The Weekday Effect on Morbidity of Lung Cancer Surgery: A Real-World Analysis.

BACKGROUND: Many authors have investigated the possible adverse effects among patients who underwent elective surgery on Friday when compared with patients operated earlier in the week. Nonetheless, the weekday effect is still a matter of debate. This study aimed at investigating the postoperative morbidity rates after lung cancer surgery and their relationship with the weekday the surgery took place. MATERIALS AND METHODS: We retrospectively reviewed the clinical records of patients who underwent elective thoracotomic lobectomies for lung cancer. Categorical data were analyzed using the chi-square test or Fisher's exact test. Association between predictors and binary outcomes while considering the weekday stratification was determined with Cochran-Mantel-Haenszel statistics. To characterize the typical Friday patient, a multiple logistic regression analysis was performed. RESULTS: A total of 817 patients (2015-2019) were identified. Complication rates divided by day of surgery were 164 (20.07%) for patients operated on Mondays, 182 (22.27%) on Tuesdays, 205 (25.09%) on Wednesdays, 172 (21.05%) on Thursdays, and 94 (11.51%) on Fridays. Crude morbidity rates by weekday were Monday 21.53%, Tuesday 20.51%, Wednesday 27.70%, Thursday 20.0%, and Friday 10.26%. No overall association between day of surgery and overall morbidity was found (ρ = 0.095). Median hospital length of stay was 5 days (range: 2-45 days), and there were no statistically significant differences between days. The Cochran-Mantel-Haenszel statistics showed no association between morbidity and the weekday. CONCLUSION: In patients undergoing elective lobectomies for lung cancer, the weekday of surgery was not statistically significantly associated with an increase in the risk of postoperative morbidity.

Safety Analysis of Salvage Surgery for Advanced Stages or Metastatic Lung Cancers.

This case series aimed to analyze the outcomes of patients referred for salvage pulmonary resections after treatment with chemotherapy and immunotherapy for previously metastatic or unresectable tumors.From October 2016, after multidisciplinary board discussion, eight patients (median: 67 years, range: 52-78 years) underwent medical treatment due to advanced-stage diseases (stage cIIIA-cIVa). Four patients underwent cisplatin-based chemotherapy and, due to progression, were moved to an immunotherapy second line (nivolumab: two patients and pembrolizumab: two patients). Instead, four patients underwent combined cisplatin-based chemotherapy and immune checkpoint inhibitors (atezolizumab: two patients and pembrolizumab: two patients). After a multidisciplinary evaluation for salvage surgery, six patients underwent lobectomies, one patient underwent left pneumonectomy, and one patient underwent upper right lobectomy enlarged to the posterior arches of four ribs. The median duration of surgery was 179 minutes (range: 122-246 minutes). At the final pathological stage, three patients showed a complete major response (ypT0 ypN0), one patient was ypT1a ypN0, one ypT3 ypN0, 2 ypT3 ypN1, and one ypT4 ypN0. The hospital length of stay was 6 days (range: 3-23 days). Two patients had a postoperative complication. At the time of follow-up (median: 15.3 months [range: 1-32 months]), six patients were alive without evidence of the recurrence. Two patients died due to recurrence progression (N3 lymph nodes involvement) of the disease after 6 and 32 months.In stage IIIB-IVA nonsmall cell lung cancer, salvage lung surgeries after chemotherapy and immunotherapy are feasible, with high rates of R0 resection. Surgery can be technically tricky without significant morbidity and encouraging outcomes (even with a short-interval follow-up).

Preliminary Results of Extracorporeal Membrane Oxygenation Assisted Tracheal Sleeve Pneumonectomy for Cancer.

OBJECTIVE: Tracheal sleeve pneumonectomy is a challenge in lung cancer management and in achieving long-term oncological results. In November 2018, we started a prospective study on the role of extracorporeal membrane oxygenation (ECMO) in tracheal sleeve pneumonectomy. We aim to present our preliminary results. METHODS: From November 2018 to November 2019, six patients (three men and three women; median age: 61 years) were eligible for tracheal sleeve pneumonectomy for lung cancer employing the veno-venous ECMO during tracheobronchial anastomosis. RESULTS: Only in one patient, an intrapericardial pneumonectomy without ECMO support was performed, but cannulas were maintained during surgery. The median length of surgery was 201 minutes (range: 162-292 minutes), and the average duration of the apneic phase was 38 minutes (range: 31-45 minutes). No complications correlated to the positioning of the cannulas were recorded. There was only one major postoperative complication (hemothorax). At the time of follow-up, all patients were alive; one patient alive with bone metastasis was being treated with radiotherapy. CONCLUSION: ECMO-assisted oncological surgery was rarely described, and its advantages include hemodynamic stability with low bleeding complications and a clean operating field. As suggested by our preliminary data, ECMO-assisted could be a useful alternative strategy in select lung cancer patients.

Self-operated stimuli improve subsequent visual motion integration.

Evidences of perceptual changes that accompany motor activity have been limited primarily to audition and somatosensation. Here we asked whether motor learning results in changes to visual motion perception. We designed a reaching task in which participants were trained to make movements along several directions, while the visual feedback was provided by an intrinsically ambiguous moving stimulus directly tied to hand motion. We find that training improves coherent motion perception and that changes in movement are correlated with perceptual changes. No perceptual changes are observed in passive training even when observers were provided with an explicit strategy to facilitate single motion perception. A Bayesian model suggests that movement training promotes the fine-tuning of the internal representation of stimulus geometry. These results emphasize the role of sensorimotor interaction in determining the persistent properties in space and time that define a percept.

Thymoma and pure red cell aplasia with hypoplasia of megakaryocytopoiesis: A rare and life-treating condition.

Thymic tumors are rare diseases with an incidence of 0.15 cases per 100,000 person-years. They can be associated with a variety of other syndromes, such as Myasthenia Gravis or autoimmune disorders. Among them, pure red cell aplasia is a hemato-pathological condition characterized by anemia, reticulocytopenia and erythroid cell hypoplasia of bone marrow. Here, we reported a case of a 62-year-old female with a long history of neurologic symptoms due to Myasthenia Gravis. She was diagnosed with thymoma, with mediastinal mass and pleural thickening. After chemoradiotherapy treatment, she was surgically resected successfully, but she developed anemia and severe thrombocytopenia, worsening in respiratory failure requiring intubation. A bone marrow biopsy was performed resulting in a red-cell aplasia with marked hypoplasia of megakaryocytopoiesis compatible with pure red cell aplasia with acquired thrombocytopenia. Considering that there are no standard treatments, clinical condition improvement was achieved only after some lines of medical treatment. Our data, together with the few already published, help to raise the attention towards acquired cytopenias and the need to optimize the treatment for a potentially life-threatening condition.

The Electronic Nose's Emerging Role in Respiratory Medicine.

New interest has grown in the respiratory disorder diagnosis and monitoring, throughout electronic nose technologies. This technology has several advantages compared to classic approach. In this short letter, we aim to emphasize electronic nose role in respiratory medicine.

Artificial Neural Networks in Lung Cancer Research: A Narrative Review.

BACKGROUND: Artificial neural networks are statistical methods that mimic complex neural connections, simulating the learning dynamics of the human brain. They play a fundamental role in clinical decision-making, although their success depends on good integration with clinical protocols. When applied to lung cancer research, artificial neural networks do not aim to be biologically realistic, but rather to provide efficient models for nonlinear regression or classification. METHODS: We conducted a comprehensive search of EMBASE (via Ovid), MEDLINE (via PubMed), Cochrane CENTRAL, and Google Scholar from April 2018 to December 2022, using a combination of keywords and related terms for "artificial neural network", "lung cancer", "non-small cell lung cancer", "diagnosis", and "treatment". RESULTS: Artificial neural networks have shown excellent aptitude in learning the relationships between the input/output mapping from a given dataset, without any prior information or assumptions about the statistical distribution of the data. They can simultaneously process numerous variables, managing complexity; hence, they have found broad application in tasks requiring attention. CONCLUSIONS: Lung cancer is the most common and lethal form of tumor, with limited diagnostic and treatment methods. The advances in tailored medicine have led to the development of novel tools for diagnosis and treatment. Artificial neural networks can provide valuable support for both basic research and clinical decision-making. Therefore, tight cooperation among surgeons, oncologists, and biostatisticians appears mandatory.

Serum proteomics profiling identifies a preliminary signature for the diagnosis of early-stage lung cancer.

PURPOSE: Lung cancer is the most common cause of death from cancer worldwide, largely due to late diagnosis. Thus, there is an urgent need to develop new approaches to improve the detection of early-stage lung cancer, which would greatly improve patient survival. EXPERIMENTAL DESIGN: The quantitative protein expression profiles of microvesicles isolated from the sera from 46 lung cancer patients and 41 high-risk non-cancer subjects were obtained using a mass spectrometry method based on a peptide library matching approach. RESULTS: We identified 33 differentially expressed proteins that allow discriminating the two groups. We also built a machine learning model based on serum protein expression profiles that can correctly classify the majority of lung cancer cases and that highlighted a decrease in the levels of Arysulfatase A (ARSA) as the most discriminating factor found in tumors. CONCLUSIONS AND CLINICAL RELEVANCE: Our study identified a preliminary, non-invasive protein signature able to discriminate with high specificity and selectivity early-stage lung cancer patients from high-risk healthy subjects. These results provide the basis for future validation studies for the development of a non-invasive diagnostic tool for lung cancer.

Learning Curve of Robotic Lobectomy for the Treatment of Lung Cancer: How Does It Impact on the Autonomic Nervous System of the Surgeon?

OBJECTIVE: Our purpose is to define the learning curve for robot-assisted thoracoscopic surgery lobectomy by reporting the experience of a single surgeon. MATERIAL AND METHODS: We progressively collected the data concerning the surgical performance of a single male thoracic surgeon, from the beginning of his robotic activity as first operator from January 2021 to June 2022. We evaluated several pre-, intra- and postoperative parameters concerning patients and intraoperative cardiovascular and respiratory outcomes of the surgeon, recorded during surgical interventions, in order to evaluate his cardiovascular stress. We used cumulative sum control charts (CUSUM) to analyze the learning curve. RESULTS: A total of 72 lung lobectomies were performed by a single surgeon in this period. Analyzing the CUSUM of several parameters, the inflection point identifying the transition beyond the surgeon learning phase was reached at cases 28, 22, 27 and 33 when considering operating time, mean heart rate, max heart rate and mean respiratory rate, respectively. CONCLUSIONS: The learning curve for robotic lobectomy seems to be safe and feasible with a correct robotic training program. The analysis of a single surgeon from the beginning of his robotic activity demonstrates that confidence, competence, dexterity and security are achieved after about 20-30 procedures, without compromising efficiency and oncological radicality.

Diagnostic Performance and Cell Count of EBUS-TBNA Needle Gauges: A Prospective Trial.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a well-established diagnostic procedure for evaluating hilar and mediastinal lymphadenopathies and is the gold standard for lung cancer diagnosis and staging. Recent studies assessed the effectiveness of the 19-G flex needle in obtaining larger EBUS-TBNA samples, and prospective small series gave similar results in terms of diagnostic yield when testing different gauge needles. The lack of homogeneity between series and the small sample size of some prospective cohorts poses a limit to the validity of those results. This prospective controlled study compared the 19-G flex and 22-G needles in terms of diagnostic yield. An objective laboratory method was used to count cells and compare the two needles' cytologic yields. MATERIAL: A prospective controlled study was conducted on 90 patients undergoing EBUS-TBNA for the diagnosis of hilar and mediastinal lymphadenopathies. The institutional ethic committee (IEO573) approved the study, and informed consent was obtained from all patients. RESULTS: A total of 90 patients were enrolled in this study, 84.4% of whom were diagnosed with malignancy and 15.6% with non-neoplastic disease. Sensitivity for malignancy was 93.4% (CI: 87.4-97.1%) for the 19-G needle and 92.6% (CI: 86.3-96.5%) for the 22-G needle (p = 0.80). The percentage of malignant cells in the cell block was 63.9% and 61.5% for the 22-G and 19-G needles, respectively. The cell count assessed by flow cytometry was 2071 cells/µL (IQR: 600,2265) with the 22-G needle and 2761 cells/µL (IQR: 505,3250) with the 19-G needle (p = 0.79). The malignant cell count was 0.05 × 103 cells/µL with the 22-G and 0.08 × 103 cells/µL with the 19-G needle (p = 0.70). There was no difference in the presence of tissue cores in the samples, and rapid on-site evaluation (ROSE) cellularity was comparable between the two needles. CONCLUSIONS: The 19-G flex EBUS-TBNA needle is comparable to the 22-G needle in terms of diagnostic yield for cyto-histological evaluation of hilar and mediastinal lymphadenopathies. There is no difference between the 19-G and 22-G needle cell counts evaluated by flow cytometry.

The Role of Surgery in Primary Chest Wall Tumors: Over 20 Years' Experience in Resection and Reconstruction.

BACKGROUND: Primary chest wall tumors comprise a heterogeneous group of neoplasms arising from soft tissues and bones. While surgical excision is the standard of care for benign tumors, the management of malignant tumors requires multimodal treatment. We conducted a predictive analysis of outcome, recurrence-free and overall survival. METHODS: We retrospectively reviewed the clinical and pathological records of all patients treated in our center between 1998 and 2020. RESULTS: 53 patients (15-85 years) were treated in our department. The average tumor diameter was 65 ± 35 mm (10-160 mm). Negative margins were obtained in 48 patients (90.6%), whereas in the remaining 5, R1 resection was accomplished. Median overall survival was 63,03 months (1-282 months). Overall survival was 90% at 1 year, 78% at 2 years, and 61% at 5 years. Our analysis identified tumor diameter, postoperative complications, and high grade of malignancy as factors that can influence prognosis. CONCLUSIONS: The treatment of primary chest wall tumors remains a very challenging process. Different histological types preclude definition of an unequivocal approach. Complete resection with healthy margins remains a definitive cornerstone in the treatment of these cancers as part of a more comprehensive approach.

Surgically Treated pT2aN0M0 (Stage IB) Non-Small Cell Lung Cancer: A 20-Year Single-Center Retrospective Study.

Introduction The suitability of adjuvant therapy (AT) in patients with stage IB non-small cell lung cancer (NSCLC) is still under debate considering the cost-benefit ratio between improvement in survival and side effects. We retrospectively evaluated survival and incidence of recurrence in radically resected stage IB NSCLC, to determine whether AT could significantly improve prognosis. Methods Between 1998 and 2020, 4692 consecutive patients underwent lobectomy and systematic lymphadenectomy for NSCLC. Two hundred nineteen patients were pathological T2aN0M0 (>3 and ≤4 cm) NSCLC 8th TNM. None received preoperative or AT. Overall survival (OS), cancer specific survival (CSS) and the cumulative incidence of relapse were plotted and log-rank or Gray's tests were used to assess the difference in outcome between groups. Results The most frequent histology was adenocarcinoma (66.7%). Median OS was 146 months. The 5-, 10-, and 15-year OS rates were 79%, 60%, and 47%, whereas the 5-, 10-, and 15-year CSS were 88%, 85%, and 83%, respectively. OS was significantly related to age (p < 0.001) and cardiovascular comorbidities (p = 0.04), whereas number of LNs removed was an independent prognostic factor of CSS (p = 0.02). Cumulative incidence of relapse at 5-, 10-, and 15-year were 23%, 31%, and 32%, respectively, and significantly related to the number of LNs removed (p = 0.01). Patients with more than 20 LNs removed and clinical stage I had a significantly lower relapse (p = 0.02). Conclusions Excellent CSS, up to 83% at 15-year, and relatively low risk of recurrence for stage IB NSCLC (8th TNM) patients suggested that AT for those patients could be reserved only for very selected high-risk cases.

Real-world survival outcomes of wedge resection versus lobectomy for cT1a/b cN0 cM0 non-small cell lung cancer: a single center retrospective analysis.

Background: JCOG0802/WJOG4607L showed benefits in overall survival (OS) of segmentectomy. CALGB 140503 confirmed that sublobar resection was not inferior to lobectomy concerning recurrence-free survival (RFS) but did not provide specific OS and RFS according to the techniques of sublobar resections. Hence, we retrospectively analyze the survival differences between wedge resection and lobectomies for stage IA lung cancer. Methods: We reviewed the clinical records of patients with clinical stage IA NSCLC over 20 years. The inclusion criteria were: preoperative staging with CT scan and whole body CT/PET; tumor size <20 mm; wedge resections or lobectomies with or without lymph node dissection; NSCLC as the only primary tumor during the follow-up period. We excluded: multiple invasive lung cancer; positive resection margin; preoperative evidence of nodal disease; distant metastasis at presentation; follow-up time <5 years. The reverse Kaplan - Meier method estimated the median OS and PFS and compared them by the log-rank test. The stratified backward stepwise Cox regression model was employed for multivariable survival analyses. Results: 539 patients were identified: 476 (88.3%) lobectomies and 63 (11.7%) wedge resections. The median OS time for the whole cohort was 189.7 months (range: 173.7 - 213.9 months). The 5-year wedge resection and lobectomy OS were 82.2% and 87.0%. The 5-year RFS of wedge resection and lobectomy were 17.8% and 28.9%. The log-rank test showed no significant differences (p = 0.39) between wedge resections and lobectomies regarding OS and RFS (p = 0.23). Conclusions: Lobectomy and wedge resection are equivalent oncologic treatments for individuals with cN0/cM0 stage IA NSCLC <20 mm. Validating the current findings requires a prospective, randomized comparison between wedge resection and standard lobectomy to establish the prognostic significance of wedge resection.

Learning bio-inspired head-centric representations of 3D shapes in an active fixation setting.

When exploring the surrounding environment with the eyes, humans and primates need to interpret three-dimensional (3D) shapes in a fast and invariant way, exploiting a highly variant and gaze-dependent visual information. Since they have front-facing eyes, binocular disparity is a prominent cue for depth perception. Specifically, it serves as computational substrate for two ground mechanisms of binocular active vision: stereopsis and binocular coordination. To this aim, disparity information, which is expressed in a retinotopic reference frame, is combined along the visual cortical pathways with gaze information and transformed in a head-centric reference frame. Despite the importance of this mechanism, the underlying neural substrates still remain widely unknown. In this work, we investigate the capabilities of the human visual system to interpret the 3D scene exploiting disparity and gaze information. In a psychophysical experiment, human subjects were asked to judge the depth orientation of a planar surface either while fixating a target point or while freely exploring the surface. Moreover, we used the same stimuli to train a recurrent neural network to exploit the responses of a modelled population of cortical (V1) cells to interpret the 3D scene layout. The results for both human performance and from the model network show that integrating disparity information across gaze directions is crucial for a reliable and invariant interpretation of the 3D geometry of the scene.

Pneumonectomy and broncho-pleural fistula: predicting factors and stratification of the risk.

The goal of the study is to evaluate the different risk factors and stratify the patients, before the surgery, into distinct risk classes. We retrospectively reviewed pre, peri, and postoperative outcomes of 366 consecutive patients who underwent pneumonectomy for lung cancer between the last 10 years (2009-2019). We classified the patients into four classes, depending on preoperative assessments. Differences between groups were assessed with the log-rank test. Multivariable Cox proportional hazards regression analysis was used to assess the independent prognostic significance of the variables associated with the development of BPF at univariate analysis. Finally, we performed non-linear [artificial neural network (ANN)] multiple regression analyses. All tests were two-sided, and p values < 0.05 were considered significant. Fifty-one patients (13.9%) out of 366 developed BPF. Male sex (p = 0.048), right side (p = 0.015), postoperative pulmonary complications (p = 0.0139) and adjuvant treatments (p = 0.0169) were the independent predicting factors of fistulas in multivariate analysis. The right side (p = 0.043) and adjuvant treatments (p = 0.032) were the independent predicting factors of BPF after the ANN analysis. Based on multivariate and artificial neural network analysis and our experience, we observed a trend of growing risk of BPF in the first 4 weeks (early fistula), considering the four classes. Preoperative differentiation of the patients into four risk classes could allow a correct stratification of the growing risk of developing early BPF. This information could be significant to share with patients and the other physicians during the decision-making process, to minimise the risk of BPF.

Long-Term Outcomes of Robotic-Assisted, Video-Assisted and Open Surgery in Non-Small Cell Lung Cancer: A Matched Analysis.

INTRODUCTION: This study makes a comparison between stage I non-small cell lung cancer (NSCLC) patients subjected to either robotic-assisted thoracic surgery (RATS), video-assisted thoracic surgery (VATS) or open thoracotomy, with the aim to evaluate differences between these three approaches in terms of oncological outcomes. METHOD: We reviewed data from 1367 consecutive patients who, between 2011 and 2017, underwent lobectomy for NSCLC with either open surgery, VATS or RATS, and performed a matched case-control study based on patients' age, gender, clinical stage (IA, IB) and ASA score. RESULTS: 180 patients (n = 72 RATS, n = 36 VATS, n = 72 open) were analyzed. Complication rates were found to be comparable (72.2% open, 86.1% VATS, 81.9% RATS), with similar grades of severity. The median number of resected lymph nodes was higher in open surgery (n = 22) than in VATS (n = 15; p = 0.0001) and in RATS (n = 17; p = 0.004). Pathological N2 upstaging was higher in open surgery (9.7%) compared to VATS (5.6%) and RATS (5.6%). However, the recurrence rate in VATS was significantly higher than in RATS (log rank p = 0.03). No statistically significant differences were detected in 5-year OS and cancer-specific survival. CONCLUSIONS: no differences were found in OS and cancer-specific survival between VATS, RATS and open lobectomy for stage I NSCLC patients; even if in VATS, the incidence of recurrences, in particular local recurrences, was higher than in RATS and in open surgery.

Long-term clinical outcomes and prognostic factors of upfront surgery as a first-line therapy in biopsy-proven clinical N2 non-small cell lung cancer.

Background: Multimodality therapy offers the best opportunity to improve pathological N2 non-small cell lung cancer (NSCLC) prognosis. This paper aimed to evaluate the long-term clinical outcomes and the prognostic factors of upfront surgery as first-line therapy in biopsy-proven clinical N2. Methods: Retrospective review of biopsy-proven cN2 NSCLC patients operated between 2007 and 2017. Upfront surgery was considered if the primary tumour was deemed completely resectable, with mediastinal nodal involvement confined to a single station and no preoperative evidence of extranodal tumour invasion. Results: Two hundred eighty-five patients who underwent radical resections were included. One hundred fifty-nine patients (55.8%) received induction chemotherapy. At follow-up completion, 127 (44.6%) patients had died. For the induction chemotherapy group, the median overall survival (OS) was 49 months [95% confidence interval (CI): 38-70 months], and the 5-year OS was 44.4%. The median and 5-year OS for the up front surgery group was 66 months (95% CI: 40-119 months) and 66.3%, respectively. There were no statistically significant differences between treatment approaches (p = 0.48). One hundred thirty-four patients (47.0%) developed recurrence. The recurrence-free survival (RFS) at 5 years was 17% (95% CI: 11-25%) for induction chemotherapy and 22% (95% CI: 9-32%) for upfront surgery; there were no statistically significant differences between groups (p = 0.93). No significant differences were observed based on the clinical N status (OS, p = 0.36; RFS, p = 0.65). Conclusions: Upfront surgery as first-line therapy for biopsy-proven cN2 NSCLC showed favourable clinical outcomes, similar to those obtained after induction chemotherapy followed by surgery. Therefore, it should be considered one of the multimodality treatment options in resectable N2 NSCLC.

Cover always the bronchial stump! A flap could prevent catastrophic complications even in complete broncho-pleural fistula.

Broncho-pleural fistula after pneumonectomy is a life-threatening condition with very high mortality rate, even if detected early. All symptomatic patients should be treated immediately. The diagnosis in the absence of symptoms poses the real difficulties of management. Early detection of asymptomatic post-pneumonectomy broncho-pleural fistula is usually fortuitous. The use of bronchoscopy allows direct and accurate evaluation of the stump. This reported case allows us to make several considerations on the treatment of fistulas, but above all to consider that the systematic bronchial stump coverage is fundamental not only for preventing fistulas, but also for limiting their enlargement and communication with the residual cavity, in order to prevent catastrophic complications.