Is left upper lobectomy always worthwhile for early stage lung cancer? A comparison between left upper lobectomy, trisegmentectomy, and lingulectomy.

BACKGROUND AND OBJECTIVES: Lobectomy is the gold standard treatment for resectable Non-Small Cell Lung Cancer (NSCLC). We compared oncological outcomes of patients undergoing a "multi-segmentectomy" (trisegmentectomy or lingulectomy) and left upper lobectomy for early stage (T1-2, N0) NSCLC of the left upper lobe. METHODS: We retrospectively analyzed all patients with pathological early stage (T1-T2 N0) NSCLC located in left upper lobe who underwent a lobectomy, a trisegmentectomy, or a lingulectomy between 2006 and 2013, focusing on surgical and oncological outcomes. RESULTS: Among 159 patients, 105 patients underwent a lobectomy and 54 patients a multi-segmentectomy (33 lingulectomy and 21 trisegmentectomy). Actuarial mean Overall Survival was 87 months (95%CI 79-95) and 89 months (95%CI 76-101) for lobectomies and multi-segmentectomies, respectively (P-value: 0.895), while actuarial mean Disease Free Interval was 91 months (95%CI 82-100) and 96 months (95%CI 84-108) respectively (P-value: 0.565). We did not observe any difference in terms of local recurrence rate between the two groups (P = 0.337). CONCLUSIONS: Lingulectomy and trisegmentectomy lead to similar oncological outcomes compared to left upper lobectomy for T1 and T2 N0 NSCLC, and they could be used as an alternative to lobectomy even in patients with a good pulmonary function.

General Practitioner-Performed Compression Ultrasonography for Diagnosis of Deep Vein Thrombosis of the Leg: A Multicenter, Prospective Cohort Study.

BACKGROUND: Patients with suspected deep vein thrombosis (DVT) of the lower limb represent a diagnostic dilemma for general practitioners. Compression ultrasonography (US) is universally recognized as the best test of choice. We assessed the diagnostic accuracy of compression US performed by general practitioners given short training in the management of symptomatic proximal DVT. METHODS: From May 2014 to May 2016, we evaluated in a multicenter, prospective cohort study all consecutive outpatients with suspected DVT; bilateral proximal lower limb compression US was performed by general practitioners and by physicians expert in vascular US, each group blinded to the other's findings. In all examinations with a negative or nondiagnostic result, compression US was repeated by the same operator after 5 to 7 days. Inter-observer agreement and accuracy were calculated. RESULTS: We enrolled a total of 1,107 patients. The expert physicians diagnosed DVT in 200 patients, corresponding to an overall prevalence of 18.1% (95% CI, 15.8%-20.3%). The agreement between the trained general practitioners and the experts was excellent (Cohen κ = 0.86; 95% CI, 0.84-0.88). Compression US performed by general practitioners had a sensitivity of 90.0% (95% CI, 88.2%-91.8%) and a specificity of 97.1% (95% CI, 96.2%-98.1%) with a diagnostic accuracy for DVT of 95.8% (95% CI, 94.7%-97.0%). CONCLUSIONS: Our results suggest that, even in hands of physicians not expert in vascular US, compression US can be a reliable tool in the diagnosis of DVT. We found that the sensitivity achieved by general practitioners appeared suboptimal, however, so future studies should evaluate the implementation of proper training strategies to maximize skill.

The Clinical Impact of the Pulmonary Embolism Severity Index on the Length of Hospital Stay of Patients with Pulmonary Embolism: A Randomized Controlled Trial.

BACKGROUND: The Pulmonary Embolism Severity Index (PESI) is an extensively validated prognostic score, but impact analyses of the PESI on management strategies, outcomes and health care costs are lacking. Our aim was to assess whether the adoption of the PESI for patients admitted to an internal medicine ward has the potential to safely reduce the length of hospital stay (LOS). METHODS: We carried out a multicenter randomized controlled trial, enrolling consecutive adult outpatients diagnosed with acute PE and admitted to an internal medicine ward. Within 48 h after diagnosis, the treating physicians were randomized, for every patient, to calculate and report the PESI in the clinical record form on top of the standard of care (experimental arm) or to continue routine clinical practice (standard of care). The ClinicalTrials.gov identifier is NCT03002467. RESULTS: This study was prematurely stopped due to slow recruitment. A total of 118 patients were enrolled at six internal medicine units from 2016 to 2019. The treating physicians were randomized to the use of the PESI for 59 patients or to the standard of care for 59 patients. No difference in the median LOS was found between the experimental arm (8, IQR 6-12) and the standard-of-care arm (8, IQR 6-12) (p = 0.63). A pre-specified secondary analysis showed that the LOS was significantly shorter among the patients who were treated with DOACs (median of 8 days, IQR 5-11) compared to VKAs or heparin (median of 9 days, IQR 7-12) (p = 0.04). CONCLUSIONS: The formal calculation of the PESI in the patients already admitted to internal medicine units did not impact the length of hospital stay.

Cold coagulation in thoracoscopic treatment of primary pneumothorax: a comparison with apicectomy.

OBJECTIVES: Primary spontaneous pneumothorax is a common disease, whose surgical treatment is still enigmatic in terms of timing and technique. Herein, we reported our experience with the parenchymal-sparing technique via cold coagulation (CC), in comparison to stapler apicectomy (SA). METHODS: We retrospectively collected data of all patients with apical blebs or <2 cm bullae treated with minimally invasive surgery for recurrent or persistent spontaneous pneumothorax, from 2010 to 2020. Two different surgical techniques were used: SA and the parenchymal-sparing CC of the apex. Perioperative and long-term results were analysed and compared. RESULTS: Out of 177 patients enrolled, 77 patients (CC group) underwent cold-coagulation of the apex while 100 patients (SA group) were treated with SA. Two groups were comparable in terms of age, surgical indication, intraoperative findings and affected side. CC group had a mean operative time of 43.2 min (standard deviation ± 19.5), shorter than SA group with 49.3 min (standard deviation ± 20.1, P-value: 0.050). Complication rate was significantly different between 2 groups, 5 (7%) and 16 (16%), for the CC and SA groups, respectively (P: 0.048), even if not in terms of prolonged postoperative air leak (P: 0.16). During the follow-up, 13 homolateral recurrences were reported: 2 (3%) in group CC and 11 (11%) in group SA; with a significant difference (P: 0.044). All reinterventions (postoperative prolonged air leak and recurrences) required an SA. CONCLUSIONS: Parenchymal-sparing technique through CC of apical blebs and bullae is an effective treatment for primary spontaneous pneumothorax and guarantees a good immediate lung sealing, despite stapling still represents the choice treatment in complex cases.

Hyperthermic Intrathoracic Chemotherapy for Malignant Pleural Mesothelioma: The Forefront of Surgery-Based Multimodality Treatment.

INTRODUCTION: Malignant Pleural Mesothelioma (MPM) is characterized by an aggressive behavior and an inevitably fatal prognosis, whose treatment is still far from being standardized. The role of surgery is questionable since a radical resection is unattainable in most cases. Hyperthermic IntraTHOracic Chemotherapy (HITHOC) combines the advantages of antitumoral effects together with those of high temperature on the exposed tissues with the aim to improve surgical radicality. MATERIAL AND METHODS: this is a narrative review on the role of HITHOC in the management of MPM patients. To provide data on the beginnings and the historical evolution of this technique, we searched the available literature by selecting the more exhaustive papers on this topic. RESULTS: from 1994 to date different authors experimented HITHOC following a cytoreductive surgery in MPM, obtaining in most cases a good local control and a better overall survival associated to very low complication rate. CONCLUSIONS: HITHOC may be considered as a safe, feasible and effective procedure although there is a high heterogeneity between different protocols adopted worldwide. More structured studies are needed to reach a unanimous consensus on this technique.

N2 lung cancer is not all the same: an analysis of different prognostic groups.

OBJECTIVES: The International Association for the Study of Lung Cancer (IASLC) recently proposed a change in the staging system for N2, based on the metastatic station number: N2a1 (a single metastatic station with no hilar involvement), N2a2 (a single metastatic station with hilar involvement) and N2b (multiple metastatic stations). The aim of our study was to validate the IASLC proposal in a cohort of patients with pathological N2 disease. METHODS: All patients with pathological T1-T2 N2 non-small-cell lung cancer who were operated on between 2006 and 2010 in our department were enrolled. The patients had lobectomy, bilobectomy or pneumonectomy without induction therapy; patients with any type of extended resection were excluded. All patients had adjuvant treatment. The impact of the new IASLC proposal on the overall and disease-free survival rates was then analysed. RESULTS: Ninety-three patients were selected. The median follow-up period and overall survival time were 92 and 28.8 months, respectively. According to the new IASLC proposal, we observed 22 cases of N2a1, 54 N2a2 and 17 N2b. Patients with N2a1 had a significantly better overall survival than those with N2a2 and N2b (P = 0.041); the difference between N2a2 and N2b was not significant (P = 0.19). Patients with N2a1 squamous cell carcinoma had a significantly better overall survival than those with other histological diagnoses (P = 0.046). The disease-free interval was longer in patients with N2a1 than those in other groups (P = 0.021). CONCLUSIONS: Our experience partially validates the IASLC proposal; the introduction of quantitative criteria for N staging might improve stratification of patients and the assignment to the correct therapeutic path.

New approaches in pulmonary rehabilitation.

Patients who have mild to severe chronic obstructive pulmonary disease may obtain improvement in dyspnea, exercise capacity, and health-related quality of life as a result of exercise training. The type and intensity of training is of key importance in determining outcomes. High-intensity aerobic training leads to physiologic gains in aerobic fitness. Nevertheless, extreme breathlessness or peripheral muscle fatigue may prevent some patients from performing high-intensity exercise; therefore, new tools are needed to improve the effectiveness of pulmonary rehabilitation.

Association of thymoma and myasthenia gravis: oncological and neurological results of the surgical treatment.

BACKGROUND: Thymoma occurs in about 10-20% of myasthenic patients and in turn, 20-25% of patients with a thymoma have myasthenia gravis. Both diseases are treated by surgery. The aims of this study were to analyze the clinical features of these patients and the oncological and neurological outcomes after thymectomy. METHODS: Clinical and pathological data, complete remission rate as well as overall survival rates were retrospectively analyzed in a cohort of myasthenic patients who underwent extended thymectomy for thymoma between 1993 and 2006. RESULTS: One hundred and twenty-three patients (60 m and 63 f) with a mean age of 56 years (range 22-83) underwent extended thymectomy. The WHO histological classification was: A in 22 cases, AB in 18, B1 in 33, B2 in 22, and B3 in 28. The Masaoka clinical staging was: I in 10 cases, IIA in 33, IIB in 50, III in 14, IVA in 15, IVB in 1. We experienced 2 postoperative deaths. With a overall mean follow-up of 76 months 42 patients had a complete remission, 39 a remission with medications, 35 an improvement of the symptoms, 3 remained nearly in the same status and 4 worsened. At the last follow-up, 112 patients were alive; 11 with disease. Four deaths were related to the tumor. Actuarial 5- and 10-year survival was 93.4% and 79.6%, respectively. CONCLUSIONS: Neurological outcome of the extended thymectomy in myasthenic thymoma patients was satisfactory. Higher complete remission rate is expected in early stage thymoma. Regarding the overall survival it was dependent on the Masaoka stage, the WHO classification and the achievement of complete remission of myasthenic symptoms.

Management of pleural recurrence after curative resection of thymoma.

OBJECTIVE: A complete surgical resection is the cornerstone of therapy of thymic tumors. Unfortunately, there is no standard treatment for pleural recurrence. This article describes our overall experience with the surgical treatment of pleural implants in patients who previously underwent resection of a thymoma. MATERIAL AND METHODS: From January 1980 to June 2006, 20 patients previously operated on for a thymoma were operated on for the surgical resection of pleural implants. Patients with the initial Masaoka stage IVA were excluded from our analysis. Our sample comprised 10 male and 10 female patients (12-65 years old). The surgical approach to the resection of the thymoma was as follows: video-assissted thoracic surgery in 2 patients, sternotomy in 13 patients, thoracotomy in 2 patients, and sternothoracotomy in 3 patients. The initial Masaoka stage of the thymoma was IIA in 2 patients, IIB in 7 patients, and III in 11 patients. RESULTS: The interval between resection of the thymoma and pleural implants ranged from 11 to 156 (median 60) months. Fifteen patients had a thymus-related syndrome (in 13 patients it resulted myasthenia gravis), and in 11 patients it improved or remitted after treatment of the pleural recurrence. All the resections were performed through a posterolateral thoracotomy. Three patients underwent an iterative resection of new pleural implants. At the latest follow-up, 10 patients are still alive (8 disease-free) and 10 have died (9 of a relapse and 1 of the complications of red cell aplasia). From the pleural recurrence resection, the overall 5- and 10-year survivals are 43.1% and 25.8%, respectively. CONCLUSIONS: Repeat operation on patients with thymoma pleural recurrences is feasible and safe. It can produce satisfactory results in terms of overall survival and paraneoplastic syndrome control. Moreover, the multimodality treatment could improve the results of surgical treatment.