Solitary fibrous tumours of the pleura: do we need a different perspective on malignancy?

OBJECTIVES: Solitary fibrous tumours of the pleura (SFTP) are historically considered to be benign soft tissue neoplasms. However, a clinical relevant number of these neoplasms have malignant histological features. The objective of this study was to evaluate the percentage of SFTP presenting unfavourable clinical behaviour in order to predict negative long-term outcome. METHODS: A retrospective review of 74 patients treated at 4 hospitals between 1990 and 2013 was performed. The median follow-up was 10 years (range: 1-20 years). Risk of tumour recurrence and metastases (unfavourable clinical behaviour) with regard to histology using the Kaplan-Meier and Cox proportional hazards methods. RESULTS: The mean age was 61 years (SD 12.75 years). There were 31 male patients (58%) and 43 female patients (42%). Tumour size ranged from 1 to 30 cm (mean 9.09 cm; SD 6.22 cm). Complete resection (R0) was achieved by minimally invasive thoracoscopic resection in 29% and thoracotomy in 57%; 25% of SFTPs showed histological evidence of malignancy, according to England criteria. Recurrence occurred in 21% and 10% of patients had metastases; 83% of patients with metastases and 39% of patients with recurrence died within 5 years. The median recurrence-free survival for histologically benign SFTP was not reached, compared to 8 years for malignant SFTP. The five-year overall survival rate was 84%. Mitotic rate ≥1/10 HPF, high cellularity, nuclear atypia, Ki-67 level >5% and poorly circumscribed (sessile) growth pattern were associated with poor long-term outcome. CONCLUSIONS: Pathological differentiation of SFTP morphology into pedunculated, well circumscribed and poorly circumscribed (sessile) growth pattern is recommended. Due to the misleading classification into histologically benign and malignant, all unpedunculated SFTP should be classified as potentially aggressive. Lifelong follow-up is mandatory.

[Delphi Expert Consensus of the German Society for Thoracic Surgery on Segmentectomy for Non-small Cell Lung Cancer]. / Delphi-Experten-Konsens der Deutschen Gesellschaft für Thoraxchirurgie über die anatomische Segmentresektion bei nicht kleinzelligem Lungenkarzinom.

BACKGROUND: Findings from two recently published randomised controlled trials have shown favourable oncological results of segmentectomy for early-stage NSCLC < 2 cm. This has generated a growing interest in this procedure, which is however considered technically more challenging than lobectomy. The aim of the working group of the German Society for Thoracic Surgery (DGT) was to address, via an expert consensus project, topics concerning implementation of segmentectomy in lung cancer surgery. METHODS: The assigned group of the DGT designed and conducted two electronic rounds of questions in all major thoracic and lung cancer centres in Germany. The steering group predefined a priori the threshold of consensus of 75% or greater. The results were discussed in an expert meeting, leading to a final Delphi poll for selected topics and questions. RESULTS: Thirty-eight questions on segmentectomy for NSCLC were proposed in two rounds and voted on. After the final Delphi process, a consensus was reached for the following topics: non-inferiority of segmentectomy vs. lobectomy for tumours < 2 cm, segmentectomy as an alternative if lobectomy is functionally not feasible, use of intraoperative techniques for identification of intersegmental borders. No consensus could be reached for topics such as frozen section for intraoperative ascertainment of radicality, as also for the indication of a re-do lobectomy in case of an occult N1 lymph node status. CONCLUSION: Our manuscript depicts the results of a Delphi process in 2020/2021 involving experts of the German Society for Thoracic Surgery on the implementation of segmentectomy in lung cancer patients. In general, a very high rate of consensus was documented for the majority of the topics concerning the indication and execution of lung segmentectomy.

Outcome of Repeat Pulmonary Metastasectomy.

Pulmonary metastasectomy is a well-established contribution to the cure of oligometastatic cancers, but its exact effectiveness is poorly understood. Here we report the outcomes of repeat pulmonary metastasectomy from a multicenter trial. This retrospective study included patients who underwent re-do metastasectomies between January 2010 and December 2014. The exclusion criterion was metastasectomy without curative intent. We reviewed medical files of 621 consecutive patients who underwent initial pulmonary metastasectomy. Of those, 64 patients underwent repeat metastasectomies, and these patients were included in the analysis. All the 64 patients underwent a second metastasectomy, later 35 of them underwent a third metastasectomy, 12 underwent a fourth metastasectomy, and 6 underwent a fifth metastasectomy. The total number of re-do metastasectomies was 181. The median overall survival among the patients undergoing re-do metastasectomy was 66.0 ± 3.8 months. Three and 5-year survival rates were 82.3% and 63.3%, respectively. The 5-year survival rates were 63.3% after the first, 50.9% after the second, 74.4% after the third, 83.3% after the fourth, and 60.0% after the fifth metastasectomy. We conclude that at the current stage of knowledge, there is an indication for repeat re-do metastasectomy with curative intent.

Endoscopic lung volume reduction with endobronchial valves in very low D LCO patients: results from the German Registry - Lungenemphysemregister e.V.

BACKGROUND: Endoscopic lung volume reduction (ELVR) with valves has been suggested to be the key strategy for patients with severe emphysema and concomitant low diffusing capacity of the lung for carbon monoxide (D LCO). However, robust evidence is still missing. We therefore aim to compare clinical outcomes in relation to D LCO for patients treated with ELVR. METHODS: We assessed D LCO at baseline and 3 months follow-up and compared pre- and postprocedural pulmonary function test, quality of life, exercise capacity and adverse events. This is a retrospective subanalysis of prospectively collected data from the German Lung Emphysema Registry. RESULTS: In total, 121 patients treated with ELVR were analysed. Thirty-four patients with a D LCO ≤20% and 87 patients with a D LCO >20% showed similar baseline characteristics. After ELVR, there was a decrease of residual volume (both p<0.001 to baseline) in both groups, and both demonstrated better quality of life (p<0.01 to baseline). Forced expiratory volume in 1 s (FEV1) improved significantly only in patients with a D LCO >20% (p<0.001 to baseline). Exercise capacity remained almost unchanged in both groups (p=0.3). The most frequent complication for both groups was a pneumothorax (D LCO ≤20%: 17.6% versus D LCO >20%: 16.1%; p=0.728). However, there were no significant differences in other adverse events between both groups. CONCLUSIONS: ELVR improves lung function as well as quality of life in patients with D LCO >20% and D LCO ≤20%. Adverse events did not differ between groups. Therefore, ELVR should be considered as a treatment option, even in patients with a very low D LCO.

[Delphi Expert Consensus of the German Thoracic Surgery Society on the Management of Chest Tube Drainage]. / Delphi-Konsens der Deutschen Gesellschaft für Thoraxchirurgie über das Management von Thoraxdrainagen.

BACKGROUND: Chest tubes are a valuable instrument and are used on a daily basis - not only by thoracic surgeons but also by a variety of medical specialists who treat pneumothorax or pleural effusions. The goal of the working group of the German Thoracic Society (DGT) was to achieve a consensus on the management of chest tube/drainage using the Delphi process. METHODS: The assigned group of the DGT designed and conducted two electronic rounds of questions in all major thoracic and lung cancer centres. Consensus was considered as rate of ≥ 75%. After statistical analysis of the results, an expert meeting took place and a final Delphi process poll was used in order to reach consensus for controversial topics. RESULTS: Thirteen questions on the management of chest tubes were proposed and voted on. A consensus was reached for the following topics: conditions for chest tube insertion, size of drainage/tube, technique of insertion, diagnostic measures after insertion and prior to removal, post-interventional management, documentation, number of chest tubes after anatomical lung resection, use of fibrinolytic agents, type of negative pressure. No consensus was reached for the following topics: autologous blood pleurodesis, reduction of suction in cases of persistent air leakage. CONCLUSION: Our manuscript depicts the results of a Delphi process in 2017 - 1018 involving experts of the German Thoracic Society from high volume departments certified for thoracic surgery. A very high rate of consensus was documented for topics such as chest tube insertion, peri-interventional management and removal algorithm. The most important topic for which there was no consensus was the case of persistent air leakage. The resulting expert recommendations of the Delphi process could be used as a starting point for internal clinical procedures.

Residual thymic tissue and lymph node involvement by acute myeloid leukaemia presenting as mediastinal, strongly 18 FDG-PET-positive masses.

We report on a multidisciplinary management of a 68-year-old AML patient presenting with a PET-positive mediastinal tumour typical for lymph node metastasis. It was removed via minimally invasive thoracoscopic intervention and was identified as a thymus residual infiltrated by AML. Follow-up PET-CT scan after resection and remission induction chemotherapy was completely normal. To our knowledge, this is the first documented case report of AML presenting with PET-positive infiltrates of thymic and lymph node tissue along the aortic bow mimicking a second intrathoracic malignancy. Our observation indicates the usefulness of this imaging technique and supports clarification of these unusual findings in AML patients, in case of need also by invasive diagnostic procedures, to enable an adequate therapeutic decision.