Lymphadenectomy for lung carcinoids: Which factors may predict nodal upstaging? A multi centric, retrospective study.

OBJECTIVE: To investigate risk factors for nodal upstaging in patients with lung carcinoids and to understand which type of lymphadenectomy is most appropriate. METHODS: Data regarding patients with lung carcinoids, who underwent surgical resection and lymphadenectomy in five institutions from January 1, 2005 to December 31, 2019, were collected and retrospectively analyzed. Clinical and pathological tumor characteristics were correlated to analyze lymph node upstaging. RESULTS: The analysis was conducted on 283 patients. Pathology showed 230 typical and 53 atypical carcinoids. Nodal and mediastinal upstaging occurred in 33 (11.6%) and 16 (5.6%) patients, respectively. At the univariable analysis, nodal upstaging was significantly correlated with central location (p = 0.003), atypical histology (p < 0.001), pT dimension (p = 0.004), and advanced age (p = 0.043). The multivariable analysis confirmed atypical histology (odds ratio [OR]: 11.030; 95% confidence interval [CI]: 4.837-25.153, p < 0.001) and central location (OR: 3.295; 95% CI: 1.440-7.540, p = 0.005) as independent prognostic factors for nodal upstaging. Atypical histology (p < 0.001), pT dimension (p = 0.036), number of harvested lymph node stations (p = 0.047), and type of lymphadenectomy (p < 0.001) correlated significantly with mediastinal upstaging. The multivariable analysis confirmed atypical histology (OR: 5.408; 95% CI: 1.391-21.020, p = 0.015) and pT (OR: 1.052; 95% CI: 1.021-1.084, p = 0.001) as independent prognostic factors. CONCLUSION: Atypical histology, dimension, and central location are associated with a high-risk for occult hilo-mediastinal metastases, and mediastinal radical dissection may predict nodal upstaging. Thus, we suggest radical mediastinal lymph node dissection in high-risk tumors, reserving sampling, or lobe-specific dissection in peripheral, small typical carcinoids.

Airway injuries in pre and post-COVID-19 era: a preliminary epidemiologic investigation in our center.

BACKGROUND: Tracheal stenosis and tracheo-esophageal fistulas are serious but rare complications of prolonged invasive mechanical ventilation. Tracheal resection with end-to-end anastomosis and endoscopic procedure are the options of care in the treatment of tracheal injuries. Tracheal stenosis could be iatrogenic, associated with tracheal tumors, or idiopathic. Tracheo-esophageal fistula may be congenital or acquired; in adults about half of the cases are secondary to malignancies. METHODS: We performed a retrospective study of all the patients referred to our center between 2013 and 2022, with diagnosis of benign or malign tracheal stenosis or tracheo-esophageal fistulas due to benign or malign airway injury, undergoing tracheal surgery. Patients are divided in two temporal cohorts: cohort X if treated before SARS-CoV-2 pandemic (from 2013 to 2019) and cohort Y if treated during and after SARS-CoV-2 pandemic (from 2020 to 2022). RESULTS: From the onset of the COVID-19 outbreak, we experienced an unprecedented increase in the incidence of TEF and TS. In addition, based on our data, results show less variability for TS etiology, mainly iatrogenic, an increase of 10 years in median age and an inversion of trend regarding the sex of patients. CONCLUSIONS: The standard of care for definitive treatment of TS is tracheal resection and end-to-end anastomosis. Literature shows a high success rate (83-97%) and low mortality (0-5%) following surgery in specialized centers with experience. Management of tracheal complication after prolonged MV is still challenging. An adequate clinical and radiological follow-up should be performed in patients treated with prolonged MV in order to diagnose any tracheal lesions in the subclinical phase and to choose the correct strategy, center and time to treat it.

IgG4-infiltrate in post-intubation tracheal stenosis: a call to interventional pulmonologist and thoracic surgeons.

BACKGROUND: Since December 2019, Sars-CoV2 infection has become a pandemic health emergency. The most severe manifestation of COVID-19 is acute respiratory distress syndrome requiring intensive care unit admission and mechanical ventilation. The most serious, although rare, complication of prolonged MV is post-intubation tracheal stenosis. We hypothesized that, in addition to recognized risk factors in COVID-19 patients, additional factors may promote airways injury. METHODS: We analyzed data from 13 patients with PITS referred to our Thoracic Surgery Department from 2020 to 2022 divided in two groups: 8 ex-COVID-19 patients (in MV for ARDS during Sars-Cov2 positivity) and 5 non-COVID-19 patients (in MV for other reasons). Computer-tomography and bronchoscopy were performed to confirm diagnosis of PITS. Surgical treatment including tracheal resection and end-to-end anastomosis was performed in all patients. Tracheal samples were histologically analyzed to define the existence of any difference between the two groups. RESULTS: The presence of total immunoglobulin G (IgG) and immunoglobulin G4 (IgG4) were tested. IgG infiltrate was present in both groups. IgG4-infiltrate was significantly represented in the tracheal sample of ex-COVID-19 patients and absent in the non-COVID-19 cohort of patients. CONCLUSIONS: It is suggested that COVID-19 patients have almost double the risk of developing tracheal injuries. This work supports the idea of a major predisposition for such injuries in COVID-19 patients due to a possible immune-mediated mechanism leading to aberrant and fibrotic wound healing following a trigger insult (in this case MV with oro-tracheal tube). In the near future an increasing incidence of PITS is expected. Interventional pulmonologist and thoracic surgeons might be called to deal with this possibility. Clarification of the physiopathology of PITS is needed to prevent excessive tracheal scarring following prolonged endotracheal intubation and recurrence after endoscopic and/or surgical treatment. Careful prevention, early detection and effective management of this life-threatening condition are warranted.

VATS phrenic nerve harvesting for brachial plexus neurotization: literature review and our experience.

INTRODUCTION: Brachial plexus traumatic lesions often lead to severe upper extremity deficits that dramatically compromise quality of life of mostly young patients. Optimal treatment aims to restore elbow flexion transferring various donor nerves. Phrenic nerve (PN) is a powerful source of transferable axons and, despite supraclavicular sectioning being the most used technique, it can be harvested through video-assisted thoracoscopic surgery (VATS). EVIDENCE ACQUISITION: About PN harvesting, less than 20 articles were found in Literature. Most of them are clinical case-reports or case-series or expert opinions. Most of these studies are from China and East Asia and very rarely from Europe; none from Italy. Therefore, we present our experience in PN VATS harvesting in two patients, first cases reported in Italy. EVIDENCE SYNTHESIS: Few papers explore risks and benefits of PN as a donor site for brachial plexus reconstruction. There is no clear consensus in the literature whether a traditional approach or minimally invasive surgery is advisable to harvest PN for neurotization. Currently there's no clear indication nor a definitive contraindication about routine use of PN for surgical treatment of BPTLs, it's mostly a matter of choosing the best donor nerve for every single patient. This choice depends on the patient's characteristics, type of traumatic lesion, time from the traumatic event and on the center's experience. The only real concern about using PN as a donor is the potential loss of pulmonary function. In our center two patients with complete brachial plexus avulsion underwent PN transfer via VATS in 2021. Usually, recovery of muscle function depends on time between injury and surgical repair. A commonly accepted recommendation is to perform surgery within six months from the traumatic lesion12. In our experience, the time between trauma and surgery was five months for patient A and six months for patient B. Even if some authors13 consider previous thoracic trauma with rib fractures a major contraindication for homolateral PN harvesting, we believe that the presence of pleural adhesions should not exclude a patient from surgery. No intra or postoperative complications were observed. Both patients were discharged on IV postoperative day. An intense rehabilitation program within three months after surgery is mandatory and regular follow-up is needed to monitor any improvement. No respiratory symptoms or discomfort is recorded up to now. CONCLUSIONS: Nerve transfer is a safe and reliable surgical reconstructive procedure and phrenic nerve, due to its pure motor nature, is a very good donor for brachial plexus injuries14. VATS is a valid procedure to guarantee a much longer nerve, avoiding any graft use, and doesn't seem to determine significant pulmonary function loss. Previous thoracic trauma, rib fractures and pneumothorax are commonly considered contraindications for VATS harvesting. However, a major trauma leading to BPTL often implies homolateral thoracic trauma with or without rib fracture or pneumothorax. This could be a reasonable justification to reconsider those contraindications and extend the potential cohort of patients that could benefit from this technique.

External Validation of a Prognostic Score for Survival in Lung Carcinoids.

Background: A prognostic score including T-dimension, age, histology and lymph node ratio was previously proposed in absence of an external validation dataset. The aim of the current study was to validate the proposed prognostic score using an independent dataset. Methods: Data of patients with lung carcinoids, who underwent surgical resection and lymphadenectomy in five institutions from 1 January 2005 to 31 December 2019, were retrospectively analyzed. Two risk groups were created based on the following data: age, histology, node ratio and pT for disease-free survival (DFS); age, sex, node ratio and pT for overall survival (OS). The previously proposed score was validated, identifying two groups of patients: a high risk (HRG) and low risk (LRG) group. Results: The final analysis was conducted on 283 patients. Regarding DFS, 230 (81.3%) patients were assigned to the LRG and 53 (18.7%) to the HRG. Considering OS, 268 (94.7%) were allocated in the LRG and 15 (5.3%) in the HRG. The 5-year DFS was 92.7% in the LRG vs. 67% in the HRG (p < 0.001) while the 5-year OS was 93.6% in the LRG vs. 86.2% in the HRG (p = 0.29) with clear curve separation. Conclusion: Our analysis confirmed the validity of the composite score for DFS in lung carcinoids. Regarding OS, statistical significance was not reached because of a low number of deaths and patients in the HRG.

Proctor-guided virtual reality-enhanced three-dimensional video-assisted thoracic surgery: an excellent tutoring model for lung segmentectomy.

OBJECTIVE: Lung segmentectomy using video-assisted thoracoscopic surgery (VATS) is an effective strategy to treat early-stage lung cancer. The objective of this case report is to show the efficacy of Hyper Accuracy 3D™ (HA3D) reconstruction as a tool for trainee surgeons and expert surgeons to perform complex procedures. METHODS: An 84-year-old man was treated for colon-rectal cancer. During follow-up, a pulmonary nodule on the right anterior upper lobe suspected for intestinal metastasis was revealed by a computed tomography scan. According to functional tests and radiology, a right anterior upper lobe segmentectomy was planned. HA3D lung reconstruction was used during surgery. RESULTS: Using the HA3D virtual model, the procedure was performed with healthy tissue sparing, ensuring safe resection margins. No postoperative morbidities were noted. The patient referred good pain control. The hospital stay was 6 days. CONCLUSIONS: VATS segmentectomy is a technically demanding procedure. HA3D lung reconstruction can help surgeons effectively perform the resection, aiding at individuating intersegmental planes, bronchi, and vessels, guaranteeing oncologic radicality and safe surgical margins, and preserving respiratory function.