Pulmonary lesion after surgery for renal cancer: progression or new primary?

PURPOSE: To investigate clinical and radiological differences between kidney metastases to the lung (RCCM +) and metachronous lung cancer (LC) detected during follow-up in patients surgically treated for Renal Cell Carcinoma (RCC). METHODS: cM0 surgically-treated RCC who harbored a pulmonary mass during follow-up were retrospectively scrutinized. Univariate logistic regression assessed predictive features for differentiating between LC and RCCM + . Multivariable analyses (MVA) were fitted to predict factors that could influence time between detection and histological diagnosis of the pulmonary mass, and how this interval could impact on survivals. RESULTS: 87% had RCCM + and 13% had LC. LC were more likely to have smoking history (75% vs. 29%, p < 0.001) and less aggressive RCC features (cT1-2: 94% vs. 65%, p = 0.01; pT1-2: 88% vs. 41%, p = 0.02; G1-2: 88% vs. 37%, p < 0.001). The median interval between RCC surgery and lung mass detection was longer between LC (55 months [32.8-107.2] vs. 20 months [9.0-45.0], p = 0.01). RCCM + had a higher likelihood of multiple (3[1-4] vs. 1[1-1], p < 0.001) and bilateral (51% vs. 6%, p = 0.002) pulmonary nodules, whereas LC usually presented with a solitary pulmonary nodule, less than 20 mm. Univariate analyses revealed that smoking history (OR:0.79; 95% CI 0.70-0.89; p < 0.001) and interval between RCC surgery and lung mass detection (OR:0.99; 95% CI 0.97-1.00; p = 0.002) predicted a higher risk of LC. Conversely, size (OR:1.02; 95% CI 1.01-1.04; p = 0.003), clinical stage (OR:1.14; 95% CI 1.06-1.23; p < 0.001), pathological stage (OR:1.14; 95% CI 1.07-1.22; p < 0.001), grade (OR:1.15; 95% CI 1.07-1.23; p < 0.001), presence of necrosis (OR:1.17; 95% CI 1.04-1.32; p = 0.01), and lymphovascular invasion (OR:1.18; 95% CI 1.01-1.37; p = 0.03) of primary RCC predicted a higher risk of RCCM + . Furthermore, number (OR:1.08; 95% CI 1.04-1.12; p < 0.001) and bilaterality (OR:1.23; 95% CI 1.09-1.38; p < 0.001) of pulmonary lesions predicted a higher risk of RCCM + . Survival analysis showed a median second PFS of 10.9 years (95% CI 3.3-not reached) for LC and a 3.8 years (95% CI 3.2-8.4) for RCCM + . The median OS time was 6.5 years (95% CI 4.4-not reached) for LC and 6 years (95% CI 4.3-11.6) for RCCM + . CONCLUSIONS: Smoking history, primary grade and stage of RCC, interval between RCC surgery and lung mass detection, and number of pulmonary lesions appear to be the most valuable predictors for differentiating new primary lung cancer from RCC progression.

Catamenial Pneumothorax as the First Expression of Thoracic Endometriosis Syndrome and Pelvic Endometriosis.

OBJECTIVE: The menstrual-related catamenial pneumothorax (CP) can be the first expression of thoracic endometriosis syndrome (TES), which is the presence of endometriotic lesions in the lungs and pleura, and pelvic endometriosis (PE). This study aims to analyze our experience with this specific correlation describing our multidisciplinary approach to CP. METHODS: Hospital records of 32 women, operated for CP at our Department from January 2001 to December 2021 were reviewed. Surgical treatment consisted of videothoracoscopy and laparoscopy when indicated. RESULTS: TES and PE were diagnosed in 13 (40.6%) and 12 (37.5%) women, respectively. The association of TES and PE was present in 11 cases (34%). Fifteen patients (46.9%) underwent laparoscopy, of which 11 concurrently with videothoracoscopy. Most of the patients affected had stage III-IV endometriosis (40.6%). All patients received hormonal therapy after surgery. Five patients with PE conceived spontaneously resulting in six live births. The mean follow-up was 117 ± 71 months (range 8-244). Pneumothorax recurrence occurred in six patients (18.8%). At present, all women are asymptomatic, with no sign of pneumothorax recurrence. CONCLUSIONS: CP might be the first expression of TES and/or PE. A multidisciplinary approach is advocated for optimal management of the disease.

Localized malignant pleural mesothelioma of the interlobar fissure mimicking a lung cancer.

We report a case of localized malignant pleural mesothelioma (LMPM) of the interlobar fissure mimicking lung cancer. A 74-year-old woman presented with dyspnoea and a left pleural effusion. Chest computed tomography revealed a bulky mass, arising from the left lower lobe with intense uptake at the 18F-FDG PET. A left lower lobectomy was performed after thoracoscopic pleural biopsies. The final histology revealed an LMPM epithelioid like. We describe the diagnostic and curative path of the disease, speculating on the differential diagnosis and treatment of LMPM.

Treatment of Thoracic Endometriosis Syndrome: A Meta-Analysis and Review.

BACKGROUND: Thoracic endometriosis syndrome (TES) is a rare disorder characterized by the presence of functional endometrial tissue within the chest cavity. Up to 80% of women with TES present with concomitant pelvic endometriosis. The diagnostic-curative path is defined by both thoracic surgeons and gynecologists, consistent with the manifestation of the disease. The aim of the study was to analyze the different approaches to generate an ideal diagnosis-treatment algorithm that can be shared by both specialties. METHODS: We searched PubMed and Scopus for studies that were completed by March 2019 and that included at least 8 patients with TES. Information on preoperative exams, surgical technique, postoperative management, and recurrence of disease was collected for meta-analysis. RESULTS: Twenty-five studies including a total of 732 patients were eligible. Almost all of the patients underwent radiologic pelvis investigation (96%; confidence interval [CI], 87%-100%). Videothoracoscopy was the preferred surgical technique (84%; 95% CI, 66%-96%). Intraoperative evaluation revealed the presence of diaphragmatic anomalies in 84% of cases (95% CI, 73%-93%). The overall pooled prevalence of concomitant or staged laparoscopy was 52% (95% CI, 18%-85%). Postoperative hormone therapy was heterogeneous with a pooled prevalence of 61% (95% CI, 33%-86%; I2 = 95.6%; P < .01). Recurrence of symptoms was documented in 27% of patients (95% CI, 20%-34%; I2 = 54.7%; P < .01). CONCLUSIONS: TES should be managed jointly by thoracic surgeons and gynecologists. Chest-abdomen magnetic resonance imaging seems to offer the most details for TES. Combined or staged videothoracoscopy and laparoscopy can provide adequate information to fine-tune proper surgical treatment and postoperative medical therapy.

Perspective: Did Covid-19 Change Non-small Cell Lung Cancer Surgery Approach?

The novel coronavirus (Covid-19), as of January 2021, infected more than 85 million people worldwide, causing the death of about 1,840 million. Italy had more than 2 million infected and about 75,000 deaths. Many hospitals reduced their ordinary activity by up to 80%, to leave healthcare staff, wards, and intensive care unit (ICU) beds available for the significant number of Covid-19 patients. All this resulted in a prolonged wait for hospitalization of all other patients, including those with non-small cell lung cancer (NSCLC) eligible for surgery. The majority of thoracic surgery departments changed the clinical-therapeutic path of patients, re-adapting procedures based on the needs dictated by the pandemic while not delaying the necessary treatment. The establishment of Covid-19-free hub centers allowed some elective surgery in NSCLC patients but most of the operations were delayed. The technology has partly facilitated patients' visits through telemedicine when security protocols have prevented face-to-face assessments. Multidisciplinary consultations had to deal also with the priority of the NSCLC cases discussed. Interpretation of radiologic exams had to take into account the differential diagnosis with Covid-19 infection. All the knowledge and experience of the past months reveal that the Covid-19 pandemic has not substantially changed the indications and type of surgical treatment in NSCLC. However, the diagnostic process has become more complex, requiring rigorous planning, thus changing the approach with the patients.

A risk stratification scheme for synchronous oligometastatic non-small cell lung cancer developed by a multicentre analysis.

BACKGROUNDS: Oligometastatic Non-Small Cell Lung Cancer (NSCLC) patients represent a category without a standard therapeutic approach. However, in selected oligometastatic NSCLC, radical surgery seems to offer a good prognosis. This retrospective study aimed to analyse the long-term outcomes of synchronous oligometastatic patients treated with curative intent and identify the factors associated with better results and the proposal of a risk stratification system for classifying the synchronous oligometastatic NSCLC. METHODS: The medical records of patients from 18 centres with pathologically diagnosed synchronous oligometastatic NSCLC were retrospectively reviewed. The inclusion criteria were synchronous oligometastatic NSCLC, radical surgical treatment of the primary tumour with or without neoadjuvant/adjuvant therapy and radical treatment of all metastatic sites. The Kaplan - Meier method estimated survivals. A stratified backward stepwise Cox regression model was assessed for multivariable survival analyses. RESULTS: 281 patients were included. The most common site of metastasis was the brain, in 50.89 % patients. Median overall survival was 40 months (95 % CI: 29-53). Age ≤65 years (HR = 1.02, 95 % CI: 1.00-1.05; p = 0.019), single metastasis (HR = 0.71, 95 % CI: 0.45-1.13; p = 0.15) and presence of contralateral lung metastases (HR = 0.30, 95 % CI: 0.15 - 0.62; p = 0.001) were associated with a good prognosis. The presence of pathological N2 metastases negatively affected survival (HR = 2.00, 95 % CI: 1.21-3.32; p = 0.0065). These prognostic factors were used to build a simple risk classification scheme. CONCLUSIONS: Treatment of selected synchronous oligometastatic NSCLC with curative purpose could be conducted safely and at acceptable 5-year survival levels, especially in younger patients with pN0 disease.

Correlation of Computed Tomography Parameters with Histology, Stage and Prognosis in Surgically Treated Thymomas.

Background and objectives: The histological classification and staging of thymic tumors remains a matter of debate. The correlation of computed tomography (CT) parameters with tumor histology and stage also still has to be completely assessed. The aim of this study was therefore to analyze the correlation of radiological parameters with histological and staging classifications of thymomas evaluating their prognostic role. Methods: Data of 50 patients with thymoma submitted to a complete surgical treatment between 2005 and 2015 were retrospectively analyzed. Tumors were classified according to the WHO and Suster and Moran (S&M) histological classifications and to the Masaoka-Koga and tumor, node and metastases (TNM) staging systems. The correlation of CT features with histology and stage and the prognostic role of histopathological and radiological features were assessed. Results: Five-year overall (OS) and disease-free survival (DFS) were 90.3% and 81.1%, respectively. A significant correlation of DFS with the Masaoka-Koga (p = 0.001) and TNM staging systems (p = 0.002) and with the S&M (p = 0.02) and WHO histological classifications (p = 0.04) was observed. CT scan features correlated with tumor stage, histology and prognosis. Moderately differentiated tumors (WHO B3) had a significantly higher incidence of irregular shape and contours (p = 0.002 and p = 0.001, respectively) and pericardial contact (p = 0.036). A larger tumor volume (p = 0.03) and a greater length of pleural contact (p = 0.04) adversely influenced DFS. The presence of pleural (p < 0.001) or lung invasion (p = 0.02) and of pleural effusion (p = 0.004) was associated with a significantly worse OS. Conclusions: Pre-operative CT scan parameters correlate with stage and histology, and have a prognostic role in surgically treated thymomas.

Prognostic role of positron emission tomography and computed tomography parameters in stage I lung adenocarcinoma.

Background According to the current pathological classification, lung adenocarcinoma includes histological subtypes with significantly different prognoses, which may require specific surgical approaches. The aim of the study was to assess the role of CT and PET parameters in stratifying patients with stage I adenocarcinoma according to prognosis. Patients and methods Fifty-eight patients with pathological stage I lung adenocarcinoma who underwent surgical treatment were retrospectively reviewed. Adenocarcinoma in situ and minimally-invasive adenocarcinoma were grouped as non-invasive adenocarcinoma. Other histotypes were referred as invasive adenocarcinoma. CT scan assessed parameters were: ground glass opacity (GGO) ratio, tumour disappearance rate (TDR) and consolidation diameter. The prognostic role of the following PET parameters was also assessed: standardized uptake value (SUV) max, SUVindex (SUVmax to liver SUVratio), metabolic tumour volume (MTV), total lesion glycolysis (TLG). Results Seven patients had a non-invasive adenocarcinoma and 51 an invasive adenocarcinoma. Five-year disease-free survival (DFS) and cancer-specific survival (CSS) for non-invasive and invasive adenocarcinoma were 100% and 100%, 70% and 91%, respectively. Univariate analysis showed a significant difference in SUVmax, SUVindex, GGO ratio and TDR ratio values between non-invasive and invasive adenocarcinoma groups. Optimal SUVmax, SUVindex, GGO ratio and TDR cut-off ratios to predict invasive tumours were 2.6, 0.9, 40% and 56%, respectively. TLG, SUVmax, SUVindex significantly correlated with cancer specific survival. Conclusions CT and PET scan parameters may differentiate between non-invasive and invasive stage I adenocarcinomas. If these data are confirmed in larger series, surgical strategy may be selected on the basis of preoperative imaging.

Therapeutic strategy for tracheal chondrosarcoma: report of two cases.

Primary chondrosarcoma of the trachea is an extremely rare tumor. We report two cases of tracheal chondrosarcoma describing the role of surgical and conservative treatment. Endoscopic treatment with rigid bronchoscopy was performed in both patients to restore airway patency and obtain histological specimens for diagnosis. One of the patients subsequently underwent successful tracheal resection and reconstruction. The other patient, who had a contraindication to surgical treatment due to associated diseases underwent iterative endoscopic LASER treatment and is alive three years after the first diagnosis. Surgical treatment remains the treatment of choice of tracheal chondrosarcoma. When surgery is contraindicated endoscopic treatment may allow relatively longterm survival due to the slow growth of these tumors.

Surgical treatment of single and multiple thymoma recurrences.

OBJECTIVES: A significant number of patients with thymoma develop a recurrence after surgery. The results of previous studies analyzing therapeutic strategies in the treatment of recurrences have been controversial. Aim of the study was to evaluate the role of surgery in the treatment of thymoma recurrences assessing prognostic factors related with survival. METHODS: Between January 1993 and September 2018, 27 of 161 patients had a recurrence after complete thymoma resection. Twenty-one (13%) underwent surgical treatment of the recurrence. Primary tumor stage was: I in a patient, IIa in five, IIb in nine and III in six. The recurrence was regional in all patients and both regional and distant in four. WHO histological classification was: A in two patients, B1 in two, B2 in seven and B3 in 10 patients. RESULTS: Median disease-free survival from surgical treatment of the primary tumor and recurrence was 44 months (1-124). Thirty-eight operations were performed (range 1-5). Complete resection rate was 66%. Adjuvant radiotherapy and chemotherapy after surgical treatment of recurrences were performed respectively in ten and nine patients, including eight patients with multiple recurrences. Five and 10-year tumor-specific survival from recurrence was, respectively, 79% and 66%. Survival analysis showed a significant correlation between survival and WHO classification, with a significantly lower survival in patients with B3 tumors in comparison with A to B2 tumors (p = 0.026). CONCLUSIONS: Long-term survival was observed following surgical treatment of thymoma recurrences. These results were observed even after multiple recurrences when surgical treatment was performed within a multimodality oncological approach.

Laryngo-tracheal stenosis in a woman with ablepharon macrostomia syndrome.

BACKGROUND: Ablepharon macrostomia syndrome (AMS) is a rare congenital malformation disorder caused by the autosomal-dominant mutations in gene TWIST2. Patients affected by the disease present abnormalities in ectoderm-derived structures mainly consisting in major facial dysmorphic features and rarely in visceral anomalies. The only laryngo-tracheal defect reported is malacia, with no reference to any anatomical stenosis. We describe a unique case of laryngo-tracheal stenosis in a woman, with genetically confirmed AMS currently followed at our Department. CASE PRESENTATION: A 37-year-old Caucasian woman was admitted to the intensive care unit for acute dyspnea that required orotracheal intubation followed by tracheostomy. The bronchoscopy revealed abnormal tracheal tissue at the level of the cricoid and the first three tracheal rings reducing airway caliber by 80% (grade III according to the Cotton-Meyer classification). Treatment of the stenosis by means of temporary tracheostomy and corticosteroids therapy resulted in airway patency restoration and patient's return to her normal activities. Bronchoscopy at four and five months showed disappearance of the abnormal tissue and a residual anatomical laryngo-tracheal stenosis of about 20% (grade I according to the Cotton-Meyer classification) of the normal airway caliber. CONCLUSIONS: To our knowledge, this is the first patient affected by AMS presenting with laryngo-tracheal stenosis.

Safety and Early Oncologic Outcomes of Lung Resection in Patients with Isolated Pulmonary Recurrent Prostate Cancer: A Single-center Experience.

The introduction of novel imaging approaches for recurrent prostate cancer (PC) has paved the way for the use of nonsystemic approaches in patients with recurrent disease. While use of surgery or radiotherapy is standard for men with nodal or bone recurrence only, there are no significant data on the possible curative role of surgery for pulmonary metastases. We aimed to assess the efficacy of lung resection in patients with isolated pulmonary recurrence after radical prostatectomy (RP) for clinically localized PC. Overall, nine patients with biochemical recurrence after RP and either single (n=4) or multiple (n=5) pulmonary uptake spots on fluorodeoxyglugose, choline, or prostate-specific membrane antigen positron emission tomography/computed tomography underwent a total of 20 lung resections between 2011 and 2017 at our institution. No postoperative complications occurred. After lung resection, seven of the nine patients experienced a biochemical response (defined as prostate-specific antigen <0.2ng/ml at 40d after surgery). All patients except for one were free of clinical recurrence (CR) at median follow-up of 23mo. One patient experienced CR and received androgen deprivation therapy at the time of bone recurrence. Although larger prospective studies are needed, our series demonstrates that surgical resection of isolated pulmonary metastases is safe and effective in selected PC patients with recurrent disease.

Isolated tension pneumoperitoneum following endobronchial ultrasound-guided transbronchial needle aspiration complicated by cardiac peri-arrest: A case report.

Transbronchial needle aspiration under endobronchial ultrasound guidance (EBUS-TBNA) is recommended for the diagnosis and staging of lung cancer. Major complications following EBUS-TBNA are uncommon. We report a case of isolated tension pneumoperitoneum following EBUS-TBNA under deep sedation in an 80-year-old male patient affected by a right hilar mass suspicious for lung cancer. At the end of the procedure, the patient suddenly manifested desaturation, severe bradycardia and hypotension, and abdominal distension. After resuscitation, in the suspect of intraperitoneal free air, needle decompression led to respiratory and hemodynamic improvement. A total body CT-scan showed isolated pneumoperitoneum without signs of gastrointestinal perforation, confirmed by a subsequent upper digestive contrast study. The patient recovered well without the need of surgical exploration. Isolated tension pneumoperitoneum can be an exceptional complication of EBUS-TBNA; a conservative treatment can avoid unnecessary surgery in the absence of peritonism.

Assessment of the prognostic role of neutrophil-to-lymphocyte ratio following complete resection of thymoma.

BACKGROUND: The introduction of the new TNM staging system for thymic epithelial malignancies produced a significant increase in the proportion of patients with stage I disease. The identification of new prognostic factors could help to select patients for adjuvant therapies based on their risk of recurrence. Neutrophil-to-lymphocyte ratio (NLR) has recently gained popularity as reliable prognostic biomarker in many different solid tumors. The aim of this study is to assess the utility of NLR evaluation as a prognostic marker in patients with surgically-treated thymoma. METHODS: A retrospective analysis was conducted among patients who underwent resection for thymoma in a single center. Patients were divided in two groups, under (low-NLR-Group = 47 patients, 60%) and above (high-NLR-Group = 32 patients, 40%) a ROC-derived NLR cut-off (2.27). Associations with clinical-pathological variables were analyzed; disease-free survival (DFS) was identified as the primary endpoint. RESULTS: Between 2007 and 2017, 79 patients had surgery for thymoma. Overall 5-year DFS was 80%. Univariate survival analysis demonstrated that NLR was significantly related to DFS when patients were stratified for TNM stage (p = 0.043). Five-year DFS in the low-NLR-Group and in the high-NLR-Group were respectively 100 and 84% in stage I-II, and 66 and 0% in stage III. TNM stage resulted as the only independent prognostic factor at multivariate analysis, with hazard ratio of 3.986 (95% CI 1.644-9.665, p = 0.002). CONCLUSIONS: High preoperative NLR seems to be associated to a shorter DFS in patients submitted to surgery for thymoma and stratified for TNM stage.

18F-FAZA PET/CT in the Preoperative Evaluation of NSCLC: Comparison with 18F-FDG and Immunohistochemistry.

PURPOSE: To assess the capability of 18F-FAZA PET/CT in identifying intratumoral hypoxic areas in early and locally advanced non-small cell lung cancer (NSCLC) patients and to compare 18FFAZA PET/CT with 18F-FDG PET/CT and histopathological biomarkers and to investigate whether the assessment of tumour to blood (T/B) and tumour to muscle (T/M) ratios provide comparable information regarding the hypoxic fractions of the tumour. MATERIALS AND METHODS: Seven patients with NSCLC were prospectively enrolled (3 men, 4 women; median age: 71 years; range 63-80). All patients underwent to 18F-FDG PET/CT and 18F-FAZA PET/CT before surgery. Maximum standardized uptake value (SUVmax) was used to evaluate 18FFDG PET/CT images, while 18F-FAZA PET/CT images have been interpreted by using tumour-toblood (T/B) and tumour-to-muscle (T/M) ratio. Surgery was performed in all patients; immunohistochemical analysis for hypoxia biomarkers was performed on histologic tumor samples. RESULTS: All lung lesions showed intense 18F-FDG uptake (mean SUVmax: 7.35; range: 2.35-25.20). A faint 18F-FAZA uptake was observed in 6/7 patients (T/B < 1.2) while significant uptake was present in the remaining 1/7 (T/B and T/M=2.24). On both 2 and 4 h imaging after injection, no differences were observed between T/M and T/B (p=0.5), suggesting that both blood and muscle are equivalent in estimating the background activity for image analysis. Immunohisotchemical analysis showed low or absent staining for hypoxia biomarkers in 3 patients (CA-IX and GLUT-1: 0%; HIF-1α: mean 3.3%; range 0-10). Two patients showed staining for HIF-1α of 5%, with CA-IX being 60% and 30%, respectively and GLUT-1 being 30% and 80%, respectively; in 1/7 HIF-1α was 10%, CA-IX was 50% and GLUT-1 was 90%. In one patient a higher percentage of HIF-1α and CA-IX (20% and 70%, respectively) positive cells was present, with GLUT-1 being 30%. CONCLUSIONS: To the best of our knowledge, this is the first paper assessing hypoxia and glucose metabolism in comparison with immunohistochemistry in patients candidate to surgery for NSCLC. Although including a small number of patients, useful insight regarding correlation between imaging and immunohistochemistry are reported along with methodological suggestions for clinical practice.

Multidisciplinary management of a giant cervico-mediastinal liposarcoma: A case report and literature review.

Liposarcomas are rare mesenchymal tumors that usually develop in lower extremities or retroperitoneum; cervico-mediastinal presentation is quite uncommon. These neoplasms are commonly diagnosed at a late stage because they remain asymptomatic until nearby structures are compressed. This makes radical excision particularly challenging. To date, alternative chemoradiotherapy protocols have not yet been standardized. We report a case of a 55-year-old man with a right laterocervical mass and without substantial symptoms. Fine-needle aspiration cytology results were compatible with a well-differentiated liposarcoma. Contrast-enhanced magnetic resonance imaging revealed the magnitude of the mass, which was expanding into the mediastinum; displacing the trachea, esophagus, cervical neurovascular bundle, and thoracic aorta; and encasing the brachiocephalic artery. Compression of the left brachiocephalic vein resulted in a focal enhancement spot in the fourth liver segment, the expression of superior vena cava compression, which can promote the development of collateral venous pathways, such as the caval-mammary-phrenic-hepatic capsule-portal venous pathway. The mass was successfully excised by a team of surgical subspecialists (otorhinolaryngologists and thoracic, cardiac, and vascular surgeons). Adjuvant tomotherapy was administered to increase local disease control. The patient remained disease-free 38 months postoperatively. This case underlines the importance of accurate preoperative radiologic evaluation in patients presenting with neck masses but without substantial symptoms. Because of the involvement of many critical structures, the cooperation of many surgical subspecialties is mandatory to achieve a satisfying oncologic outcome.