Pathological N1/N2 in Clinical Stage I Bronchogenic Carcinoma. Analysis From a Prospective Multicentre Database

Objectives: To determine the incidence of occult N1/N2 nodal metastases and associated risk factors in patients with non-small cell lung cancer no larger than 3cm and deemed cN0 by CT and PET-CT in a prospective, multicentre national database. Methods: Patients with a NSCLC no larger than 3cm, deemed cN0 by PET-CT and CT scan, who had undergone at least a lobectomy, were selected from a national multicentre database of 3533 patients who had undergone anatomic lung resection between 2016 and 2018. Clinical and pathological variables of patients with pN0 and patients with pN1/N2 were compared to identify factors associated with the presence of lymph node metastases. Chi2 and the Mann–Whitney U test were used for categorical and numerical variables, respectively. All variables with p<0.2 in the univariate analysis were included in the multivariate logistic regression analysis. Results: The study included 1205 patients from the cohort. The incidence of occult pN1/N2 disease was 10.70% (95%CI, 9.01–12.58). The multivariable analysis revealed that the degree of differentiation, size, location (central or peripheral) and SUV of the tumour in PET, surgeon experience and number of lymph nodes resected were associated with occult N1/N2 metastases. Conclusions: The incidence of occult N1/N2 in patients with bronchogenic carcinoma with cN0 tumours no larger than 3cm is no negligible. Data about the degree of differentiation, tumour size in CT scan, maximal uptake of the tumour in PET-CT, location (central or peripheral), number of lymph nodes resected and surgeon seniority is relevant in order to detect patients at risk. (AU)

Resultados de la estadificación clínica ganglionar mediastínica del cáncer pulmonar quirúrgico: datos de la cohorte prospectiva nacional del Grupo Español de Cirugía Torácica Videoasistida / Results in mediastinal lymph node staging of surgical lung cancer: Data from the prospective cohort of the Spanish Video-Assisted Thoracic Surgery Group

Introducción: El objetivo del estudio es valorar el rendimiento diagnóstico de la tomografía computarizada (TC) y la tomografía por emisión de positrones (PET) en la estadificación clínica mediastínica del cáncer pulmonar quirúrgico según los datos de la cohorte prospectiva del Grupo Español de Cirugía Torácica Videoasistida (GEVATS). Métodos: Se han analizado 2.782 pacientes intervenidos por carcinoma pulmonar primario. Se ha estudiado el acierto diagnóstico en la estadificación mediastínica (cN2). Se ha realizado un análisis bivariante y multivariante de los factores que influyen en el acierto. Se ha estudiado el riesgo de pN2 inesperado en los factores con los que se recomienda una prueba invasiva de estadificación: cN1, tumor central o tamaño mayor de 3cm. Resultados: El acierto global de la TC y PET en conjunto es del 82,9% con VPP y VPN de 0,21 y 0,93. En tumores mayores de 3cm y a mayor SUVmax del mediastino, el acierto es menor, OR de 0,59 (0,44 – 0,79) y 0,71 (0,66 – 0,75), respectivamente. En el abordaje VATS el acierto es mayor, OR de 2,04 (1,52 – 2,73). El riesgo de pN2 inesperado aumenta con el número de los factores cN1, tumor central o tamaño mayor de 3cm: entre el 4,5% (0 factores) y 18,8% (3 factores), pero no hay diferencias significativas con la realización de prueba invasiva. Conclusiones: La TC y PET en conjunto tienen un elevado valor predictivo negativo. Su acierto global es menor en tumores mayores de 3cm y SUVmax del mediastino elevado, y mayor en el abordaje VATS. El riesgo de pN2 inesperado es mayor si cN1, tumor central o mayor de 3cm y no varía significativamente con prueba invasiva. (AU)

Objectives: The objective of this study was to assess the diagnostic performance of combined computerised tomography (CT) and positron emission tomography (PET) in mediastinal staging of surgical lung cancer based on data obtained from the prospective cohort of the Spanish Group for Video-Assisted Thoracic Surgery (GEVATS). Methods: A total of 2782 patients underwent surgery for primary lung carcinoma. We analysed diagnostic success in mediastinal lymph node staging (cN2) using CT and PET. Bivariate and multivariate analyses were performed of the factors involved in this success. The risk of unexpected pN2 disease was analysed for cases in which an invasive testing is recommended: cN1, the tumour centrally located or the tumour diameter >3cm. Results: The overall success of CT together with PET was 82.9% with a positive predictive value of 0.21 and negative predictive value of 0.93. If the tumour was larger than 3cm and for each unit increase in mediastinal SUVmax, the probability of success was lower with OR 0.59 (0.44–0.79) and 0.71 (0.66–0.75), respectively. In the video-assisted thoracic surgery (VATS) approach, the probability of success was higher with OR 2.04 (1.52–2.73). The risk of unexpected pN2 increased with the risk factors cN1, the tumour centrally located or the tumour diameter >3cm: from 4.5% (0 factors) to 18.8% (3 factors) but did not differ significantly as a function of whether invasive testing was performed. Conclusions: CT and PET together have a high negative predictive value. The overall success of the staging is lower in the case of tumours >3cm and high mediastinal SUVmax, and it is higher when VATS is performed. The risk of unexpected pN2 is higher if the disease is cN1, the tumour centrally located or the tumour diameter >3cm but does not vary significantly as a function of whether patients have undergone invasive testing. (AU)

Pathological N1/N2 in Clinical Stage I Bronchogenic Carcinoma. Analysis From a Prospective Multicentre Database.

OBJECTIVES: To determine the incidence of occult N1/N2 nodal metastases and associated risk factors in patients with non-small cell lung cancer no larger than 3cm and deemed cN0 by CT and PET-CT in a prospective, multicentre national database. METHODS: Patients with a NSCLC no larger than 3cm, deemed cN0 by PET-CT and CT scan, who had undergone at least a lobectomy, were selected from a national multicentre database of 3533 patients who had undergone anatomic lung resection between 2016 and 2018. Clinical and pathological variables of patients with pN0 and patients with pN1/N2 were compared to identify factors associated with the presence of lymph node metastases. Chi2 and the Mann-Whitney U test were used for categorical and numerical variables, respectively. All variables with p<0.2 in the univariate analysis were included in the multivariate logistic regression analysis. RESULTS: The study included 1205 patients from the cohort. The incidence of occult pN1/N2 disease was 10.70% (95%CI, 9.01-12.58). The multivariable analysis revealed that the degree of differentiation, size, location (central or peripheral) and SUV of the tumour in PET, surgeon experience and number of lymph nodes resected were associated with occult N1/N2 metastases. CONCLUSIONS: The incidence of occult N1/N2 in patients with bronchogenic carcinoma with cN0 tumours no larger than 3cm is no negligible. Data about the degree of differentiation, tumour size in CT scan, maximal uptake of the tumour in PET-CT, location (central or peripheral), number of lymph nodes resected and surgeon seniority is relevant in order to detect patients at risk.

Riesgo quirúrgico tras resección pulmonar anatómica en cirugía torácica. Modelo predictivo a partir de una base de datos nacional multicéntrica / Surgical Risk Following Anatomic Lung Resection in Thoracic Surgery: A Prediction Model Derived from a Spanish Multicenter Database

Introducción: El objetivo es obtener un modelo predictor de riesgo quirúrgico en pacientes sometidos a resecciones pulmonares anatómicas a partir del registro del Grupo Español de Cirugía Torácica Videoasistida. Métodos: Se recogen datos de 3.533 pacientes sometidos a resección pulmonar anatómica por cualquier diagnóstico entre el 20 de diciembre de 2016 y el 20 de marzo de 2018.Definimos una variable resultado combinada: mortalidad o complicación Clavien Dindo IV a 90 días tras intervención quirúrgica. Se realizó análisis univariable y multivariable por regresión logística. La validación interna del modelo se llevó a cabo por técnicas de remuestreo. Resultados: La incidencia de la variable resultado fue del 4,29% (IC 95%: 3,6-4,9). Las variables que permanecen en el modelo logístico final fueron: edad, sexo, resección pulmonar oncológica previa, disnea (mMRC), neumonectomía derecha y DLCOppo. Los parámetros de rendimiento del modelo, ajustados por remuestreo, fueron: C-statistic 0,712 (IC 95%: 0,648-0,750), Brier score 0,042 y Booststrap shrinkage 0,854. Conclusiones: El modelo predictivo de riesgo obtenido a partir de la base de datos Grupo Español de Cirugía Torácica Videoasistida es un modelo sencillo, válido y fiable, y constituye una herramienta muy útil a la hora de establecer el riesgo de un paciente que se va a someter a una resección pulmonar anatómica. (AU)

Introduction: The aim of this study was to develop a surgical risk prediction model in patients undergoing anatomic lung resections from the registry of the Spanish Video-Assisted Thoracic Surgery Group (GEVATS). Methods: Data were collected from 3,533 patients undergoing anatomic lung resection for any diagnosis between December 20, 2016 and March 20, 2018.We defined a combined outcome variable: death or Clavien Dindo grade IV complication at 90 day.s after surgery. Univariate and multivariate analyses were performed by logistic regression. Internal validation of the model was performed using resampling techniques. Results: The incidence of the outcome variable was 4.29% (95% CI 3.6-4.9). The variables remaining in the final logistic model were: age, sex, previous lung cancer resection, dyspnea (mMRC), right pneumonectomy, and ppo DLCO. The performance parameters of the model adjusted by resampling were: C-statistic 0.712 (95% CI 0.648-0.750), Brier score 0.042 and bootstrap shrinkage 0.854. Conclusions: The risk prediction model obtained from the GEVATS database is a simple, valid, and reliable model that is a useful tool for establishing the risk of a patient undergoing anatomic lung resection. (AU)

[Translated article] Surgical Risk Following Anatomic Lung Resection in Thoracic Surgery: A Prediction Model Derived From a Spanish Multicenter Database / Riesgo quirúrgico tras resección pulmonar anatómica en cirugía torácica. Modelo predictivo a partir de una base de datos nacional multicéntrica

Introduction: The aim of this study was to develop a surgical risk prediction model in patients undergoing anatomic lung resections from the registry of the Spanish Video-Assisted Thoracic Surgery Group (GEVATS). Methods: Data were collected from 3,533 patients undergoing anatomic lung resection for any diagnosis between December 20, 2016 and March 20, 2018.We defined a combined outcome variable: death or Clavien Dindo grade IV complication at 90 day.s after surgery. Univariate and multivariate analyses were performed by logistic regression. Internal validation of the model was performed using resampling techniques. Results: The incidence of the outcome variable was 4.29% (95% CI 3.6-4.9). The variables remaining in the final logistic model were: age, sex, previous lung cancer resection, dyspnea (mMRC), right pneumonectomy, and ppo DLCO. The performance parameters of the model adjusted by resampling were: C-statistic 0.712 (95% CI 0.648-0.750), Brier score 0.042 and bootstrap shrinkage 0.854. Conclusions: The risk prediction model obtained from the GEVATS database is a simple, valid, and reliable model that is a useful tool for establishing the risk of a patient undergoing anatomic lung resection. (AU)

Introducción: El objetivo es obtener un modelo predictor de riesgo quirúrgico en pacientes sometidos a resecciones pulmonares anatómicas a partir del registro del Grupo Español de Cirugía Torácica Videoasistida. Métodos: Se recogen datos de 3.533 pacientes sometidos a resección pulmonar anatómica por cualquier diagnóstico entre el 20 de diciembre de 2016 y el 20 de marzo de 2018.Definimos una variable resultado combinada: mortalidad o complicación Clavien Dindo IV a 90 días tras intervención quirúrgica. Se realizó análisis univariable y multivariable por regresión logística. La validación interna del modelo se llevó a cabo por técnicas de remuestreo. Resultados: La incidencia de la variable resultado fue del 4,29% (IC 95%: 3,6-4,9). Las variables que permanecen en el modelo logístico final fueron: edad, sexo, resección pulmonar oncológica previa, disnea (mMRC), neumonectomía derecha y DLCOppo. Los parámetros de rendimiento del modelo, ajustados por remuestreo, fueron: C-statistic 0,712 (IC 95%: 0,648-0,750), Brier score 0,042 y Booststrap shrinkage 0,854. Conclusiones: El modelo predictivo de riesgo obtenido a partir de la base de datos Grupo Español de Cirugía Torácica Videoasistida es un modelo sencillo, válido y fiable, y constituye una herramienta muy útil a la hora de establecer el riesgo de un paciente que se va a someter a una resección pulmonar anatómica. (AU)

Recomendaciones de la sociedad Española de cirugía torácica para el manejo del derrame pleural maligno [Pré-print] / Recommendations of the Spanish Society of Thoracic Surgery for the management of malignant pleural effusion

This article summarizes the clinical guidelines for the diagnosis and treatment of malignant pleural effusion (MPE) sponsored by the Spanish Society of Thoracic Surgery (SECT). Ten clinical controversies were elaborated under the methodology of PICO (Patient, Intervention, Comparison, Outcome) questions and the quality of the evidence and grading of the strength of the recommendations was based on the GRADE system. Immunocytochemical and molecular analyses of pleural fluid may avoid further invasive diagnostic procedures. Currently, the definitive control of MPE can be achieved either by pleurodesis (talc poudrage or slurry) or the insertion of a tunneled pleural catheter (TPC). It is likely that the combination of both techniques (i.e., thoracoscopy with talc poudrage and insertion of a TPC, or instillation of talc slurry through a TPC) will have a predominant role in the future therapeutic management.

Este artículo resume la guía clínica de diagnóstico y tratamiento del derrame pleural maligno (DPM) auspiciada por la Sociedad Española de Cirugía Torácica (SECT). Se elaboraron 10 controversias clínicas bajo la metodología de preguntas PICO (Patient, Intervention, Comparison, Outcome) y la calidad de la evidencia y graduación de la fuerza de las recomendaciones se basó en el sistema Grading of Recommendations, Assessment, Development and Evaluations (GRADE). El análisis inmunocitoquímico y molecular del líquido pleural puede evitar procedimientos invasivos ulteriores con finalidad diagnóstica. Actualmente, el control definitivo del DPM se puede realizar indistintamente a través de una pleurodesis (talco poudrage o slurry) o de la inserción de un catéter pleural tunelizado (CPT). Es probable que la combinación de ambas técnicas (p.ej. toracoscopia con talco poudrage e inserción de un CPT, o instilación de talco slurry a través de un CPT) ocupe un lugar predominante en el manejo terapéutico futuro.

External validation of the European Society of Thoracic Surgeons morbidity and mortality risk models.

OBJECTIVES: There is a wide variety of predictive models of postoperative risk, although some of them are specific to thoracic surgery, none of them is widely used. The European Society for Thoracic Surgery has recently updated its models of cardiopulmonary morbidity (Eurolung 1) and 30-day mortality (Eurolung 2) after anatomic lung resection. The aim of our work is to carry out the external validation of both models in a multicentre national database. METHODS: External validation of Eurolung 1 and Eurolung 2 was evaluated through calibration (calibration plot, Brier score and Hosmer-Lemeshow test) and discrimination [area under receiver operating characteristic curves (AUC ROC)], on a national multicentre database of 2858 patients undergoing anatomic lung resection between 2016 and 2018. RESULTS: For Eurolung 1, calibration plot showed suboptimal overlapping (slope = 0.921) and a Hosmer-Lemeshow test and Brier score of P = 0.353 and 0.104, respectively. In terms of discrimination, AUC ROC for Eurolung 1 was 0.653 (95% confidence interval, 0.623-0.684). In contrast, Eurolung 2 showed a good calibration (slope = 1.038) and a Hosmer-Lemeshow test and Brier score of P = 0.234 and 0.020, respectively. AUC ROC for Eurolung 2 was 0.760 (95% confidence interval, 0.701-0.819). CONCLUSIONS: Thirty-day mortality score (Eurolung 2) seems to be transportable to other anatomic lung-resected patients. On the other hand, postoperative cardiopulmonary morbidity score (Eurolung 1) seems not to have sufficient generalizability for new patients.

Surgical Risk Following Anatomic Lung Resection in Thoracic Surgery: A Prediction Model Derived from a Spanish Multicenter Database. / Riesgo quirúrgico tras resección pulmonar anatómica en cirugía torácica. Modelo predictivo a partir de una base de datos nacional multicéntrica.

INTRODUCTION: The aim of this study was to develop a surgical risk prediction model in patients undergoing anatomic lung resections from the registry of the Spanish Video-Assisted Thoracic Surgery Group (GEVATS). METHODS: Data were collected from 3,533 patients undergoing anatomic lung resection for any diagnosis between December 20, 2016 and March 20, 2018. We defined a combined outcome variable: death or Clavien Dindo grade IV complication at 90 days after surgery. Univariate and multivariate analyses were performed by logistic regression. Internal validation of the model was performed using resampling techniques. RESULTS: The incidence of the outcome variable was 4.29% (95% CI 3.6-4.9). The variables remaining in the final logistic model were: age, sex, previous lung cancer resection, dyspnea (mMRC), right pneumonectomy, and ppo DLCO. The performance parameters of the model adjusted by resampling were: C-statistic 0.712 (95% CI 0.648-0.750), Brier score 0.042 and bootstrap shrinkage 0.854. CONCLUSIONS: The risk prediction model obtained from the GEVATS database is a simple, valid, and reliable model that is a useful tool for establishing the risk of a patient undergoing anatomic lung resection.

Recomendaciones de actuación en cirugía torácica electiva y urgente en contexto de pandemia por SARS-CoV-2 de la Sociedad Española de Cirugía Torácica (SECT) / Recommendations for acting in elective and urgent thoracic surgery during SARS-CoV-2 pandemic. Spanish Society of Thoracic Surgery

La expansión de la pandemia producida por el nuevo coronavirus SARS-CoV-2 ha obligado a focalizar casi toda la asistencia sanitaria en pacientes con enfermedad COVID-19, obligando a suspender la mayoría de intervenciones quirúrgicas electivas programadas. La cirugía torácica es eminentemente oncológica, por lo que resulta obligada una adecuada priorización de los pacientes para ser intervenidos lo antes posible y en condiciones de máxima seguridad. Por otra parte, la afectación pulmonar grave COVID-19 presenta complicaciones que con frecuencia requieren procedimientos quirúrgicos torácicos urgentes en un contexto nuevo. La Sociedad Española de Cirugía Torácica (SECT) ha desarrollado este documento para establecer unas recomendaciones básicas para mantener la actividad quirúrgica electiva imprescindible y para orientar a los cirujanos que deban afrontar urgencias torácicas en este nuevo y desconocido entorno

Expansion of the pandemic produced by new coronavirus SATS-CoV-2 has made healthcare focused on patients with COVID-19 disease, leading to discontinue most of elective surgical procedures. Being thoracic surgery eminently oncological, an optimal triage of patients amenable to be safely operated on is mandatory. Moreover, severe pulmonary involvement by COVID-19 causes complications frequently needing urgent thoracic surgical procedures under a new context. The Spanish Society of Thoracic Surgery (SECT) has developed this document to establish basic recommendations to keep up essential elective surgical activity and to guide surgeons facing thoracic urgencies in this new and unknown environment

Recommendations for acting in elective and urgent thoracic surgery during SARS-CoV-2 pandemic. Spanish Society of Thoracic Surgery. / Recomendaciones de actuación en cirugía torácica electiva y urgente en contexto de pandemia por SARS-CoV-2 de la Sociedad Española de Cirugía Torácica (SECT).

Expansion of the pandemic produced by new coronavirus SATS-CoV-2 has made healthcare focused on patients with COVID-19 disease, leading to discontinue most of elective surgical procedures. Being thoracic surgery eminently oncological, an optimal triage of patients amenable to be safely operated on is mandatory. Moreover, severe pulmonary involvement by COVID-19 causes complications frequently needing urgent thoracic surgical procedures under a new context. The Spanish Society of Thoracic Surgery (SECT) has developed this document to establish basic recommendations to keep up essential elective surgical activity and to guide surgeons facing thoracic urgencies in this new and unknown environment.

EV-associated miRNAs from pleural lavage as potential diagnostic biomarkers in lung cancer.

Lung cancer is the leading cause of cancer-related deaths among men and women in the world, accounting for the 25% of cancer mortality. Early diagnosis is an unmet clinical issue. In this work, we focused to develop a novel approach to identify highly sensitive and specific biomarkers by investigating the use of extracellular vesicles (EVs) isolated from the pleural lavage, a proximal fluid in lung cancer patients, as a source of potential biomarkers. We isolated EVs by ultracentrifuge method from 25 control pleural fluids and 21 pleural lavages from lung cancer patients. Analysis of the expression of EV-associated miRNAs was performed using Taqman OpenArray technology through which we could detect 288 out of the 754 miRNAs that were contained in the OpenArray. The differential expression analysis yielded a list of 14 miRNAs that were significantly dysregulated (adj. p-value < 0.05 and logFC lower or higher than 3). Using Machine Learning approach we discovered the lung cancer diagnostic biomarkers; miRNA-1-3p, miRNA-144-5p and miRNA-150-5p were found to be the best by accuracy. Accordance with our finding, these miRNAs have been related to cancer processes in previous studies. This results opens the avenue to the use of EV-associated miRNA of pleural fluids and lavages as an untapped source of biomarkers, and specifically, identifies miRNA-1-3p, miRNA-144-5p and miRNA 150-5p as promising biomarkers of lung cancer diagnosis.

Clinicopathological and Immunohistochemical Study of 14 Cases of Morbihan Disease: An Insight Into Its Pathogenesis.

INTRODUCTION: Morbihan disease (MORD) is rare with only 45 clear-cut cases previously reported. Histopathologic findings are supposed to be nonspecific. We report 14 patients and review the previous cases. OBJECTIVES: To characterize the clinicopathologic findings, outcomes, and immunophenotype of MORD. MATERIAL AND METHODS: Inclusion criteria were a clinical picture of persistent, nonpitting edema affecting the mid and or upper third of the face and histopathological findings fitting previous reports and exclusion of other entities. RESULTS: The majority of our patients were males (71.5%) with a male/female ratio of 10/4. The mean age when diagnosed was 58.8 years. Eyelids and forehead were the most frequently involved areas. Two of the patients presented previous rosacea. Most constant histopathological findings were lymphatic vessel dilatations in the upper dermis and the presence of mast cells (7.5 in 10 high-power field as a mean). Mild edema was also present in most of the cases. Granulomas were found in 7 of the cases, and immunostaining with CD68 and CD14 only revealed an additional case. CONCLUSIONS: MORD occurs more in middle-aged males, not associated with rosacea and mostly affects eyelids and forehead. Granulomas are not mandatory for the diagnosis. Histopathology of MORD fits within the spectrum of localized lymphedema.

Three dimensional computed tomography for preoperative assessment of the pulmonary artery in patients undergoing endoscopic lobectomy or segmentectomy. / Rentabilidad de la reconstrucción volumétrica de la arteria pulmonar para la planificación de lobectomías y segmentectomías endoscópicas.

BACKGROUND: The interest for endoscopic pulmonary anatomic resections has grown exponentially during the last decade. During thoracoscopic procedures surgeons cannot rely on digital handling and operative field is viewed on a two-dimensional video monitor, thus frequently encountering anatomical difficulties. The hypothesis is that foreknowledge of the anatomy of each patient would greatly contribute to the safety and accuracy of the operation. The aim of the study was to evaluate the effectiveness of 3dimensional multidetector computed tomography (3D-MDCT) software to identify the pulmonary artery branching pattern during the preoperative study of endoscopic lobectomies and segmentectomies. METHODS: Descriptive prospective study of 25consecutive patients scheduled from November 2015 to July 2016 in a tertiary referral academic hospital for VATS lobectomy or segmentectomy and evaluated about branching pattern of the pulmonary artery with preoperative 16-row 3D-MDCT angiography. Intraoperative findings of the pulmonary branching pattern were compared with the preoperative 3D-MDCT angiography images. RESULTS: According to the intraoperative findings, 67 out of 68 (98%) of pulmonary artery branches were well defined in the 3D-MDCT angiography images. There was a unique 2mm undetected branch. No conversion to open thoracotomy was needed because of intraoperative bleending. CONCLUSION: 3D-MDCT angiography imaging is useful for preoperative identification of the pulmonary artery branching pattern.

Rentabilidad de la reconstrucción volumétrica de la arteria pulmonar para la planificación de lobectomías y segmentectomías endoscópicas / Three dimensional computed tomography for preoperative assessment of the pulmonary artery in patients undergoing endoscopic lobectomy or segmentectomy

INTRODUCCIÓN: El número de resecciones pulmonares mayores endoscópicas ha presentado un incremento exponencial durante la última década. La realización de la videotoracoscopia (VTC) puede ocasionar dificultades para la correcta interpretación de la anatomía torácica debido a la ausencia de exploración manual y de la visión en profundidad en el caso de trabajar con monitores bidimensionales. En consecuencia, el hecho de conocer con exactitud la anatomía de cada paciente contribuiría enormemente a la realización de una cirugía segura y precisa. El objetivo del estudio es analizar la eficacia de las reconstrucciones volumétricas realizadas mediante angiotomografía computarizada multidetector para identificar el patrón de ramificación de la arteria pulmonar en el preoperatorio de lobectomías y segmentectomías endoscópicas. MÉTODOS: Estudio descriptivo prospectivo de 25 pacientes seleccionados de noviembre de 2015 a julio de 2016 para realización de lobectomía/segmentectomía VTC en un hospital de tercer nivel. En todos los casos se realizó una reconstrucción volumétrica de la arteria pulmonar mediante angiotomografía computarizada multidetector de 16 coronas. Se analizaron comparativamente el número de ramas arteriales identificadas mediante reconstrucción volumétrica y las observadas durante la resección pulmonar. RESULTADOS: En total 67 de las 68 (98%) ramas de la arteria pulmonar fueron correctamente identificadas mediante la reconstrucción volumétrica preoperatoria. La única rama no objetivada mediante la reconstrucción volumétrica presentaba un diámetro menor a 2mm. No fue precisa ninguna conversión a toracotomía abierta debido a accidente vascular. CONCLUSIONES: La reconstrucción volumétrica es útil como herramienta diagnóstica preoperatoria para la correcta identificación del patrón de ramificación de la arteria pulmonar

BACKGROUND: The interest for endoscopic pulmonary anatomic resections has grown exponentially during the last decade. During thoracoscopic procedures surgeons cannot rely on digital handling and operative field is viewed on a two-dimensional video monitor, thus frequently encountering anatomical difficulties. The hypothesis is that foreknowledge of the anatomy of each patient would greatly contribute to the safety and accuracy of the operation. The aim of the study was to evaluate the effectiveness of 3dimensional multidetector computed tomography (3D-MDCT) software to identify the pulmonary artery branching pattern during the preoperative study of endoscopic lobectomies and segmentectomies. METHODS: Descriptive prospective study of 25consecutive patients scheduled from November 2015 to July 2016 in a tertiary referral academic hospital for VATS lobectomy or segmentectomy and evaluated about branching pattern of the pulmonary artery with preoperative 16-row 3D-MDCT angiography. Intraoperative findings of the pulmonary branching pattern were compared with the preoperative 3D-MDCT angiography images. RESULTS: According to the intraoperative findings, 67 out of 68 (98%) of pulmonary artery branches were well defined in the 3D-MDCT angiography images. There was a unique 2mm undetected branch. No conversion to open thoracotomy was needed because of intraoperative bleending. CONCLUSION: 3D-MDCT angiography imaging is useful for preoperative identification of the pulmonary artery branching pattern

Superficial Acral Fibromyxoma: Report of 13 Cases With New Immunohistochemical Findings.

BACKGROUND: Superficial acral fibromyxoma (SAF) is a benign, soft tissue neoplasm preferably located on the digits. METHODS: We collected 13 cases of SAF and evaluated their clinical, histopathologic, and immunohistochemical features. RESULTS: This study included 9 males and 4 females, median age 54 years. The patients presented with a solitary asymptomatic or tender mass, most of them arising on fingers or toes. Histopathologically all lesions consisted of nonencapsulated dermal nodules, composed of spindled cells with variable myxoid and/or fibrotic stroma. Some lesions were well circumscribed (6/12, 50%), whereas other ones appeared poorly demarcated (6/12, 50%). The stroma was predominantly myxoid (53%), myxoid-collagenous (31%) or mostly collagenous (15%). Neoplastic cells expressed immunoreactivity for CD34 (8/11), CD99 (9/12), and nestin (7/7); whereas MUC4 (0/11) and Bcl-2 (0/7) resulted negative. CONCLUSIONS: Nestin is the best immunohistochemical marker for SAF with higher sensitivity than CD34, although nestin is also positive in dermatofibrosarcoma protuberans and therefore is not helpful in differential diagnosis between SAF and dermatofibrosarcoma protuberans. Cellular digital fibromas and acquired reactive digital fibroma probably are neoplasms closely related to SAF. The homogeneous reactivity for CD99, the negativity for Bcl-2 and lack of the honeycomb infiltration of the subcutis help to rule out myxoid dermatofibrosarcoma protuberans, whereas the negativity for MUC4 and Bcl-2 are helpful tools to rule out low-grade fibromyxoid sarcoma and spindled-cell lipoma, respectively.