Malignant Solitary Fibrous Tumours of the Pleura Are Not All the Same: Analysis of Long-Term Outcomes and Evaluation of Risk Stratification Models in a Large Single-Centre Series.

Introduction: Malignant solitary fibrous tumours of the pleura (mSFTP) are extremely rare diseases (<5% of all pleural neoplasms) with unpredictable behaviour. Surgery remains the standard of care for these tumours; however, estimating patient prognosis and planning follow-up remain challenging. Several risk stratification models have been proposed, but a classification with diagnostic and prognostic potential has not been well standardised yet. The aim of this study was to analyse the clinicopathological data of mSFTP to investigate their prognostic features and to compare the performance of three risk stratification models proposed in the literature. Methods: Observational retrospective cohort study on all proven cases of mSFTP surgically resected with radical intent between 2000 and 2019 in a single centre. Demographic, surgical and pathological data were examined. All patients were risk-stratified by using three prediction models: modified Demicco, De Perrot and Tapias. Overall survival (OS) and disease-free survival (DFS) were analysed. Results: There were 21 men and 13 women (median age, 67 years, range, 23-83 years). Twenty-one patients (62%) were symptomatic. The median follow-up was 111 months (range, 6-258 months). The 5-year OS and DFS were 81.2% and 77.4%, respectively. Nine patients (26.5%) experimented recurrences. At univariate analysis, the presence of necrosis (p = 0.019), nuclear atypia (p = 0.006), dimension greater than 11.5 cm (median value of our cohort) (p = 0.037) and relapse/disease progression (p = 0.001) were independent prognostic factor of worse OS. The administration of adjuvant treatment was a protective independent factor for survival (p = 0.001). Radicality of resection (p = 0.005); tumour dimension (p = 0.013), presence of necrosis (p = 0.041) and nuclear atypia (p = 0.007) and pleural pattern (p = 0.011) were independent prognostic factors of worse DFS. Analysing the three risk stratification models, the Tapias score was revealed as the best index to predict both OS (p = 0.002) and DFS (p = 0.047) in patients with mSFTP. Conclusions: Using the risk stratification model proposed by Tapias, patients with the highest risk of recurrence could be identified at the time of surgery to establish a more frequent imaging surveillance and longer follow-up. The role of adjuvant treatment in mSFTP therapy has not been established yet, but further analysis on patients with a high risk of recurrence, stratified according to risk models, along with biomolecular panels may tailor future post-surgical therapies.

Post-intubation tracheal lacerations: Risk-stratification and treatment protocol according to morphological classification.

Background: Post-intubation tracheal laceration (PITL) is a rare condition (0.005% of intubations). The treatment of choice has traditionally been surgical repair. Following our first report in 2010 of treatment protocol tailored to a risk-stratified morphological classification there is now clear evidence that conservative therapy represents the gold standard in the majority of patients. In this paper we aim to validate our risk-stratified treatment protocol through the largest ever reported series of patients. Methods: This retrospective analysis is based on a prospectively collected series (2003-2020) of 62 patients with PITL, staged and treated according to our revised morphological classification. Results: Fifty-five patients with Level I (#8), II (#36) and IIIA (#11) PITL were successfully treated conservatively. Six patients with Level IIIB injury and 1 patient with Level IV underwent a surgical repair of the trachea. No mortality was reported. Bronchoscopy confirmed complete healing in all patients by day 30. Statistical analysis showed age only to be a risk factor for PITL severity. Conclusions: Our previously proposed risk-stratified morphological classification has been validated as the major tool for defining the type of treatment in PITL.

Which Surgery for Stage II-III Empyema Patients? Observational Single-Center Cohort Study of 719 Consecutive Patients.

OBJECTIVE: Recent guidelines support the use of thoracoscopic surgery in stage II-III empyema; however, there is still debate regarding the best surgical approach. The aim of our study is to compare postoperative outcomes of VATS and open surgical approaches for the treatment of post-pneumonic empyema. METHODS: Observational cohort study on prospectively collected cases of post-pneumonic empyema surgically treated in a single center (2000-2020). Patients were divided into an open group (OT, posterolateral muscle sparing thoracotomy) and VATS group (VT, 2 or 3 port ± utility incision). The primary outcome of the study was empyema resolution, assessed by the recurrence rate. Secondary outcomes were mortality, complications, pain and return to daily life. All patients were followed up at 1, 3 and 6 months after surgery in the outpatient clinic with a chest radiograph/CT scan. RESULTS: In total, 719 consecutive patients were surgically treated for stage II-III empyema, with 644 belonging to the VT group and 75 to the OT group. All patients had a clinical history of pneumonia lasting no more than 6 months before surgery, and 553 (76.9%) had stage II empyema. Operative time was 92.7 ± 6.8 min for the OT group and 112.2 ± 7.4 for the VT group. The conversion rate was 8.4% (46/545) for stage II and 19.2% (19/99) for stage III. Twelve patients (1.86%) in the VT group and four patients (5.3%) in the OT group underwent additional surgery for bleeding. Postoperative mortality was 1.25% (9/719): 5.3% (4/75) in OT and 0.77% (5/644) in VT. Postoperative stay was 10 ± 6.5 days in OT and 8 ± 2.4 in VT. Overall morbidity was 14.7% (106/719): 21.3% (16/75) in OT and 13.9% (90/644) in VT. In VT, six patients (0.93%) showed recurrent empyema: five were treated with chest drainage and one with additional open surgery. CONCLUSIONS: Our findings suggest that the VATS approach, showing a 99% success rate, shorter length of stay and lower postoperative morbidity, should be considered the treatment of choice for thoracic empyema.

Malignant Pleural Mesothelioma Nodal Status: Where Are We at?

Due to the lack of both prospective trial and high-volume retrospective studies, the management of clinical N+ malignant pleural mesothelioma (MPM) patients remains highly debated. Node positive patients show poor survival compared with node-negative ones; thus, lymph node staging appears crucial in determining treatment strategy. Notwithstanding the improvement in pre-treatment staging and the update on lymph node classification in the 8th edition of TNM, several open controversies remain on N parameter. How should we stage suspected N+ patients? How should we treat node positive patients? Which is the definition of a "resectable patient"? Is the site or the number the main prognostic factor for node positive patients? The aim of our narrative review is to analyse the existing relevant literature on lymph node status in MPM.

3D Reconstruction Model of an Extra-Abdominal Desmoid Tumor: A Case Study.

In recent years, three-dimensional reconstruction (3DR) models have become a standard tool in several medical fields such as education, surgical training simulation, patient-doctor communication, and surgical planning. Postoncologic reconstructive surgery in thoracic diseases might benefit from 3DR models; however, limited data on this application have been published worldwide. In this paper, the aim was to report our experience with 3DR modeling to determine resection and plan the surgical reconstruction in a patient with a desmoid tumor of the chest wall. For a better understanding of the case study, we describe all the steps from acquiring computed tomography (CT) scans to the final 3D rendering. A 68-year-old, non-smoking man presented at our outpatient department with painless swelling of the right anterobasal chest wall. A thorax-abdomen-brain CT scan revealed homogenous solid tissue with a dense mass measuring 80 mm × 62 mm. The final 3D model was evaluated by the surgical team (three medical doctors), who found the model to be powerful. Based on the results and the accuracy of the model, the multidisciplinary team decided that the tumor was resectable. Consequently, a surgical plan based on the 3D model was developed to perform chest wall reconstruction after radical resection. The patient underwent right anterolateral thoracotomy at the seventh intercostal space, which confirmed the CT scan findings and revealed infiltration of the serratus muscle and medial portion of the diaphragm. A radical tumor en bloc resection with chest wall and diaphragm resection was performed. The full-thickness chest wall and diaphragm defects were reconstructed using two separate biological patches of a porcine dermal collagen implant (Permacol™ Surgical Implant). Postoperative X-ray revealed unremarkable findings; the patient had an uneventful recovery and was discharged 6 days after surgery. This case study illustrates that 3DR models enable a personalized approach to the treatment of desmoid tumors. Therefore, this approach should be developed further and studied systematically.

Is 18F-fluorodeoxyglucose positron emission tomography/computed tomography useful to discriminate metachronous lung cancer from metastasis in patients with oncological history?

BACKGROUND: Solitary pulmonary nodules detected during follow-up in patients with previous cancer history have a high probability of malignancy being either a metachronous lung cancer or a metastasis. This distinction represents a crucial issue in the perspective of "personalized medicine," implying different treatments and prognosis. Aim, to evaluate the role of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) in distinguishing whether solitary pulmonary nodules are metachronous cancers or metastases and the relationship between the nodule's characteristics and their nature. METHODS: From a single-institution database, we retrospectively selected all patients with a previous cancer history who performed 18F-FDG PET/CT to evaluate pulmonary nodules detected during follow-up, ranging from 5 mm to 40 mm, and histologically diagnosed as malignant. RESULTS: Between September 2009 and August 2017, 127 patients (80 males; mean age=70.2±8.5years) with 127 malignant nodules were included: 103/127 (81%) metachronous cancers, 24/127 (19%) metastases. In both groups, PET/CT provided good and equivalent detection rate of malignancy (81% vs. 83%). No differences between metachronous cancers and metastases were found in: patient's age (70.3±8.1 years vs. 69.5±9.7years), gender (males=63.1% vs. 62.5%), interval between previous cancer diagnosis and nodules' detection (median time=4years vs. 4.5years), location (right-lung=55% vs. 54%; upper-lobes=64% vs. 67%; central-site=31% vs. 25%), size (median size=17mm vs. 19.5mm), 18F-FDG standardized uptake value (median SUVmax=5.2 vs. 5.9). CONCLUSIONS: In oncological patients, despite its high detection rate, 18F-FDG PET/CT, as well as any other clinico-anatomical features, cannot distinguish whether a malignant solitary pulmonary nodule is a metachronous lung cancer or a metastasis, supporting the need of histological differential diagnosis.

Is Adjuvant Chemotherapy Worthwhile After Radical Resection for Single Lung Metastasis From Colorectal Cancer? A Multicentric Analysis Evaluating the Risk of Recurrence.

Background: Adjuvant chemotherapy after resection of colorectal cancer (CRC) lung metastases may reduce recurrences and improve survival. The choice of best candidates for adjuvant chemotherapy in this setting is controversial, especially when a single lung metastases (SLM) is resected. The aim of this study is to evaluate the risk of recurrence after radical resection for single lung metastasis from CRC. Patients and methods: Demographic, clinical, and pathological data were retrospectively collected for patients radically operated on for single pulmonary metastasis from CRC in 4 centers. Survival was computed by Kaplan-Meyer methods. Chi-square, log-rank test, and for multivariate analysis, Cox-regression and binary logistic regression were used when indicated. Results: The sample consisted of 344 patients, mean age 65 yrs. Overall 5 yrs survival was 61.9%. Recurrence occurred in 113 pts (32.8%). At univariate analysis, age > 70 (p = 0.046) and tumor size > 2 cm (p = 0.038) were predictive of the worst survival chance, while synchronous lung metastasis (p = 0.039), previous resection of extrathoracic metastasis (p = 0.017), uptake at FDG-PET scan (p = 0.006) and short (<12 months) disease-free interval (DFI) prior to lung metastasectomy (p = 0.048) were risk factors for recurrence. At multivariate analysis, only high CEA (>4 ng/mL) was associated with worst survival (HR: 4.3, p = 0.014), while prior abdominal surgery (HR: 3, p = 0.033), PET positivity (HR: 2.7, p = 0.041), and DFI > 12 months (HR: 0.14, p < 0.001) confirmed to predict recurrence of disease. Conclusions: Surgical resection of solitary lung metastases from CRC is associated with prolonged survival. High value of CEA, PET positivity, previous extrathoracic resected metastasis, and short (<12 months) DFI were found to be predictive of death or disease recurrence and might identify in this scenario patients at higher risk which could potential benefit of chemotherapy.

Hybrid treatment of T3 chest wall lung cancer lobectomy.

Nowadays the treatment of patients with non-small cell lung cancer (NSCLC) that invades the chest wall is still questioned. The classic approach is a lobectomy that requires chest wall resection through thoracotomy, but thanks to the progress in the field of thoracoscopic surgery, this procedure can be performed by video-assisted thoracoscopic surgery (VATS). Major advances have been made in recent years both in the surgical technique associated with thoracoscopy and in the instrumentation available today. This has allowed the use of thoracoscopic technique even in advanced disease. To choose to perform complex surgery in assisted video surgery, considerable experience is needed to avoid making mistakes and giving up a better approach for the patient only for any technical difficulties. Thoracoscopy is not currently the preferred intervention for patients with chest wall invasion because there are insufficient studies on the feasibility of lobectomy with thoracoscopic wall resection, although the thoracoscopic approach has reduced mortality and morbidity in lung cancer cases not in advanced stage. We discuss our experience in three patients using hybrid approach with assisted video thoracoscopic lobectomy and a chest wall en-block resection with an alternative method of estimating thoracic wall resection that uses assisted video surgery and hypodermic needles (minimally invasive posterior approach).

Control of major pulmonary artery bleeding with a gelatin matrix-thrombin solution: a retrospective analysis.

BACKGROUND: Intraoperative pulmonary artery (PA) bleeding is common during thoracic surgery. We investigated the efficacy of the gelatin matrix-thrombin solution FloSeal (Baxter International, Deerfield, IL, USA) for control of major PA bleeding. METHODS: Retrospective data were collected on all intraoperative PA injuries during open or minimally invasive lobectomy or pneumonectomy between January 2000 and January 2014. Patients received either 4/0 prolene sutures (Standard) or the gelatin matrix-thrombin solution, plus sutures as needed (Matrix), with at least 6-month follow-up. Endpoints included time to hemostasis, total blood loss, transfusion and complications. RESULTS: Of 2809 procedures, 39 (1.4%) had intraoperative PA injury, of which 21 received standard care and 18 the gelatin matrix-thrombin solution. Hemostasis was achieved in all Standard group patients after 2 minutes, and after 5 minutes in Matrix patients. Additional sutures were required in 4 (19.0%) Standard group patients. Three (16.7%) Matrix patients had a second solution application, while 17 (77.8%) received precautionary sutures. Mean blood loss on postoperative day 1 was 836.1±186.1 mL and 957.1±163.0 mL in the Matrix and Standard groups, respectively (P=0.003). Four (22.2%) Matrix patients received postoperative transfusions versus eight (38.0%) Standard patients (P=0.02). Two Standard and no Matrix patients underwent surgical revision. There were no complications and no mortalities. CONCLUSIONS: Our analysis suggests that the gelatin matrix-thrombin solution is safe and effective for the control of major bleeding following intraoperative PA injury, and may improve outcomes. Further prospective studies are required to confirm our findings.

Primary spontaneous pneumothorax: a cohort study of VATS with talc poudrage.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is an increasingly common treatment for recurrent or persistent primary spontaneous pneumothorax (PSP). Surgery usually involves diffuse treatment of the pleura and possible targeted therapy to areas of bullous disease. The purpose of this large cohort study was to examine incidence of recurrence after VATS and identify predictors of outcome. METHODS: Patients undergoing VATS for PSP at a single centre between 2000 and 2012 were prospectively enrolled. All patients underwent talc poudrage. Targeted surgical techniques were used based on presence of air leak and Vanderschueren's stage. Patients had clinical and radiological follow-up for at least 2 years (median 8.5 years). RESULTS: 1415 patients with PSP underwent VATS with talc poudrage. The most frequent indications were recurrent pneumothorax (92.2%) and persistent air leak (6.5%). The complication rate was 2.0% of which 1.7% was prolonged air leak. There was no mortality. Median length of stay was 5 days. Recurrent pneumothorax occurred in 26 patients (1.9%). At the time of surgery, 592 patients smoked (43%) and they had a significantly higher incidence of recurrence (24/575, 4.2%) than non-smokers (2/805, 0.2%), p<0.001. The incidence of recurrence in those undergoing bullae suturing (3.8%, n=260) was significant higher than those undergoing poudrage alone (0.3%, p=0.036). CONCLUSION: The marked difference in recurrence between smokers and non-smokers suggests this as an important predictor of outcome. This study demonstrates a low incidence of recurrence and complications for patients with PSP undergoing VATS with talc poudrage. Talc poudrage requires prospective comparison with pleurectomy and mechanical abrasion.

The Rationale for Treatment of Postresectional Bronchopleural Fistula: Analysis of 52 Patients.

BACKGROUND: Bronchopleural fistulas are a major therapeutic challenge. We have reviewed our experience to establish the best choice of treatment. METHODS: From January 2001 to December 2013, the records of 3,832 patients who underwent pulmonary anatomic resections were retrospectively reviewed. RESULTS: The overall incidence of bronchopleural fistulas was 1.4% (52 of 3,832): 1.2% after lobectomy and 4.4% after pneumonectomy. Pneumonectomy vs lobectomy, right-sided vs left-sided resection, and hand-sewn closure of the stump vs stapling showed a statistically significant correlation with fistula formation. Primary bronchoscopic treatment was performed in 35 of 52 patients (67.3%) with a fistula of less than 1 cm and with a viable stump. The remaining 17 patients (32.7%) underwent primary operation. The fistula was cured with endoscopic treatment in 80% and with operative repair in 88.2%. Cure rates were 62.5% after pneumonectomy and 86.4% after lobectomy. The cure rate with endoscopic treatment was 92.3% in very small fistulas, 71.4% in small fistulas, and 80% in intermediate fistulas. The cure rate after surgical treatment was 100% in small fistulas, 75% in intermediate fistulas, and 100% in very large fistulas. Morbidity and mortality rates were 5.8% and 3.8%, respectively. CONCLUSIONS: The bronchoscopic approach shows very promising results in all but the largest bronchopleural fistulas. Very small, small, and intermediate fistulas with a viable bronchial stump can be managed endoscopically, using mechanical abrasion, polidocanol sclerosing agent, and cyanoacrylate glue. Bronchoscopic treatment can be repeated, and if it fails, does not preclude subsequent successful surgical treatment.

Safety and effectiveness of a new fibrin pleural air leak sealant: a multicenter, controlled, prospective, parallel-group, randomized clinical trial.

BACKGROUND: This study evaluated the sealing capacity and safety of a new fibrin sealant (FS) to reduce alveolar air leaks (AALs) after pulmonary resections in a randomized controlled clinical trial conducted in 3 Italian centers. METHODS: The study randomized (1:1) 185 patients with an intraoperative AAL graded 1 to 3 according to the Macchiarini scale: 91 received FS and 94 had standard lung closure. The primary outcomes were the length of postoperative AAL duration and the mean time to chest drain removal. Other end points included the percentage of patients without AAL, the development of serum antibodies against bovine aprotinin, and any adverse event related to FS. Chest drains were removed when fluid output was 100 mL/day or less, with no air leak. RESULTS: The study groups were comparable with respect to demographic variables and surgical procedures. The FS group showed a statistically significant reduction in duration of postoperative AALs (9.52 vs 35.8 hours; p < 0.005) and in the percentage of patients with AALs at wound closure (81.11% vs 100%; p < 0.001); the difference in time to chest drain removal was not significant. Pleural empyema developed in 1 patient with FS treatment vs in 4 with standard treatment, and antibodies against bovine aprotinin were found in 34 of 91 FS-treated patients. CONCLUSIONS: The present study showed that the new FS is safe and effective in preventing AALs after lung resections and in shortening the duration of postoperative AALs.

Chronic postpneumonic pleural empyema: comparative merits of thoracoscopic versus open decortication.

OBJECTIVE: We seek to evaluate the comparative merits of thoracoscopic versus open decortication in the surgical management of patients with chronic postpneumonic pleural empyema. METHODS: From January 1996 to December 2006, 308 patients (180 males, 128 females, mean age: 56.3 years, range: 17-82 years) with chronic postpneumonic pleural empyema underwent decortication after failure of conservative treatment. RESULTS: Decortication was performed by open thoracotomy in 123 (39.9%) patients (OT) and by videothoracoscopy (VT) in 185 (60.1%). Mortality was 1.29% (4/308). Morbidity was 21.1% (65/308). At 6 months follow-up, three VT patients showed recurrent empyema and underwent re-do surgery by video-assisted-thoracoscopy (VATS) (one patient) or by thoracotomy (two patients). The videothoracoscopic approach showed statistically significant better results in terms of in-hospital postoperative (day 1 and day 7), pain (p<0.0001), postoperative air leak (p=0.004), operative time (p<0.0001), hospital stay (p=0.020) and time to return to work (p<0.0001). The analysis of postoperative pain at 6 months follow-up showed no significant differences among the different groups. CONCLUSIONS: In the light of our experience, videothoracoscopic decortication appears to be the surgical treatment of choice for chronic postpneumonic pleural empyema even if a multicentric-randomised trial should be performed before videothoracoscopic decortication becomes the gold standard for the treatment of pleural empyema.

Long-term lung function following videothoracoscopic talc poudrage for primary spontaneous recurrent pneumothorax.

OBJECTIVE: Some concern still exists regarding long-term lung function following videothoracoscopic talc poudrage for primary spontaneous pneumothorax (PSP). We evaluated lung function at 5 years in a series of 100 patients surgically treated for PSP. METHODS: Out of 1065 patients treated for PSP by means of videothoracoscopic talc poudrage from September 1995 to January 2006, we consecutively enrolled 50 patients (33 males, 17 females, mean age: 24.22 years, median age: 24 years; range: 13-40 years) (group A) with no recurrence for functional evaluation with measurement of static and dynamic volumes (FEV1-FVC-TLC-RV), and DLCO at 60 months after surgery. Fifty patients (35 males, 15 females, mean age: 23.56 years; median age: 22.5 years; range: 16-37 years) underwent same pulmonary function tests 5 years after simple drainage for recurrent PSP because of refusal of surgery (group B). RESULTS: Pulmonary function tests showed (mean % value+/-SD for group A vs group B): FEV1 93+/-6.6 versus 95.4+/-6.4; FVC 98+/-6.5 versus 100.1+/-6.9; TLC 91.7+/-7.7 versus 94.36+/-5.8; RV 97+/-7 versus 99.2+/-4.9; DLCO 91.4+/-2.8 versus 91.98+/-4.2. No patient in both groups showed FEV1<80%. Analysis of mean difference of pulmonary function values was computed between group A and group B patients. CONCLUSIONS: No statistically significant differences in long-term lung function have been found between patients treated with pleural drainage only versus patients treated with videothoracoscopic talc poudrage for PSP. Lung function is not impaired by videothoracoscopic talc poudrage.

Bronchial carcinoid tumors: nodal status and long-term survival after resection.

BACKGROUND: Bronchial carcinoid tumors show a favorable outcome. We sought to determinate the variables influencing the long-term survival of patients treated for bronchial carcinoid tumors. METHODS: We conducted a retrospective single institutional review of 163 patients surgically treated from January 1990 to April 2002. According to 1999 World Health Organization criteria, cases were segregated into typical (<2 mitoses per 2 mm, no necrosis) and atypical carcinoids (2 to 10 mitoses per 2 mm or necrosis). RESULTS: There were 86 men and 77 women with a mean age of 49.5 +/- 11 years. Symptoms were present in 89 patients (54.6%). Operations included 145 formal lung resections (89%), 9 wedge resections (5.52%), 8 sleeve lobectomies (4.9%), and 1 segmental resection (0.61%) plus radical mediastinal lymphadenectomy in all cases. No operative mortality was reported. Histologic examination showed 121 (74.2%) typical carcinoids (107 N0 and 14 N1), and 42 (25.8%) atypical carcinoids (15 N0, 18 N1, 9 N2). All patients were included in a follow-up (median, 54 months; mean, 58 months; range, 4 to 150 months), which included total body computed tomographic scan and bronchoscopy every year. Overall 5-year survival was 90.3% with a mean survival time of 139 months (95% confidence interval, 133 to 145). In N0 patients with either typical or atypical carcinoid tumors, no disease-related mortality was reported (100% 5-year survival). In N1 patients, 5-year survival was 90.0% for those with typical carcinoids, and 78.8% for those with atypical carcinoids (p = 0.394). In atypical carcinoids with N2 disease, 5-year survival was 22.2%. CONCLUSIONS: Prognosis in bronchial carcinoid tumors is more related to nodal status than to histologic subtype. In N0 and N1 patients no statistical significant difference has been found between typical and atypical subtype. However, N2 bronchial carcinoid tumors show a dismal prognosis.

Videothoracoscopic management of the solitary pulmonary nodule: a single-institution study on 429 cases.

BACKGROUND: Solitary pulmonary nodules (SPNs) sometimes are malignant. We evaluated our 9-year experience in the videothoracoscopic (VATS) management of indeterminate SPNs in order to identify malignant nodules on the basis of clinical and radiologic characteristics. METHODS: From July 1992 to May 2001, 429 patients (276 men and 153 women) were treated by VATS because of a SPN. RESULTS: Three hundred and seventy lesions were benign (86.24%): mean age, 49 years; mean diameter, 1.8 cm; evidence of calcifications, 43 cases (11.62%); smokers, 201 cases (54.32%); history of previous cancer, 11 cases (2.97%). Fifty-nine lesions (13.75%) were malignant (52 NSCLC and seven metastases): mean age, 59 years; mean diameter, 2.31 cm; evidence of calcifications, two cases (3.38%); smokers, 40 cases (67.79%); history of previous cancer, 12 cases (20.33%). Solitary pulmonary nodules were succesfully resected by VATS in 333 (77.62%) cases (309 benign and 24 malignant). Minithoracotomy was necessary to locate the SPNs in 93 (21.67%) cases (61 benign and 32 malignant). Multivariate analysis showed that age greater than 55 years (OR 4.9), diameter of the lesion greater than 2 cm (OR 4.7), history of previous cancer (OR 17.7), and need for conversion to thoracotomy (OR 6.6) to locate the nodule were statistically significant factors in order to identify malignant SPNs. CONCLUSIONS: VATS represents the approach of choice for both diagnosis and treatment of SPNs. The probability of malignancy for SPNs increases with size of the lesion, age of the patients, history of previous cancer, and the need for thoracotomy to locate the nodule.