Chest CT in patients with a moderate or high pretest probability of COVID-19 and negative swab.

OBJECTIVES: We aimed to assess the diagnostic performance of CT in patients with a negative first RT-PCR testing and to identify typical features of COVID-19 pneumonia that can guide diagnosis in this case. METHODS: Patients suspected of COVID-19 with a negative first RT-PCR testing were retrospectively revalued after undergoing CT. CT was reviewed by two radiologists and classified as suspected COVID-19 pneumonia, non-COVID-19 pneumonia or negative. The performance of both first RT-PCR result and CT was evaluated by using sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV) and area under the curve (AUC) and by using the second RT-PCR test as the reference standard. CT findings for confirmed COVID-19 positive or negative were compared by using the Pearson chi-squared test (P values < 0.05) RESULTS: Totally, 337 patients suspected of COVID-19 underwent CT and nasopharyngeal swabs in March 2020. Eighty-seven out of 337 patients had a negative first RT-PCR result; of these, 68 repeated RT-PCR testing and were included in the study. The first RT-PCR test showed SE 0, SP = 100%, PPV = NaN, NPV = 70%, AUC = 50%, and CT showed SE = 70% SP = 79%, PPV = 86%, NPV = 76%, AUC = 75%. The most relevant CT variables were ground glass opacity more than 50% and peripheral and/or perihilar distribution. DISCUSSION: Negative RT-PCR test but positive CT features should be highly suggestive of COVID-19 in a cluster or community transmission scenarios, and the second RT-PCR test should be promptly requested to confirm the final diagnosis.

Long-Term Follow-up Results of the DANTE Trial, a Randomized Study of Lung Cancer Screening with Spiral Computed Tomography.

RATIONALE: Screening for lung cancer with low-dose spiral computed tomography (LDCT) has been shown to reduce lung cancer mortality by 20% compared with screening with chest X-ray (CXR) in the National Lung Screening Trial, but uncertainty remains concerning the efficacy of LDCT screening in a community setting. OBJECTIVES: To explore the effect of LDCT screening on lung cancer mortality compared with no screening. Secondary endpoints included incidence, stage, and resectability rates. METHODS: Male smokers of 20+ pack-years, aged 60 to 74 years, underwent a baseline CXR and sputum cytology examination and received five screening rounds with LDCT or a yearly clinical review only in a randomized fashion. MEASUREMENTS AND MAIN RESULTS: A total of 1,264 subjects were enrolled in the LDCT arm and 1,186 in the control arm. Their median age was 64.0 years (interquartile range, 5), and median smoking exposure was 45.0 pack-years. The median follow-up was 8.35 years. One hundred four patients (8.23%) were diagnosed with lung cancer in the screening arm (66 by CT), 47 of whom (3.71%) had stage I disease; 72 control patients (6.07%) were diagnosed with lung cancer, with 16 (1.35%) being stage I cases. Lung cancer mortality was 543 per 100,000 person-years (95% confidence interval, 413-700) in the LDCT arm versus 544 per 100,000 person-years (95% CI, 410-709) in the control arm (hazard ratio, 0.993; 95% confidence interval, 0.688-1.433). CONCLUSIONS: Because of its limited statistical power, the results of the DANTE (Detection And screening of early lung cancer with Novel imaging TEchnology) trial do not allow us to make a definitive statement about the efficacy of LDCT screening. However, they underline the importance of obtaining additional data from randomized trials with intervention-free reference arms before the implementation of population screening.

Analysis of Risk Factors for Tracheal Stenosis Managed during COVID-19 Pandemic: A Retrospective, Case-Control Study from Two European Referral Centre.

INTRODUCTION: Benign subglottic/tracheal stenosis (SG/TS) is a life-threatening condition commonly caused by prolonged endotracheal intubation or tracheostomy. Invasive mechanical ventilation was frequently used to manage severe COVID-19, resulting in an increased number of patients with various degrees of residual stenosis following respiratory weaning. The aim of this study was to compare demographics, radiological characteristics, and surgical outcomes between COVID-19 and non-COVID patients treated for tracheal stenosis and investigate the potential differences between the groups. MATERIALS AND METHODS: We retrospectively retrieved electronical medical records of patients managed at two referral centers for airways diseases (IRCCS Humanitas Research Hospital and Avicenne Hospital) with tracheal stenosis between March 2020 and May 2022 and grouped according to SAR-CoV-2 infection status. All patients underwent a radiological and endoscopic evaluation followed by multidisciplinary team consultation. Follow-up was performed through quarterly outpatient consultation. Clinical findings and outcomes were analyzed by using SPPS software. A significance level of 5% (p < 0.05) was adopted for comparisons. RESULTS: A total of 59 patients with a mean age of 56.4 (±13.4) years were surgically managed. Tracheal stenosis was COVID related in 36 (61%) patients. Obesity was frequent in the COVID-19 group (29.7 ± 5.4 vs. 26.9 ± 3, p = 0.043) while no difference was found regarding age, sex, number, and types of comorbidities between the two groups. In the COVID-19 group, orotracheal intubation lasted longer (17.7 ± 14.5 vs. 9.7 ± 5.8 days, p = 0.001), tracheotomy (80%, p = 0.003) as well as re-tracheotomy (6% of cases, p = 0.025) were more frequent and tracheotomy maintenance was longer (21.5 ± 11.9 days, p = 0.006) when compared to the non-COVID group. COVID-19 stenosis was located more distal from vocal folds (3.0 ± 1.86 vs. 1.8 ± 2.03 cm) yet without evidence of a difference (p = 0.07). The number of tracheal rings involved was lower in the non-COVID group (1.7 ± 1 vs. 2.6 ± 0.8 p = 0.001) and stenosis were more frequently managed by rigid bronchoscopy (74% vs. 47%, p = 0.04) when compared to the COVID-19 group. Finally, no difference in recurrence rate was detected between the groups (35% vs. 15%, p = 0.18). CONCLUSIONS: Obesity, a longer time of intubation, tracheostomy, re-tracheostomy, and longer decannulation time occurred more frequently in COVID-related tracheal stenosis. These events may explain the higher number of tracheal rings involved, although we cannot exclude the direct role of SARS-CoV-2 infection in the genesis of tracheal stenosis. Further studies with in vitro/in vivo models will be helpful to better understand the role of inflammatory status caused by SARS-CoV-2 in upper airways.

Single-Center 20-Year Experience in Surgical Treatment of Malignant Pleural Mesothelioma.

Objectives: We examined a series of malignant pleural mesothelioma (MPM) patients who consecutively underwent surgery in our institution during the last 20 years. Across this period, we changed our surgical approach to MPM, adopting extended pleurectomy and decortication (eP/D) instead of extrapleural pneumonectomy (EPP). In this study, we compare the perioperative outcomes and long-term survival of patients who underwent EPP vs. eP/D. Methods: A retrospective analysis was carried out of all the MPM patients identified from our departmental database who underwent EPP or P/D from 2000 to 2021. Clavien−Dindo criteria was adopted to score postoperative complications, while Kaplan−Meier methods and a Cox multivariable analysis were used to perform the survival analysis. Results: Of 163 patients, 78 (48%) underwent EPP and 85 (52%) eP/D. Induction chemotherapy was significantly administrated more often in the eP/D group (88% vs. 51%). Complete trimodality treatment including induction chemotherapy, radical surgery, and adjuvant radiotherapy was administered in 74% of the eP/D group versus 32% of the EPP group (p < 0.001). The postoperative morbidity rate was higher in the eP/D group (54%) compared to the EPP group (36%) (p = 0.02); no statistically significant differences were identified concerning major complications (EPP 43% vs. eP/D 24%, p = 0.08). No statistical differences were identified in 30-day mortality, 90-day mortality, median disease-free, and overall survival statistics between the two groups. The Cox multivariable analysis confirmed no induction chemotherapy (HR, 0.5; p = 0.002), RDW (HR, 1.08; p = 0.02), and the presence of pathological nodal disease (HR, 1.99; p = 0.001) as factors associated with worse survival in the entire series. Conclusions: Our data support that eP/D is a well-tolerated procedure allowing the implementation of a trimodality strategy (induction chemotherapy, surgery, and radiotherapy) in most MPM patients. When eP/D is offered in this setting, the oncological results are comparable to EPP. To obtain the best oncological results, the goal of surgical resection should be macroscopic complete resection (R0) in carefully selected patients (clinical N0).

Bronchoscopic Intra-Pleural Instillation of Fibrin Glue and Autologous Blood to Manage Persistent Air Leaks after Lung Resection.

Background: Persistent air leak is a common complication after lung resection causing prolonged length of stay and increased healthcare costs. Surgical intervention can be an option, but other more conservative approaches should be considered first. Here, we describe the use of flexible bronchoscopy to apply fibrin glue and autologous blood sequentially to the damaged lung. We named the technique "flexible thoracoscopy". METHODS: Medical records from patients with persistent air leaks after lung resection were collected retrospectively. Depending on the type of aerostasis that was performed, two groups were created: flexible thoracoscopy and surgery (thoracotomy). Flexible thoracoscopy was introduced at our institution in 2013. We entered the pleural space with a bronchoscope following the same surgical pathway that was used for tube thoracostomy. Perioperative characteristics and outcomes were analyzed using R software (ver. 3.4.4). RESULTS: From 1997 to 2021, a total of 23 patients required an intervention for persistent air leaks. Aerostasis was performed via flexible thoracoscopy in seventeen patients (69%) and via thoracotomy in six patients (31%). The median age was 70 years (22-82). Twenty patients were males (87%). There was no difference in age, sex distribution, BMI, comorbidities and FEV1%. An ASA score of 3 was more represented in the flexible thoracoscopy group; however, no evidence of a difference was found when compared to the thoracotomy group (p = 0.124). Length of in-hospital stay and chest tube duration was also similar between groups (p = 1 and p = 0.68, respectively). CONCLUSIONS: Aerostasis achieved either by flexible thoracoscopy or by thoracotomy showed similar results. We believe that flexible thoracoscopy could be a valid alternative to facilitate minimally invasive treatments for persistent air leaks. Further studies are needed to confirm these results.

Endoscopic Lipofilling for the Treatment of Bronchopleural Fistulas After Anatomic Lung Resection.

A bronchopleural fistula is a potentially fatal complication of anatomic lung resection surgery. Bronchoscopy has been described in the treatment of small-caliber fistulas. An endoscopic procedure based on instillation of mesenchymal stem cells for the treatment of bronchopleural fistula has recently been successful. Fat tissue is rich in mesenchymal stem cells, and we describe a technique based on the instillation of autologous fat (lipofilling) for the treatment of bronchopleural fistulas. The procedure was applied to 8 subjects affected by bronchopleural fistulas that were greater than 8 mm in diameter, and saw resolution in all cases.

Tracheal polypoid combined small cell lung cancer (C-SCLC): A case report.

Small cell lung cancer (SCLC) is an aggressive malignancy with a poor prognosis that accounts for 10% of all cases of clinical lung cancer. Due to its high growth fraction and rapid doubling time it is usually diagnosed as extensive local or metastatic disease in 60%-70% of cases. Combined small cell lung cancer (C-SCLC) is a relatively rare subtype of SCLC and is defined as SCLC combined with any elements of non-small cell lung cancer (NSCLC). Clinical presentation of SCLC as an isolated pedunculated endotracheal lesion is an especially rare occurrence. Here, we report for the first time the occurrence of a C-SCLC as a polypoid tumor of the trachea diagnosed in an 80-year-old woman admitted to the emergency department with a principal complaint of cough and wheezing.

Bronchoalveolar lavage in suspected COVID-19 cases with a negative nasopharyngeal swab: a retrospective cross-sectional study in a high-impact Northern Italy area.

COVID-19 diagnosis relies on molecular testing for SARS-CoV-2 via nasopharyngeal swab in the presence of suggestive clinical, radiological and laboratory findings. Since bronchoalveolar lavage liquid (BAL) collected during fibrobronchoscopy may increase test sensitivity compared to nasopharyngeal swabs, it was performed during the 2020 pandemic in clinically or radiologically suspected cases. Our aim was to determine whether clinical features, chest computed tomography (CT) findings or laboratory tests may predict patients testing positive for SARS-CoV-2 at BAL after a negative nasopharyngeal swab. We performed a retrospective cross-sectional study with multivariable analysis of suspected patients who were tested for SARS-CoV-2 at BAL after at least one negative nasopharyngeal swab. Univariable logistic regression for odds ratio and multivariate models was calculated to determine clinical, radiological and laboratory predictors. 32/198 (16%) patients had BAL positive for SARS-CoV-2, while 65/198 tested positive for other pathogens at BAL. Of the 32 patients positive for COVID, 4 had a coinfection at BAL, being thus positive both for COVID as well as for another pathogen while the remaining 105 patients were negative for COVID and other pathogens at BAL. COVID-19 patients had more often highly suggestive CT findings, higher number of involved lobes, more often ground glass opacity of more than 50% of lung parenchyma, and less frequently other radiologically suspected infections. At multivariate model, temperature also predicted BAL positivity. The procedure was well tolerated-with only one desaturation episode-while no healthcare worker was infected. In conclusion, when nasopharyngeal swabs are negative but there is clinical or imaging suspicion of COVID-19, BAL represents a complementary diagnostic tool, particularly in conjunction with suggestive/more extensive lung involvement at CT scan. The procedure did not carry increased risks for patients nor for operators, while allowing to free hospital resources, avoiding unnecessary isolations.

In-vivo imaging of methionine metabolism in patients with suspected malignant pleural mesothelioma.

OBJECTIVES: In-vivo characterization of malignant pleural mesothelioma (MPM) with C-methionine PET/computed tomography (MET PET). METHODS: Between September 2014 and February 2016, 30 consecutive patients with clinical suspicion of MPM were prospectively recruited. The study was approved and registered at www.clinicaltrials.gov (NCT02519049). Patients were evaluated at baseline with MET PET (experimental) and fluorine-18 fluorodeoxyglucose PET/computed tomography (FDG PET) (standard). Principal parameters analyzed were SUVmax, SUVmean, metabolic tumor volume (MTV), and metabolic tumor burden (MTB = MTV ×SUVmean). The reference standard for diagnostic performance was based on histology. RESULTS: The presence of malignancy was confirmed in 29/30 patients: 23 (76.6%) with MPM (20 epithelioid, two biphasic, and one sarcomatoid), five (16.6%) with adenocarcinoma of the lung, and one (3.3%) with an undifferentiated carcinoma. In one case, diagnosis was benign pleural inflammation. All tumors showed increased uptake of C-methionine: median SUVmax, SUVmean, MTV, and MTB were, respectively, 5.70 [95% confidence interval (CI): 4.51-6.79], 3.15 (95% CI: 2.71-3.40), 33.85 (95% CI: 14.08-66.64), and 105.25 (95% CI: 41.77-215.25). Pathology data revealed MTV and MTB to be significantly higher in nonepithelioid histology (P < 0.05). The other parameters showed a homogeneous distribution across the tumor types. Overall, MET PET identified 49 lymph nodes, compared with 34 nodes on FDG PET, demonstrating a sensitivity of 91% (95% CI: 80-96%), a positive predictive value of 92% (95% CI: 82- 97%), and an accuracy of 85% (P = 0.0042). CONCLUSIONS: MET PET is able to characterize MPM lesions regardless of histology. This technique shows higher sensitivity than FDG PET for the identification of secondary lymph nodes.

Ideal conditions to perform EBUS-TBNA.

EBUS-TBNA is gaining widespread acceptance as a minimally invasive procedure for mediastinal staging and re-staging of lung cancer, diagnosis of lung tumors adjacent to large airways and characterization of both malignant and benign lymphadenopathy. The aim of this article is to describe the appropriate setting and practical aspects of the procedure that may help at the start of a new EBUS-TBNA program to improve patient safety, comfort and procedural yield according to operator experience, procedure aim, and institutional needs.

A new safe and stable spiral wire needle for thoracoscopic resection of lung nodules.

BACKGROUND: To show the safety and stability of a spiral wire needle (Somatex; Rietzneuendorf, Germany) in the detection and subsequent thoracoscopic resection of subpleural and/or small nodules of the lung. METHODS: Under local anesthesia and CT control, 13 patients underwent the positioning of a spiral wire needle into the lung, with the spiral located close to or inside the nodule to be resected. Then the patients underwent video-assisted thoracoscopic surgery resection of the nodules with only two thoracoscopic accesses. RESULTS: All the nodules were identified due to the precise location of the spiral wire needle. The presence of a stable spiral wire inside the parenchyma has allowed us to put under tension the overlying parenchyma, which had previously been excluded from ventilation. The external traction on the needle facilitates the detection of the nodule and simplifies thoracoscopic resection with a stapler. With this new tool, we have always reached an adequate diagnosis and observed no cases of dislodgment of the needle during the traction maneuvers, nor cases of conversion from thoracoscopy to thoracotomy. CONCLUSIONS: Although our initial experience is limited, the use of this spiral wire needle has been shown to be extremely advantageous in identifying subpleural and/or small nodules of the lung, even sparing the classic third thoracoscopic access for their resection. The presence of a wire needle with a spiral terminal portion (which is placed firmly inside the lung parenchyma) is very useful for the thoracoscopic resection of pulmonary nodules.

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.

Healing of bronchopleural fistula using a modified Dumon stent: a case report.

BACKGROUND: Bronchopleural fistula following lung resection is a therapeutic challenge for thoracic surgeons. CASE PRESENTATION: We describe a case of late bronchopleural fistula after right extrapleural pneumonectomy for malignant mesothelioma. Bronchoscopic attempts to repair it were unsuccessful. CONCLUSION: The use of a modified Y Dumon stent associated with glue apposition on the bronchial stump allowed us to close the fistula without the need of any surgical repair.

Two-year survival after multiple bilateral lung metastasectomies for cranial meningioma.

The lung represents a common site of metastases from extrathoracic malignancies, and several studies have strengthened the evidence that complete resection of pulmonary metastases is a useful therapeutic treatment for prolonged survival in selected patients. However, fewer data are available in the literature regarding the role of lung metastasectomy in rare malignancy. We present a case of extensive bilateral lung metastases due to recurrent cranial meningioma, which was successfully treated by aggressive, staged metastasectomies.