The Case for Pulmonary Metastasectomy-Clinical Practice Narrative Review and Commentary.

Pulmonary metastasectomy has become a well-established procedure for patients with certain types of solid tumors. Patients are usually scheduled for staged lung metastasectomy in case of primary tumor control, the absence of distant non-lung metastases, and when complete resection is achievable. Nodules are removed with precision resection in order to ensure radical resection with minimal margins; this technique permits good oncological results, preserving the surrounding pulmonary parenchyma and causing minimal distortion compared to staplers. When possible, anatomical resections should be avoided since they are not justified by real oncological advantages and, in the majority of cases, sacrifice too much healthy tissue, possibly leading to inoperability in the case of metachronous relapses. Thus, preserving the maximum amount of pulmonary parenchyma is crucial because repeated metastasectomies are possible and frequent, with no theoretical limits to the number of reinterventions. In our multidisciplinary board team, we support the role of pulmonary metastasectomy as a useful curative therapy, with acceptable morbidity and mortality, with indications to be discussed case-by-case.

Thoracic endometriosis-related non-catamenial pneumothorax with peculiar histological findings.

Thoracic endometriosis-related non-catamenial pneumothorax is a rare entity whose pathogenesis is still less unclear than catamenial pneumothorax one. Hormonal therapy and/or talc pleurodesis are not sufficient for successful management. Surgical videothoracoscopic resection has a central role in the treatment. We displace a case of thoracic endometriosis-related non-catamenial pneumothorax presenting with recurrent right pneumothorax, surgically treated three times and misdiagnosed at first two interventions. At third operation, unusual histological findings on diaphragmatic and pulmonary specimens were disclosed. These results could partially clarify the presentation of some complicated misdiagnosed cases. More has to be investigated about pathogenesis of the disease and influence of the hormonal balance on it.

Nerve-sparing schwannoma removal from two infrequent origins.

Schwannomas of nerve sheath origin (Schwann cell) are the most common neurogenic thoracic tumors and they usually originate from an intercostal nerve, especially in the paravertebral region. Tumors that originate from other nerves such as the phrenic nerve, vagus, or sympathetic nerves are uncommon. We report two cases of schwannomas in rare locations. A 62-year-old woman had a giant schwannoma arising from the right phrenic nerve, and a 57-year-old woman had one from the left sympathetic nerve. Both tumors were completely removed with preservation of the nerves.

Tuberculosis a disease that created and shaped thoracic surgery.

Today it is incredible to think that an infectious disease, Tuberculosis (TB) as the disease that shaped Thoracic Surgery. The history of TB has so far evolved similarities with that of the mythological Phoenix, where the resurgence of this never completely eradicated "Insidious Disease" has now re-emerged and brought new challenges to modern medicine that of multi drug resistance. The probability of success, in treating complicated multi-drug resistant (MDR) TB pushing us back to the pre-antibiotic era, now depends on several factors: (I) optimal antibiotic management; (II) patient compliance; (III) multi-disciplinary teamwork; (IV) experience in carrying out "not-routine" surgical procedures; and finally (V) ability to offer long term patient hospitalization, frequently months, without bureaucratic and economical problems. The probability of good patient outcome is higher when all of these criteria are satisfied.

"Roman Sandal" modified method for securing the chest drain to the skin.

Chest drain insertion is a simple procedure with very low morbidity and mortality. The correct procedure provides for a good fixation of the drainage to the skin. An alternative "Roman Sandal technique" for securing the chest drain to the skin is proposed compared to the classical methods. The main feature of the method is the fact that a single suture acts as "tube fixing" and "wound closure" by creating an alpha-cross-wires into and around the wound. The new method is presented as more elegant, effective, quicker application and removal of the drainage and excellent cosmetic results.

Surgical procedures in the DANTE trial, a randomized study of lung cancer early detection with spiral computed tomography: comparative analysis in the screening and control arm.

BACKGROUND: The patient population derived from lung cancer screening programs with low-dose spiral computed tomography (LDCT) is different from the general population accessing thoracic surgical services. METHODS: Retrospective review of all surgical cases in the DANTE trial, a randomized study of lung cancer screening with LDCT. Patient characteristics, workup, procedures, resections for benign disease, complications, tumor features, and final outcomes have been analyzed in the LDCT and in the control arm. RESULTS: In the LDCT arm, 77 suspicious lesions were surgically managed in 72 patients. A benign lesion was diagnosed in 17 cases (22%). Major video-assisted thoracoscopic surgery resection was carried out in five lung cancer cases (7%) and segmentectomy in 11 (19%). Complete resection was achieved in 93%, and stage I rate was 73%. Two patients had a local recurrence after open lobectomy, and three had a resectable new primary. In the control group, 28 patients underwent 31 surgical procedures, in five cases (16%) for benign lesions. No major video-assisted thoracoscopic surgery resections were carried out. Resectability rate was 88%, and stage I rate was 52%. Five patients had a local recurrence and two had a second primary. CONCLUSIONS: Surgery for benign lesions is a relevant issue in screening-derived patients. Local control may be achieved by minimally invasive techniques or segmentectomy; however, developing the necessary skills requires an effort by the surgical team. Long-term survivors have a noticeable chance of developing second primary cancers or resectable recurrences and may benefit from a second resection.

A randomized study of lung cancer screening with spiral computed tomography: three-year results from the DANTE trial.

RATIONALE: Screening for lung cancer with modern imaging technology may decrease lung cancer mortality, but encouraging results have only been obtained in uncontrolled studies. OBJECTIVES: To explore the effect of screening with low-dose spiral computed tomography (LDCT) on lung cancer mortality. Secondary endpoints are incidence, stage at diagnosis, and resectability. METHODS: Male subjects, aged 60 to 75 years, smokers of 20 or more pack-years, were randomized to screening with LDCT or control groups. All participants underwent a baseline, once-only chest X-ray and sputum cytology examination. Screening-arm subjects had LDCT upon accrual to be repeated every year for 4 years, whereas controls had a yearly medical examination only. MEASUREMENTS AND MAIN RESULTS: A total of 2,811 subjects were randomized and 2,472 were enrolled (LDCT, 1,276; control, 1,196). After a median follow-up of 33 months, lung cancer was detected in 60 (4.7%) patients receiving LDCT and 34 (2.8%) control subjects (P = 0.016). Resectability rates were similar in both groups. More patients with stage I disease were detected by LDCT (54 vs. 34%; P = 0.06) and fewer cases were detected in the screening arm due to intercurrent symptoms. However, the number of advanced lung cancer cases was the same as in the control arm. Twenty patients in the LDCT group (1.6%) and 20 controls (1.7%) died of lung cancer, whereas 26 and 25 died of other causes, respectively. CONCLUSIONS: The mortality benefit from lung cancer screening by LDCT might be far smaller than anticipated.

Primary pulmonary meningioma: report of a case and review of the literature.

Primary pulmonary meningioma (PPM) is a rare disease and usually presents as a solitary pulmonary nodule (SPN). These lesions are mostly benign, but malignant PPMs have been reported, and primary lung cancer or metastasis may be suspected on imaging. We report one case of benign PPM, with a review of 37 cases published in the literature. Diagnostic work-up included radiological chest study and in 3 cases positron emission tomography (PET) showing increased uptake, highly suspicious for malignancy. After exclusion of 13 cases lacking radiological studies of the central nervous system (CNS), 25 patients with radiological data and histological assessment confirming PPM were considered in the analysis. All patients underwent surgical resection except for 1 case with diagnosis at autopsy. Histological assessment revealed benign PPMs in 23 cases (including all 3 cases with positive PET) and malignant PPMs in 2 cases. No recurrence was observed in long-term follow-up of patients with benign PPMs, but the two malignant PPMs relapsed. PPM is an uncommon SPN, so that it can be misdiagnosed and its management unsuited. Indeed, 8 patients (32%) were overtreated with major thoracic surgical resection or with chemotherapy. When feasible, pulmonary wedge resection by video-assisted thoracic surgery (VATS) including intra-operative histological examination is the most suitable approach to determine the diagnosis and the volume of pulmonary resection.