The Role of Hyperthermic Intrathoracic Chemotherapy (HITHOC) in Thoracic Tumors.

Pleural mesothelioma (PM) is a rare but aggressive thoracic tumor with a poor prognosis. Multimodal treatment-including induction chemotherapy, aggressive surgical resection, radiotherapy and immunotherapy in selected cases-currently represents the best therapeutic option. Single-center studies advocate hyperthermic intrathoracic chemotherapy (HITHOC) during surgical resection as an additional therapeutic option, although its impact on post-operative morbidity and survival has not yet been evaluated on a larger scale. HITHOC can be applied not only in the case of mesothelioma, but also in the case of thymoma with pleural involvement or-in very selected cases-in patients with secondary pleural metastases. Despite favorable outcomes and reduced clinical risks, there is no uniform approach to HITHOC, and a wide variety of indications and technical applications are still reported. Based on available data, HITHOC seems to offer a clear benefit in regard to overall survival of all mesothelioma patients; however, multicenter randomized controlled trials are required to validate and standardize this approach. The aim of this review is to focus on the present role of HITHOC in thoracic tumors with pleural involvement as well as on future challenges, particularly in the light of possible combined therapy of thoracic tumors still presenting poor prognoses.

Prognostic Factors and Clinical Outcomes of Surgical Treatment of Major Thoracic Trauma.

BACKGROUND: Major thoracic trauma represents a life-threatening condition, requiring a prompt multidisciplinary approach and appropriate pathways for effective recovery. While acute morbidity and mortality are well-known outcomes in thoracic-traumatized patients, long-term quality of life in patients surviving surgical treatment has not been widely investigated before. METHODS: Between November 2016 and November 2023, thirty-two consecutive patients were operated on because of thoracic trauma. Age, sex, comorbidities, location and extent of thoracic trauma, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS), Organ Injury Scale (OIS), intra and extrathoracic organ involvement, mechanism of injury, type of surgical procedure, postoperative complications, ICU and total length of stay, immediate clinical outcomes and long-term quality of life-by using the EQ-5D-3L scale and Numeric Rate Pain Score (NPRS)-were collected for each patient Results: Results indicated no significant difference in EQOL.5D3L among patients with thoracic trauma based on AIS (p = 0.55), but a significant difference was observed in relation to ISS (p = 0.000011). CONCLUSIONS: ISS is correlated with the EQOL.5D3L questionnaire on long-term quality of life, representing the best prognostic factor-in terms of long-term quality of life-in patients surviving major thoracic trauma surgical treatment.

Colorectal Cancer Pulmonary Metastasectomy: When, Why and How.

Colorectal cancer is the third-most-diagnosed cancer in males and in females, representing 8% of estimated new cases, and the third cause of cancer-related death in both sexes, accounting for 9% of cancer deaths in men and 8% in women. About 20% of patients diagnosed with CRC present metastatic disease. Although lung metachronous or synchronous metastatic spread without other involved sites has been reported in only a small proportion of patients, considering that this tumor is frequently diagnosed, the clinical approach to CRC pulmonary metastases represents a major issue for thoracic surgeons and CRC oncologists. Among patients diagnosed with pulmonary metastases from CRC, about 9-12% are eligible for local treatments with radical intent, including surgical resection, SBRT (stereotactic body radiation therapy) and ablation therapy. Due to the lack of randomized controlled trials among different local strategies, there is no definitive evidence about the optimal approach, although surgical resection is considered the most effective therapeutic option in this clinical scenario. Oncological achievement of primary radical resection, the biology of primary tumor and metastatic sites, disease free interval and or progression free survival are independent prognostic factors which make it possible to define a cohort of patients which might significantly benefit from pulmonary metastasectomy.

Pleural mesothelioma in situ: a comprehensive review.

Pleural mesothelioma is a rare and aggressive cancer that affects the pleura. In recent years, there has been increasing interest and attention in detecting and diagnosing early-stage or precancerous forms of mesothelioma because of its severe prognosis and short life expectancy at the time of diagnosis. Mesothelioma in situ represents a clear opportunity to improve and innovate the diagnostic approach and the multimodality treatment of mesothelioma: the diagnosis of pleural mesothelioma at the 'in-situ phase' means early disease detection and thus paves the way to new possible curable strategies. Since 2021, when mesothelioma in situ was finally identified and described as a new histological entity, its diagnosis and management became a challenge and the subject of ongoing research; several aspects remain open and still outstanding as regards diagnostic techniques, time and probability of progression, need for and methods of follow up, aggressive and early surgery. This narrative review aims to provide a comprehensive overview of mesothelioma in situ covering its definition, risk factors, diagnostic criteria, and tricky aspects of early detection. It also highlights its clinical significance, new perspectives, and potential future indications in the context of pleural mesothelioma multidisciplinary management.

Stem cell technology for antitumor drug loading and delivery in oncology.

The main aim of antineoplastic treatment is to maximize patient benefit by augmenting the drug accumulation within affected organs and tissues, thus incrementing drug effects and, at the same time, reducing the damage of non-involved tissues to cytotoxic agents. Mesenchymal stromal cells (MSC) represent a group of undifferentiated multipotent cells presenting wide self-renewal features and the capacity to differentiate into an assortment of mesenchymal family cells. During the last year, they have been proposed as natural carriers for the selective release of antitumor drugs to malignant cells, thus optimizing cytotoxic action on cancer cells, while significantly reducing adverse side effects on healthy cells. MSC chemotherapeutic drug loading and delivery is an encouraging new area of cell therapy for several tumors, especially for those with unsatisfactory prognosis and limited treatment options available. Although some experimental models have been successfully developed, phase I clinical studies are needed to confirm this potential application of cell therapy, in particular in the case of primary and secondary lung cancers.

Mesenchymal Stromal Cell Therapy for Thoracic Surgeons: An Update.

Stem cells are undifferentiated cells presenting extensive self-renewal features and the ability to differentiate "in vitro" and "in vivo" into a range of lineage cells, like chondrogenic, osteogenic and adipogenic lineages when cultured in specific inducing media. Two major domains of clinical applications of stem cells in thoracic surgery have been investigated: regenerative medicine, which is a section of translational research in tissue engineering focusing on the replacement, renewal or regeneration of cells, tissues and organs to re-establish damaged physiologic functions; drug loading and delivery, representing a new branch proposing stem cells as carriers to provide selected districts with anti-cancer agents for targeted treatments.

Management of COVID-19 related tracheal stenosis: The state of art.

Tracheal stenosis (TS) is a debilitating disease promoted by pathologic narrowing of the trachea. The acute respiratory distress syndrome caused by COVID-19 has been demonstrated to trigger enhanced inflammatory response and to require prolonged invasive mechanical ventilation as well as high frequency of re-intubation or emergency intubation, thus increasing the rate and complexity of TS. The standard-of-care of COVID-19-related tracheal complications has yet to be established and this is a matter of concern. This review aims at collecting latest evidence on this disease, providing an exhaustive overview on its distinctive features and open issues, and investigating different diagnostic and therapeutic strategies to handle COVID-19-induced TS, focusing on endoscopic versus open surgical approach. The former encompasses bronchoscopic procedures: electrocautery or laser-assisted incisions, ballooning dilation, submucosal steroid injection, endoluminal stenting. The latter consists of tracheal resection with end-to-end anastomosis. As a rule, traditionally, the endoscopic management is restricted to short, low-grade, and simple TS, whereas the open techniques are employed in long, high-grade, and complex TS. However, the critical conditions or extreme comorbidities of several COVID-19 patients, as well as the marked inflammation in tracheal mucosa, have led some authors to apply endoscopic management also in complex TS, recording acceptable results. Although severe COVID-19 seems to be an issue of the past, its long-term complications are still unknown and considering the increased rate and complexity of TS in these patients, we strongly believe that it is worth to focus on it, attempting to find the best management strategy for COVID-19-related TS.

Post-intubation iatrogenic tracheobronchial injuries: The state of art.

Iatrogenic tracheobronchial injury (ITI) is an infrequent but potentially life-threatening disease, with significant morbidity and mortality rates. Its incidence is presumably underestimated since several cases are underrecognized and underreported. Causes of ITI include endotracheal intubation (EI) or percutaneous tracheostomy (PT). Most frequent clinical manifestations are subcutaneous emphysema, pneumomediastinum and unilateral or bilateral pneumothorax, even if occasionally ITI can occur without significant symptoms. Diagnosis mainly relies on clinical suspicion and CT scan, although flexible bronchoscopy remains the gold standard, allowing to identify location and size of the injury. EI and PT related ITIs more commonly consist of longitudinal tear involving the pars membranacea. Based on the depth of tracheal wall injury, Cardillo and colleagues proposed a morphologic classification of ITIs, attempting to standardize their management. Nevertheless, in literature there are no unambiguous guidelines on the best therapeutic modality: management and its timing remain controversial. Historically, surgical repair was considered the gold standard, mainly in high-grade lesions (IIIa-IIIb), carrying high morbi-mortality rates, but currently the development of promising endoscopic techniques through rigid bronchoscopy and stenting could allow for bridge treatment, delaying surgical approach after improving general conditions of the patient, or even for definitive repair, ensuring lower morbi-mortality rates especially in high-risk surgical candidates. Our perspective review will cover all the above issues, aiming at providing an updated and clear diagnostic-therapeutic pathway protocol, which could be applied in case of unexpected ITI.

Volatile agents for cardiac protection in noncardiac surgery: a randomized controlled study.

OBJECTIVE: Volatile anesthetics reduce the risk of myocardial infarction and mortality in coronary artery surgery. Recently, the American College of Cardiology/American Heart Association Guidelines suggested the use of volatile anesthetic agents for the maintenance of general anesthesia during noncardiac surgery in patients at risk for perioperative myocardial ischemia, but no randomized experience to document the cardioprotective effects of these agents exists in this setting. Therefore, the authors performed a prospective, randomized, controlled trial to compare the effects of sevoflurane versus total intravenous anesthesia, in terms of postoperative cardiac troponin I release in patients undergoing noncardiac surgery. DESIGN: A randomized, controlled trial. SETTING: A teaching hospital. PARTICIPANTS: Eighty-eight consecutive patients undergoing noncardiac surgery. INTERVENTIONS: Patients were allocated randomly to receive either volatile anesthetic (44 patients) as the main anesthetic agent or total intravenous anesthesia (TIVA) (44 patients). MEASUREMENTS: Postoperative cardiac troponin I release was measured as a marker of myocardial necrosis. Patients with detectable postoperative troponin I in the sevoflurane group (12/44, 27.3%) were similar to those in the propofol group (9/44, 20.5%; p = 0.6). There was no significant reduction of postoperative median peak cTnI release (0.16 ± 0.71 ng/mL in the sevoflurane group compared with the TIVA group, 0.03 ± 0.08 ng/mL; p = 0.4). Three patients died at the 1-year follow-up for noncardiac causes (2 in the TIVA group). CONCLUSIONS: In the authors' experience, patients undergoing noncardiac surgery did not benefit from anesthesia based on halogenated anesthetics. Further studies are necessary to evaluate the cardioprotective effects of volatile agents in noncardiac surgery.