underwent segmentectomy had shorter postoperative hospital stays. CONCLUSIONS: Minimally invasive lobectomy and segmentectomy showed comparable short-term and long-term outcomes in stage IA NSCLC patients. Postoperative complication rates were similar. Minimally invasive lobectomies are associated with a higher number of harvested lymph nodes, although this did not affect the final staging or the survival outcomes.

Correction to: Cover always the bronchial stump! A flap could prevent catastrophic complications even in complete broncho­pleural fistula.

[This corrects the article DOI: 10.1007/s12055-022-01386-3.].

Cover always the bronchial stump! A flap could prevent catastrophic complications even in complete broncho-pleural fistula.

Broncho-pleural fistula after pneumonectomy is a life-threatening condition with very high mortality rate, even if detected early. All symptomatic patients should be treated immediately. The diagnosis in the absence of symptoms poses the real difficulties of management. Early detection of asymptomatic post-pneumonectomy broncho-pleural fistula is usually fortuitous. The use of bronchoscopy allows direct and accurate evaluation of the stump. This reported case allows us to make several considerations on the treatment of fistulas, but above all to consider that the systematic bronchial stump coverage is fundamental not only for preventing fistulas, but also for limiting their enlargement and communication with the residual cavity, in order to prevent catastrophic complications.

Long-term clinical outcomes and prognostic factors of upfront surgery as a first-line therapy in biopsy-proven clinical N2 non-small cell lung cancer.

Background: Multimodality therapy offers the best opportunity to improve pathological N2 non-small cell lung cancer (NSCLC) prognosis. This paper aimed to evaluate the long-term clinical outcomes and the prognostic factors of upfront surgery as first-line therapy in biopsy-proven clinical N2. Methods: Retrospective review of biopsy-proven cN2 NSCLC patients operated between 2007 and 2017. Upfront surgery was considered if the primary tumour was deemed completely resectable, with mediastinal nodal involvement confined to a single station and no preoperative evidence of extranodal tumour invasion. Results: Two hundred eighty-five patients who underwent radical resections were included. One hundred fifty-nine patients (55.8%) received induction chemotherapy. At follow-up completion, 127 (44.6%) patients had died. For the induction chemotherapy group, the median overall survival (OS) was 49 months [95% confidence interval (CI): 38-70 months], and the 5-year OS was 44.4%. The median and 5-year OS for the up front surgery group was 66 months (95% CI: 40-119 months) and 66.3%, respectively. There were no statistically significant differences between treatment approaches (p = 0.48). One hundred thirty-four patients (47.0%) developed recurrence. The recurrence-free survival (RFS) at 5 years was 17% (95% CI: 11-25%) for induction chemotherapy and 22% (95% CI: 9-32%) for upfront surgery; there were no statistically significant differences between groups (p = 0.93). No significant differences were observed based on the clinical N status (OS, p = 0.36; RFS, p = 0.65). Conclusions: Upfront surgery as first-line therapy for biopsy-proven cN2 NSCLC showed favourable clinical outcomes, similar to those obtained after induction chemotherapy followed by surgery. Therefore, it should be considered one of the multimodality treatment options in resectable N2 NSCLC.

The "Balloon-Like" Sign: Differential Diagnosis between Postoperative Air Leak and Residual Pleural Space: Radiological Findings and Clinical Implications of the Young-Laplace Equation.

In this paper, we propose a radiological sign for an appropriate differential diagnosis between postoperative pleural space and active air leak after lung resection. In the case of residual pleural space without any active air leak, the lung takes the form of a round balloon due to the hyperinflation condition, which is governed by the Young-Laplace equation describing the capillary pressure difference sustained across the interface between two static fluids, such as water and air, due to the phenomenon of wall tension. The two principal mechanisms by which a lung forms a spherical image are shear-controlled detachment induced by shear stress on the membrane surface, and spontaneous detachment induced by a gradient in Young-Laplace pressure. On the contrary, the lung maintains its tapered shape in the case of an active air leak because the continuous air refill does not allow a complete parenchyma re-expansion.

Surgical management of superior sulcus tumors: A twenty-year experience of an oncological high volume referral centre.

Objectives: Superior sulcus tumour, which affects the lung's apex, is an uncommon subtype of non-small cell lung cancer (NSCLC). The current study examined the clinical characteristics and management of superior sulcus NSCLC patients in a high-volume referral oncological centre over 22 years. Methods: Retrospective review of 100 surgeries with curative intent for superior sulcus NSCLC over 22 years (July 1998 - December 2020). The surgical approach was defined according to the lesion site and the anatomy of the thoracic inlet. Survival curves, including non-cancer-related deaths, were drawn using the Kaplan-Meier methods, and the log-rank test was used to evaluate differences in survival across groups of patients. Cox proportional hazards regression was used to assess the association between selected clinical and pathologic characteristics on OS. Results: 54 patients received induction treatments. The surgical approach was anterior thoracotomy in 53 patients, Paulson incision in 30, and a combined in 8. The median postoperative length of stay was 11 days (range: 5 - 27 days). Overall 90-day mortality was 6.93%. The median OS was 24.3 months. After a median follow-up of 3 years, 5-year and 10-year OS rates were 33.9% and 26.4%, respectively. A significantly lower 5-year OS was observed in patients with the nodal disease (46.6% in pN0 vs 13.2% in pN+; p = 0.024), without preoperative treatments (41.0% in patients without preoperative treatments versus 17.4%; p = 0.09) and anteriorly located tumour (anterior vs posterior: 17.4% vs 49.1%; p = 0.032). Cox proportional hazards regression showed better survival in the pT1 stage (HR = 4.6; 95% CI: 1.9 - 11.2; p = 0.00076) and in R0 (HR = 4.2; 95% CI: 1.4 - 12.5; p = 0.010). Conclusions: Superior sulcus tumours still represent a life-threatening condition that, while curable in a significant proportion of cases, requires complex procedures with high surgical risks and a multimodality treatment setting. An optimal surgical approach should be planned to maximise resection completeness and survival. Other factors affecting survival are related to tumour staging, emphasising the importance of a meticulous preoperative workup and candidate selection to identify those expected to benefit from a survival benefit.

Results of Surgical Resection of Locally Advanced Pulmonary Neuroendocrine Tumors.

BACKGROUND: Pulmonary neuroendocrine tumors include well-differentiated and poorly differentiated histology for which cell type has proved to be a determinant of survival in many studies. In patients diagnosed with bronchial carcinoid and large cell neuroendocrine carcinoma (LCNEC), surgery is the treatment of choice even in the case of locally advanced disease with lymph node involvement. METHODS: We retrospectively analyzed patients undergoing anatomic lung resection for bronchial carcinoid or LCNEC with lymph node involvement (N1/N2) at the final pathologic examination (pN+). Characteristics of patients and differences in overall survival and disease-free survival are presented according to tumor type. Overall survival of distinct histologic groups was compared with survival in our institutional experience in stage I patients, without nodal involvement (pN0). RESULTS: In all, 325 patients underwent surgical resection for neuroendocrine tumors; 89 patients had nodal involvement. Five-year survival was 89% in pN+ bronchial carcinoid both for typical carcinoid and atypical carcinoid but worse for pN+ LCNEC (47%). Cell type did not influence the prognosis in N0 disease, and no differences in survival were evident between N0 and N+ in the bronchial carcinoid group. In the group of LCNEC, 5-year overall survival was much worse for pN+ LCNEC (47%) compared with pN0 LCNEC (91%). CONCLUSIONS: Bronchial carcinoids have the best prognosis, and surgery remains the treatment of choice for both early and locally advanced disease. On the contrary, aggressive forms (LCNEC) with lymph nodal metastasis have a poor prognosis, and they need to be treated with an aggressive multidisciplinary approach.

When less is more: a daring conservative approach to postpneumonectomy oesophago-pleural fistula.

Oesophago-pleural fistula is an uncommon complication after pneumonectomy, usually related to high morbidity and mortality. Due to its rarity and heterogeneous clinical presentation, its diagnosis and management are challenging issues. Here, we report the case of a patient with a history of pneumonectomy for a tracheal tumour, who developed an asymptomatic oesophago-pleural fistula 7 years after primary surgery. In consideration of the patient's good clinical status and after verifying the preservation of respiratory and digestive functions, a bold conservative approach was adopted. Five-year follow-up computed tomography did not disclose any sign of recurrence of disease and showed a stable, chronic fistula.

When a Differential Diagnosis Is Fundamental: Choriocarcinoma Mimicking Lung Carcinoma.

Background: Choriocarcinoma is a rare malignant disease that is usually associated with a gestational event. Lung metastasis with no evident primary origin and choriocarcinoma, which mimics features of non-small-cell lung cancer, might be misdiagnosed as adenocarcinoma or large-cell carcinoma. This is a pivotal clinical concern since the tumor can lead to various symptoms, seriously affecting the quality of life and can escalate rapidly, with a high mortality rate, compared to lung cancer. Methods: We reported a case of a 37-year-old woman with a history of one-year enhancement of beta-human chorionic gonadotropin levels and only a single nodule in the right upper lobe, with no abnormal findings on the gynecological investigation. Then we retrospectively examined all cases treated in the Division of Thoracic Surgery at the European Institute of Oncology in the last twenty years (from 1998 to 2018). Results: This was the first time in our experience that choriocarcinoma presentation was with a single nodule without a gynecological finding. Moreover, the differential diagnosis between lung carcinoma and choriocarcinoma was achieved only after surgical removal. Conclusions: As confirmed by our literature search, precise and expedited differential diagnosis is essential in choriocarcinoma care (both with single or multiple metastases), to successfully remove the tumor and increase the patient's chances of survival.

Not everything is what it seems: malignant pleural mesothelioma mimicking lung cancer.

Malignant pleural mesothelioma usually arises from the pleural surface and progressively encases the lungs. Pulmonary involvement generally occurs at an advanced stage, while intraparenchymal nodules, in the absence of pleural lesions, constitute a less frequent presentation. We describe the case of a patient with multiple bilateral pulmonary nodules, mediastinal lymphadenopathies and left pleural effusion in the absence of pleural lesions, simulating advanced stage lung cancer. Thoracoscopic inspection did not detect any lesions. Pathological examination on one pulmonary nodule revealed malignant pleural mesothelioma. Despite its rarity, intraparenchymal malignant pleural mesothelioma should always be taken into account, when lung nodules are present, to prevent misdiagnosis and avoid delayed treatment.

Bronchial carcinoid in anomalous right upper bronchus: a "patient-tailored" bronchoplasty resection technique.

Bronchial carcinoids (BC) are indolent neuroendocrine tumors (NET) that are classified as malignant because they can locally infiltrate and metastasize. Resection is the primary treatment for most localized carcinoid tumors, with lung parenchymal-sparing surgery the favoured objective for patients with central airway tumors. Sleeve bronchoplasty techniques are complex surgical procedures defined as parenchyma-saving because they allow a radical resection with tumor-free margins while preserving the maximum amount of parenchyma. They are mainly indicated for tumors arising at the origin of a lobar bronchus, precluding simple lobectomy but not infiltrating so far as to require pneumonectomy. We describe a case of typical bronchial carcinoid of an anomalous right upper bronchus requiring a "patient-tailored" bronchoplasty technique. The surgical aspects and preoperative work-up are discussed.

Metastasectomy in pediatric patients: indications, technical tips and outcomes.

Pulmonary metastasectomy has become a standard procedure for pediatric patients with certain types of solid tumors. Surgeons, expert pediatric oncologists and radiation oncologists contribute with their different skills to the management of pulmonary metastases. Patients are usually scheduled for surgery in case of primary tumor control, in absence of metastases in other organs and when a complete resection is achievable. Nodules are removed through precision resections using electrocautery or laser methods in order to ensure radical surgery with adequate margins. With these techniques, it is possible to preserve the surrounding parenchyma and cause a limited volumetric distortion as compared with staplers. Anatomical resections (segmentectomy, lobectomy or pneumonectomy) should be reserved for selected cases, since major lung resection can only be justified if it leads to a real oncological advantage. Repeated thoracotomies are possible, since there is no theoretical limit to reinterventions. Surgery of lung metastases has a therapeutic and curative role for some histology with acceptable rate of complications but it finds its role only in an aggressive multimodality approach. Indications can be discussed case by case and exceptions can be evaluated also in presence of different evidences. Children affected by metastatic tumors need to be managed by expert multidisciplinary oncological team in referral center with large experience.

Lung metastasectomy in adenoid cystic cancer: Is it worth it?

BACKGROUND AND PURPOSE: Adenoid cystic carcinoma (ACC) of salivary glands is characterized by long-term distant metastasis, most commonly in lungs. No agreement has been reached about the role of surgical treatment of pulmonary lesions. We evaluated the long-term results of lung metastasectomy for ACC in order to identify factors that should be taken into account in selecting patients eligible for surgery and treatment planning. PATIENTS AND METHODS: A retrospective study was conducted on 109 patients selected from our institutional experience and from the International Registry of Lung Metastases. Survival was calculated by Kaplan-Meier estimate and prognostic factors endowed with a predictive power for most other metastatic cancers were investigated. RESULTS: The cumulative survival was 66.8% at 5years and 40.5% at 10years. In patients with a disease-free interval (DFI) greater than 36months, the overall survival was 76.5% at 5years. Survival in case of complete surgical resection was 69.5% at 5years. Multivariate analysis confirmed DFI and completeness of resection resulted in the best prognostic variables. DISCUSSION: Lung metastasectomy should be considered as a therapeutic option to achieve local control of disease when 2 conditions are met: (1) complete surgical resection is feasible and (2) the time to pulmonary relapse after primary tumor treatment is greater than 36months. Symptomatic benefits of an incomplete lung resection in slow-growing tumors such as ACC remain uncertain. The turning point in the management of disseminated cancers will be clarified with biological profiling of ACC and the development of targeted therapies.

Surgical approach to primary tumors of the chest wall in children and adolescents: 30 years of mono-institutional experience.

AIMS AND BACKGROUND: Chest wall reconstruction after surgical resection for malignancies in children is a challenge for surgeons because of growth-related complications. The aim of this study is to analyze the surgical treatment and outcomes of 30 pediatric and adolescent patients treated at Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy, over a 30-year period. METHODS: Pediatric patients undergoing chest wall resection were retrospectively reviewed and selected for malignant primary tumor. Endpoints were survival, recurrences, and long-term results. We also reported the use of the innovative rib-like technique in 2 young patients. RESULTS: Twenty-one patients were male. Median age was 13.7 years. Eleven patients (37%) presented with a chest wall mass. Twenty-six (87%) had Ewing sarcoma family tumors. Twenty-eight (94%) received neoadjuvant chemotherapy after histologic diagnosis. One rib was resected in 13 cases; 2 or 3 contiguous ribs in 8 cases. No postoperative mortality was observed and the complication rate was 40%. Overall survival was 85.2% (95% confidence interval [CI] 65.2%-94.2%) at 5 and 10 years. Relapse occurred in 7 patients. The 5-year disease-free survival rate was 82% (95% CI 62%-92%). CONCLUSIONS: Long-term survival is achievable for chest wall tumors in a high-volume referral center where a multimodal treatment should be set to reach the best result. As advances in medical treatment have increased survival, surgical techniques must ensure a lasting functional result. When refining the reconstruction techniques, such as the rib-like approach, it is necessary to expand the options of curative surgery for young patients.