Accuracy of 18F-FDG in Detecting Stage I Lung Adenocarcinomas According to IASLC/ATS/ERS Classification.

BACKGROUND: Only a small number of studies have explored the clinicopathological features of pulmonary adenocarcinoma (PA) associated with 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) false-negative (FN) results. Herein, we investigated the FDG-PET diagnostic performance by stratifying PAs according to International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society/American Thoracic Society/European Respiratory Society (IASLC/ATS/ERS) classification. METHODS: From January 2002 to December 2016, all consecutive patients who underwent pulmonary resection for stage I PA at six thoracic surgery institutions were retrospectively reviewed. The diagnostic performance of FDG-PET was analysed according to IASLC/ATS/ERS classification and two validated subclassifications. Univariable and multivariable logistic analysis were used to identify predictors of FDG-PET FN results. RESULTS: Five hundred and fifty (550) patients with stage I PA were included in the analyses. Most of the patients were male (n=354 [64.4%]) and smokers (n=369 [67.1%]). Ninety-seven (n=97 [17.6%]) FN cases were observed at FDG-PET imaging. On multivariable analysis, a lepidic pattern was found to be independently associated with FDG-PET FN results (odds ratio [OR], 3.20; p<0.001), while a solid pattern more commonly presented with a positive finding (OR, 0.40; p=0.066). According to Nakamura's classification, we observed an independent association between lepidic pattern and FDG-PET FN results (OR, 3.17; p<0.001), while solid/micropapillary patterns were independently related with increased FDG uptake (OR, 0.35; p=0.021). According to Yoshizawa's classification, Intermediate-grade tumours were independently correlated with FN FDG-PET results (OR, 2.78; p=0.005). CONCLUSIONS: In our cohort, histopathological features were significantly associated with FDG uptake. In particular, some adenocarcinoma subtypes (mostly Lepidic pattern) have a tendency towards FN FDG-PET findings. The correlation between computed tomography findings, clinical characteristics, and FDG uptake is mandatory, in order to tailor the precise diagnostic and therapeutic pathway for each patient.

Prognostic impact of lung adenocarcinoma second predominant pattern from a large European database.

BACKGROUND AND OBJECTIVES: Adenocarcinoma patterns could be grouped based on clinical behaviors: low- (lepidic), intermediate- (papillary or acinar), and high-grade (micropapillary and solid). We analyzed the impact of the second predominant pattern (SPP) on disease-free survival (DFS). METHODS: We retrospectively collected data of surgically resected stage I and II adenocarcinoma. SELECTION CRITERIA: anatomical resection with lymphadenectomy and pathological N0. Pure adenocarcinomas and mucinous subtypes were excluded. Recurrence rate and factors affecting DFS were analyzed according to the SPP focusing on intermediate-grade predominant pattern adenocarcinomas. RESULTS: Among 270 patients, 55% were male. The mean age was 68.3 years. SPP pattern appeared as follows: lepidic 43.0%, papillary 23.0%, solid 14.4%, acinar 11.9%, and micropapillary 7.8%. The recurrence rate was 21.5% and 5-year DFS was 71.1%. No difference in DFS was found according to SPP (p = .522). In patients with high-grade SPP, the percentage of SPP, age, and tumor size significantly influenced DFS (p = .016). In patients with lepidic SPP, size, male gender, and lymph-node sampling (p = .005; p = .014; p = .038, respectively) significantly influenced DFS. CONCLUSIONS: The impact of SPP on DFS is not homogeneous in a subset of patients with the intermediate-grade predominant patterns. The influence of high-grade SPP on DFS is related to its proportion in the tumor.

Minimally invasive treatment of diaphragmatic endometriosis: a 15-year single referral center's experience on 215 patients.

BACKGROUND: Diaphragmatic endometriosis (DE) is a rare and often misdiagnosed condition. Most of the times it is asymptomatic and due to the low accuracy of diagnostic tests, it is almost always detected during surgery for pelvic endometriosis. Its management is challenging and, until now, there are not guidelines about its treatment. METHODS: We describe a consecutive series of patients with DE managed by laparoscopy and videothoracoscopy (VATS) in our referral center in a period of 15 years. We developed a flow-chart classifying DE implants in foci, plaques and nodules and proposing an algorithm with the aim of standardizing the surgical approach. RESULTS: 215 patients were treated for DE. Lesions were almost always localized on the right hemidiaphragm (91%), and the endometriotic implants were distributed as: foci in 133 (62%), plaques in 24 (11%) and nodules in 58 patients (27%), respectively. In all cases of isolated pleural involvement, concomitant diaphragmatic hernia or lesions of the thoracic side of the diaphragm VATS was performed, alone or combined with laparoscopy, resulting in a total of 26 procedures. Following the proposed algorithm, specific surgical techniques were identified as the better approaches for the different types of the lesion, such as Argon Beam Coagulation and diathermocoagulation for diaphragmatic foci, peritoneal stripping for plaques, and nodulectomy or full-thickness resection of diaphragm for nodules. CONCLUSIONS: It is crucial to standardize the surgical approach of DE, according to the type of lesion, thus reducing the rate of under- or over-treatments and intra or postoperative complications. This kind of surgery should be performed in a Referral Center by a gynecologic surgeon with oncogynecologic expertise and skills, with the eventual support of a laparoscopic general surgeon, a specialized thoracic surgeon and a trained anesthesiologist.

Endometriosis Involving the Diaphragm: A Patient-Tailored Minimally Invasive Surgical Treatment.

BACKGROUND: Diaphragmatic endometriosis is a rare presentation of endometriosis and no standardized technique for surgical treatment is available so far. We aim to verify and describe feasibility, safety and post-operative outcomes of patients affected by diaphragmatic endometriosis treated with a minimally invasive video-assisted thoracic approach. METHODS: We prospectively collected data of all patients we operated on at our Institution for diaphragmatic endometriosis between 2015 and 2019. We included all patients with a previous histological diagnosis of pelvic or abdominal endometriosis who have complained chronic thoracic pain or who had two or more episodes of pneumothorax with or without radiological evidence of pleural and diaphragmatic endometriosis. RESULTS: During the study period, we operated on 22 patients, 20 on the right side, one on the left side and one bilaterally. Indication for surgery was based on symptoms and/or radiological evidence of diaphragmatic disease. Diaphragm was resected and reconstructed according to intraoperative findings; in 11 cases, an additional mesh was used to reinforce the suture. According to our experience with VATS, we shift from an open approach to a uniportal VATS technique. CONCLUSIONS: Surgery for diaphragmatic endometriosis can be safely performed using a minimally invasive VATS approach, which is feasible and safe even when more extensive diaphragmatic resections are required, and it allows a lower post-operative pain compared to the open approach. Moreover, uniportal VATS approach guarantees similar outcomes with better cosmetic results.

The everlasting issue of prolonged air leaks after lobectomy for non-small cell lung cancer: A data-driven prevention planning model in the era of minimally invasive approaches.

BACKGROUND AND OBJECTIVES: Prolonged air leaks (PAL) are the most frequent complication after lobectomy for non-small cell lung cancer, even in case of minimally invasive approaches. We developed a novel score to identify high-risk patients for PAL during minimally invasive lobectomy. METHODS: A dedicated database was created. We investigated preoperative candidate features and specific intraoperative variables. Univariate and subsequent logistic regression analysis with bootstrap resampling have been used. Model performance has been assessed by reckoning the area under the receiver operating characteristics curve and the Hosmer-Lemeshow goodness of fit. RESULTS: PAL (>5 days) occurred in 72 (15.69%) patients. Five variables emerged from the model. Each one was assigned a score to provide a cumulative scoring system: forced expiratory volume in 1 second below 86% (P = 0.004, 1.5 points), body mass index <24 ( P = 0.002, 1 point), active smoking ( P = 0.001, 1.5 points), incomplete fissures ( P = 0.004, 1.5 points), and adhesions ( P = 0.0001, 1 point). The new score provided a stratification into four risk classes. CONCLUSIONS: The risk score incorporates either general or more specific variables, providing a risk stratification that could be readily applied intra- and postoperatively. Henceforth, specific technical and management measures could be properly allocated to curb PAL.

Ergon-trial: ergonomic evaluation of single-port access versus three-port access video-assisted thoracic surgery.

BACKGROUND: Single-port access video-assisted thoracic surgery (VATS), a technique progressively developed from the standard three-port approach in minimally invasive surgery, offers ergonomic advantages but also new challenges for the surgeon. We compared the ergonomics of three-port versus single-port VATS. METHODS: Posture analysis of surgeons was evaluated during 100 consecutive VATS wedge resections (50 triportal vs. 50 uniportal). Technically demanding procedures (major lung resection) were excluded. Operating table height, monitor height, distance and inclination were adjusted according to operator preference. Body posture was assessed by measuring head-trunk axial rotation and head flexion. Perceived physical strain was self-evaluated on the Borg Category Ratio (CR-10) scale. Mental workload was assessed with the National Aeronautics Space Administration-Task Load indeX (NASA-TLX), a multidimensional tool that rates workloads on six scales (mental, physical and temporal demand; effort; performance; frustration). RESULTS: All procedures were completed without complications. Head-trunk axial rotation was significantly reduced and neck flexion significantly improved in uniportal VATS. Viewing direction significantly declined (p = 0.01), body posture as measured on the Borg CR-10 scale was perceived as more stressful and the NASA-TLX score for overall workload was higher (p = 0.04) during triportal VATS. The NASA-TLX score for frustration was higher with uniportal VATS (p = 0.02), but the score for physical demand was higher in triportal VATS (p = 0.006). CONCLUSIONS: The surgeon can maintain a more neutral body posture during uniportal VATS by standing straight and facing the monitor with only minimal neck extension/rotation; however, frustration is greater than with triportal VATS.

Analysis of spontaneous pneumothorax in the city of Cuneo: environmental correlations with meteorological and air pollutant variables.

BACKGROUND AND PURPOSE: Primary spontaneous pneumothorax (PSP) tends to cluster. Previous studies have found a correlation between PSP and atmospheric pressure variations or thunderstorms. We conducted this study to analyze the PSP correlations with meteorological variables and the concentrations of air pollutants in the city of Cuneo in Italy (IT). METHODS: We evaluated prospectively 451 consecutive PSP patients treated between 2004 and 2010. For each day within the period analyzed, the meteorological parameters and pollutants data were recorded. Statistical analyses on PSP were done for distribution characteristics, spectral autocorrelation, and spectral analysis. Multivariate regression analyses were performed using artificial neural networks. RESULTS: Analysis of annual, seasonal, and monthly distributions showed no significant correlation between PSP and the time series. The spectral analysis showed that PSP events were not random. Correlations between meteorological and environmental variables confirmed that PSP was significantly more likely to occur on warm windy days with high atmospheric pressure and high mean nitrogen dioxide concentration. CONCLUSIONS: Meteorological parameters and atmospheric pollutants might explain the cluster onset of PSP.

The relationship between meteorological variations and the onset of spontaneous pneumothorax.

This is in reference to: Obuchi et al. (Surg Today 41(10):1380-1384, 2011).

Prognostic role of standard uptake value according to pathologic features of lung adenocarcinoma.

OBJECTIVE: To evaluate the influence of lung adenocarcinoma second predominant pattern on the maximal standard uptake value (SUVmax) and its prognostic effect in different histologic groups. METHODS: We retrospectively collected surgically resected pathologic stage I and II lung adenocarcinoma from nine European institutions. Only patients who underwent preoperative PET-CT and with available information regarding SUVmax of T (SUVmaxT) and N1 (SUVmaxN1) component were included. RESULTS: We enrolled 344 patients with lung adenocarcinoma. SUVmaxT did not show any significant relation according to the second predominant pattern (p = 0.139); this relationship remained nonsignificant in patients with similar predominant pattern. SUVmaxT influenced the disease-free survival in the whole cohort (p = 0.002) and in low- and intermediate-grade predominant pattern groups (p = 0.040 and p = 0.008, respectively). In the high-grade predominant pattern cohort and in the pathologic N1 cases, SUVmaxT lost its prognostic power. SUVmaxN1 did not show any significant correlation with predominant and second predominant patterns and did not have any prognostic impact on DFS. CONCLUSIONS: SUVmaxT is influenced only by the adenocarcinoma predominant pattern, but not by second predominant pattern. Concurrently, in high-grade predominant pattern and pN1 group the prognostic power of SUVmaxT becomes nonsignificant.

Exploring consensus for the optimal sealant use to prevent air leak following lung surgery: a modified Delphi survey from The European Society of Thoracic Surgeons.

OBJECTIVES: The use of sealants is one of the methods available to reduce the occurrence of intraoperative air leaks. The objective of this modified Delphi survey among ESTS members is to understand the attitudes of clinicians to the optimal use of sealants in air leak management. METHODS: To understand the attitudes of a wider sample of clinicians, a questionnaire was developed highlighting key issues through 37 statements. Respondents were invited to score their level of agreement with each. A modified Delphi methodology was used to review responses with a threshold of agreement for consensus of 75%. RESULTS: A total of 258 responses were received (response rate 17%). Respondents agreed that prolonged air leaks are a common complication in thoracic surgery presenting a burden to the patient and increasing the costs of care. There is clear support for the use of sealants to reduce costs and improve the efficiency of healthcare provision and duration of chest tube use in selected high-risk patients with intraoperative air leak at the end of the lung surgery. Respondents also agreed that, due to often complex nature of thoracic surgery, sealants should be developed specifically for this application. CONCLUSION: There is a clear role for sealants in the management of air leaks and certain surgical procedures demand their use (i.e. lung volume reduction surgery, decortication). This opinion-based consensus review helps to raise the debate about the burden of air leaks in thoracic surgery in order that this issue is recognized in practice and informs the optimal use of sealants in lung surgery.

Work in progress report of a multicentre retrospective observational study to evaluate the association between the airflows and the intrapleural pressures digitally recorded after video-assisted lobectomy.

OBJECTIVES: Digital chest drainage systems allow real-time and continuous monitoring and recording of air leak flow rate and intrapleural pressure (IPP) from the immediate postoperative period to the chest drainage removal. A multicentre retrospective observational analysis of consecutive patients undergoing pulmonary lobectomy for lung cancer was performed to evaluate the association between the airflow and IPP digitally recorded during the immediate postoperative period after video-assisted thoracic surgery (VATS) lobectomy for lung cancer. Here, we present a work in progress report. METHODS: All patients treated with VATS lobectomies for lung cancer were included. Multiple airflow measurements and minimum and maximum IPP through the chest tubes were digitally monitored and recorded using microelectronic mechanical sensor technology. The PALs were defined as an air leak lasting >5 days from the conclusion of the surgical procedure. The cessation of air leaks was defined as an airflow <10 ml/min during 6 consecutive hours. RESULTS: This analysis comprised 76 patients who underwent VATS lobectomy for lung cancer. Nineteen patients (25%) showed prolonged air leaks (PAL) (≥5 days). The operative time was higher in the PAL group (mean difference = 44 min) without a statistically significant difference. Before the 7th postoperative hours, there were no statistically significant differences in IPPs. CONCLUSIONS: Patients with PAL showed less negative IPP in the first 24 postoperative hours. Therefore, the 7th-24th postoperative hours were critical in PAL prediction since the mechanism for PAL seems to develop after the 7th postoperative hour.

Chronic chest pain and paresthesia after video-assisted thoracoscopy for primary pneumothorax.

BACKGROUND: This study aims to identify clinical and surgical risk factors for chronic chest pain and paresthesia after video thoracoscopic surgery for primary spontaneous pneumothorax. METHODS: We retrospectively collected the data of 1,178 consecutive patients <40-years-old undergoing video thoracoscopic surgery for primary spontaneous pneumothorax in 9 Italian centers in 2007-2017. Cases with <2-month follow-up were excluded, leaving 920 patients [80% male; median age: 21 (IQR, 18-27) years] for statistical analysis. The following risk factors for chronic chest pain and chronic paresthesia were assessed by univariable and multivariable Cox regression model: age, gender, cannabis smoking, video thoracoscopy ports number, pleurodesis technique (partial pleurectomy/pleural electrocauterization/pleural abrasion/talc poudrage), chest tube size (24/28 F), postoperative chest tube stay. RESULTS: Blebs/bullae resection with pleurodesis was performed in 732 (80%) cases; pleurodesis alone in 188 (20%). During a median follow-up of 68 (IQR: 42-95) months, chronic chest pain developed in 8% of patients, chronic chest paresthesia in 22%; 0.5% of patients regularly assumed painkillers. Chronic chest pain was independently associated with partial pleurectomy/pleura abrasion (P<0.001) and postoperative chest tube stay (P=0.019). Chronic chest paresthesia was independently associated with pleurodesis by partial pleurectomy (P<0.001), chest tube stay (P=0.035) and 28 F chest tube (P<0.001). CONCLUSIONS: After video thoracoscopic surgery for primary spontaneous pneumothorax, the incidence of chronic chest pain and paresthesia was significantly lower when pleurodesis was performed by pleural electrocauterization or talc poudrage, and chest tube was removed early. A 24 F chest tube was associated with lower risk of chronic chest paresthesia.

Serratus plane block for video-assisted thoracoscopic surgery major lung resection: a randomized controlled trial.

OBJECTIVES: The aim of this study was to evaluate the impact of 2 different analgesic approaches on pain, postoperative rehabilitation exercises and rescue analgesics of 2 groups of patients undergoing video-assisted thoracoscopic surgery (VATS) major lung resection for cancer. METHODS: A total of 94 patients undergoing a VATS major lung resection were randomly allocated to 2 groups: the control group received intravenous and oral (i.e. systemic) analgesics while the intervention group received systemic analgesics plus pre-emptive serratus plane block. Pain perception was recorded until drainage removal or until 2 p.m. of postoperative day (POD) 3. In particular, the primary end point was defined as the peak pain perception on POD 1 (in the time frame between 6 a.m. and 2 p.m.). Secondary end points were the number of forced inspiration manoeuvers during rehabilitative incentive spirometry on POD 1 and 2 and the overall number of rescue analgesics requested by patients. RESULTS: Serratus plane block provided a better pain control between 6 a.m. and 2 p.m. of POD 1 (Numeric Rating Scale 1.7 vs 3.5; P < 0.001). Patients in the intervention group performed more forced inspiration manoeuvers at a mean higher volume during incentive spirometry (8.9 vs 7, P < 0.001, and 1010 vs 865 ml, P = 0.02). They required fewer rescue doses of analgesics (0.57 vs 1.1; P = 0.008). CONCLUSIONS: Serratus plane block provided a better pain control, entailing a better performance during postoperative rehabilitation exercises in terms of duration and quality of incentive spirometry. It diminished the patient's need for rescue analgesics during the early postoperative period. CLINICAL TRIAL REGISTRATION NUMBER: NCT03134729.

Analysis of pneumothorax recurrence risk factors in 843 patients who underwent videothoracoscopy for primary spontaneous pneumothorax: results of a multicentric study.

OBJECTIVES: Risk factors for pneumothorax recurrence after videothoracoscopy for primary spontaneous pneumothorax are still being debated. The goal of this study was to assess whether the pleurodesis technique and other variables are possibly associated with the postoperative ipsilateral recurrence of pneumothorax. METHODS: We retrospectively collected data of 1178 consecutive ≤40-year-old patients who underwent videothoracoscopy for primary spontaneous pneumothorax in 9 centres between 2007 and 2017. We excluded patients with hybrid pleurodesis and/or incomplete follow-up, leaving for analysis 843 cases [80% men; median age (interquartile range) 22 (18-28) years]. Univariable and multivariable analyses were performed by logistic regression and tested by Cox regression model to assess factors related to ipsilateral pneumothorax recurrence including age, gender, body mass index, smoking habit, cannabis smoking, respiratory comorbidity, dystrophic severity score, surgical indication, videothoracoscopy port number and side, lung resection, pleurodesis technique and postoperative prolonged air leak (>5 days). RESULTS: Blebs/bullae resection was performed in 664 (79%) patients. Pleurodesis was achieved by partial pleurectomy in 228 (27%) cases; by pleural electrocauterization in 176 (21%); by pleural abrasion in 121 (14%); and by talc poudrage in 318 (38%). During a median follow-up period of 70.0 months (95% confidence interval 66.6-73.4), pneumothorax recurred in 79 patients (9.4%); among these, 29 underwent redo surgery; 34, chest drain/talc slurry; and 16, clinicoradiological observation. The only independent risk factor for recurrence was postoperative prolonged air leak (P < 0.001) that was significantly related to blebs/bullae resection (P = 0.03). CONCLUSIONS: In this multicentric series, postoperative ipsilateral pneumothorax recurrence was remarkable and independently related to prolonged postoperative air leak; besides the retrospective study setting, the pleurodesis method did not have an impact on recurrence. To prevent prolonged air leak, blebs/bullae treatment should be accurate and performed only if indicated.

IgG4-related disease: a new challenging diagnosis mimicking lung cancer.

IgG4-related disease (IgG4-RD) is a progressive inflammatory disease that might rarely involve only the lungs. We retrospectively reviewed the preoperative, clinical and surgical features of patients with a pathology highly suggestive or probable diagnosis of IgG4-RD without extra-thoracic involvement. Five patients were selected, 2 were operated on the right side. Positron emission tomography-computed tomography (PET-CT) showed an uptake in all the patients (median 5.5), and 2 patients had an uptake at the thoracic lymph nodes. Two diagnoses were made through a CT-guided needle biopsy, while 3 were determined based on a lung wedge resection. The levels of serum IgG4 were elevated (>1.35 g/dl) in all the patients. Two patients had a highly suggestive diagnosis of IgG4-RD, and 3 patients had a probable diagnosis of IgG4-RD. The differential diagnosis between IgG4-RD and lung malignancies based only on radiological features is challenging and often requires histological confirmation. A careful preoperative workup and a multidisciplinary approach to PET-positive nodules might help to avoid unnecessary major lung resections.

Chest drain and thoracotomy for chest trauma.

Traumas are the leading cause of death in the first four decades of life. Nevertheless, thoracic traumas only seldom require invasive procedures. In particular, chest drain placement is required in case of pleural disruption causing haemothorax, pneumothorax or haemopneumothorax. Although large-bore chest drains have been traditionally used in case of haemothorax, recent evidences seem to question this routine, showing good performances of small-bore and pig tail drains. Although it is a common procedures, experience and training is needed to avoid complications which might be even lethal. Surgical exploration after thoracic trauma is rare, accounting for less than 3% of traumas. Penetrating traumas more likely require surgical exploration compared to blunt trauma. Anterolateral thoracotomy is usually performed in this setting, but also clamshell or hemi-clamshell approach can be used. In selected patients, minimally invasive techniques can be performed. Large randomized trials are still needed to assess and standardized the role of new tools and procedures in the thoracic trauma setting.

Intraoperative sentinel lymph node mapping in stage I non-small cell lung cancer: detection of micrometastases by polymerase chain reaction.

OBJECTIVE: We previously reported the results achieved in detecting sentinel lymph nodes (SLN). We applied the molecular techniques (RT-PCR) to improve the detection of micrometastasis in order to evaluate an improvement of staging in early non-small cell lung cancer (NSCLC) patients (pts). METHODS: This study was carried out on 22 consecutive NSCLC pts with stage I disease. A dose of 37MBq (1 ml (99m)Tc-nanocolloid suspension) was administered. The intralesional injection was performed under CT-guidance (7 pts), by using bronchoscopy (5 pts), VATS (2 pts) and at time of the thoracotomy (8 pts). RT-PCR analysis for cytokeratin 7 and 19 (CK7-CK19) was used to identify tumour-derived material in lymph nodes (LN). Each SLN was bisected: half was used for conventional examination (H&E staining/by immunohistochemistry (IHC), half was snap-frozen to -80 degrees C for RNA-detection of CK7 and CK19. RESULTS: SLN was detected in 16 out of 19 pts. In three pts SLN was not identified (due to an incorrect technique). Conventional pathologic examination showed stage I disease in 13 pts, T3N0 disease in 1 pt, N2 in 5 pts. The IHC analysis identified micrometastasis in seven pts (two evaluated N0 according to H&E staining). RT-PCR analysis, performed in 10/16 pts, identified micrometastasis in 6 pts (3 pts evaluated N0 disease by H&E ; 1 of these evaluated N0 even by IHC). All N2 patients relapsed. One patient (N0 pts after H&E and IHC analysis) with positive CK7 and CK19 expression by RT-PCR analysis relapsed (systemic relapse) 3 months after surgery. CONCLUSIONS: SLN technique could provide a subgroup of patients in which the use of RT-PCR could be applied on a well-focused target. This approach may be useful for stratifying histologically N0 patients into higher risk and lower risk groups.