Lung nodule management: a new classification proposal.

Management of solitary pulmonary nodule (SPN) and micronodule (SPMN) is still debated. The use of 18F-FDG PET/CT or CT multislice screening for early lung cancer detection, have increased the frequency of displaying indeterminate single lung nodule with diameter between 0.1 cm and 2 cm. The first choice is to wait and do radiological follow-up, since the evaluation of temporal changes in a small mass may contribute to differentiate a malign from benign pathology. In case of unchanged images not capable of orientating the diagnostician or no possible preoperative diagnosis by bronchoscopy and percutaneous needle biopsy, surgical treatment is necessary allowing the histological characterization of lesion and a good prognosis of disease. Video-assisted thoracoscopic surgery and muscle-sparing minithoracotomy have become routine, each of these furnishing precise indications. The purpose of the study was to establish the main investigative method for indeterminate lung nodules, considering the continuous evolution of endoscopic and radiological techniques.

18-fluorine fluorodeoxyglucose positron emission tomography with computerized tomography versus computerized tomography alone for the management of solitary lung nodules with diameters inferior to 1.5 cm.

OBJECTIVE: Aim of the study was to establish a noninvasive method for the preoperative characterisation of a pulmonary nodule when biopsy of the small mass is impossible. METHODS: From 1 January 2006 to 31 December 2008, we observed 124 asymptomatic patients with a noncalcified single lung nodule highlighted by computerised tomography (CT) of the thorax. Patients were divided into 2 groups: Group A consisted of 57 patients with lesion diameters between 0.5 cm and 0.99 cm; Group B consisted of 67 patients with lesion diameters between 1.0 cm and 1.5 cm. Fibreoptic bronchoscopy was negative for endobronchial neoformation in all patients. The topographic distribution of the lesions advised against CT-guided transthoracic needle biopsy or video-assisted thoracoscopy. All patients had preoperative 18-fluorine fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) associated with CT of the thorax, which was compared with CT for evaluation of the mass. RESULTS: Postoperative histological diagnosis revealed 54 primary lung cancers, 47 lung metastases and 23 benign lesions. In Group A the sensitivity of 18F-FDG PET/CT and CT was 95 % and 73 % and the specificity was 72 % and 64 %, respectively ( P = 0.000001 for 18F-FDG PET/CT; P = 0.000177 for CT). In Group B the sensitivity of 18F-FDG PET/CT and CT was 95 % and 97 %, and the specificity was 80 % and 87 %, respectively ( P = 0.000001). CONCLUSIONS: Our study shows that 18F-FDG PET/CT improves the identification and characterisation of potentially malignant pulmonary nodules with a diameter < 1 cm. This technique could be a valid alternative to a surgical approach, currently the main method to investigate indeterminate lung nodules.

Ethmoidal adenocarcinoma with lung metastases: diagnosis and multimodal treatment.

We report a case of 68-year-old patient underwent a magnetic resonance imaging (MRI) of the skull and a computed tomography (CT) of the thorax for rhinorrhea and dyspnea. The MRI showed an irregular ethmoidal lesion and the CT of the thorax underlined a solid nodular neoformation in the upper right pulmonary lobe. The patient underwent rhinoscopy with biopsies that showed an ethmoidal adenocarcinoma; excision of the tumour was carried out via trans-sphenoid. After one month the patient underwent wedge-resections in video-thoracoscopy (VATS). Perioperative histologic examination revealed a lung metastases due to an adenocarcinoma of the ethmoid. The patient was treated with chemotherapy and did not show relapses after 12 months from VATS.

Necrotizing mediastinitis linked to Boerhaave's syndrome: a surgical approach.

We report 5 cases of Boerhaave's syndrome with necrotizing mediastinitis and pleural empyema. We chose a surgical treatment characterized by manual suture and heterologous tissue to repair esophagus rupture. This option allows a better result in terms of morbidity and mortality.

Foreign bodies aspirated in children: role of bronchoscopy.

OBJECTIVE: To examine the diagnostic and therapeutic role of fiber-optic and rigid bronchoscopy in pediatric patients with foreign body inhalations. METHODS: From January 1986 to December 2004, we observed 128 young patients with suspicion of foreign body aspiration. Patients were divided into 3 groups: group I, patients with negative chest X-ray; group II, patients with radiological direct signs; group III, patients with radiological indirect signs. RESULTS: Removal of the foreign body was effected in 105 patients by rigid bronchoscopy and in 13 patients by fiber-optic bronchoscopy. In 3 group II patients a thoracotomy with a bronchotomy was necessary. CONCLUSIONS: Fiber-optic bronchoscopy showed a diagnostic accuracy rate of 100 % but played a poor therapeutic role with a case resolution of 10.7 %. Rigid bronchoscopy was the main technique, permitting the removal of the tracheobronchial foreign body in 97.2 % of patients.

Multimodal treatment of osteosarcoma lung metastases.

OBJECTIVE: The diagnostic procedures, role of surgery and multimodal treatment for osteosarcoma pulmonary metastases are examined. METHODS: From January 2000 to June 2005, we observed 35 patients with osteogenic repetitions. Patients were studied by total-body computerised tomography (CT) and by thoracic single-photon emission computerised tomography (SPECT). Preoperative histological diagnosis was obtained by CT-guided transthoracic needle biopsy (23 cases) and fibre-optic bronchoscopy (12 cases). RESULTS: Four lower, 6 upper and 2 middle lobectomies were carried out using a thoracotomy approach. Video-assisted thoracoscopy was used in the other 23 patients who underwent 36 wedge resections. CT showed a sensitivity of 86 % and a specificity of 66 %; SPECT had a sensitivity of 80 % and a specificity of 100 %. Twenty-five patients are still living 25 +/- 11 months after the intervention. CONCLUSIONS: SPECT was demonstrated to offer a better result in the individualisation of secondary pulmonary nodules after primary osteosarcoma. The excision of all resectable lung metastases, integrated in a multidisciplinary strategy, offers good results in terms of survival.

Pulmonary and parotid hydatid cyst: an unusual double localization.

We described a rare case of pulmonary and parotid cyst for echinococcus granulosus in an eighty-one-year-old patient. Lesion was discovered in the lung owing to a clinical presentation. A swelling was the only sign in the parotid gland. Time between lung and parotid excision was 14 days. Time of hospitalizations was 4+/-1 day.

Carcinoid tumors of the lung and multimodal therapy.

AIM: To report our experience with bronchial carcinoids. METHODS: From January 1990 to March 2003 we treated 42 such patients, 30 females and 12 males. All patients underwent preoperative total body computed tomography (CT), total body In-111 octreotide scintigraphy, and SPECT of the thorax, with evaluation of serum levels of CEA, CgA, NSE, and urinary 5-HIAA. Diagnosis was obtained in 28 patients with fibre-optic bronchoscopy and in 14 patients with CT-guided trans-thoracic needle biopsy. RESULTS: There were 26 typical and 16 atypical carcinoids. 30 lobectomies, 5 bilobectomies, 6 wedge resections, and 1 pneumonectomy were carried out. The 3-year and the 5-year survival rates in the typical and atypical carcinoid groups were 100 % and 96 % vs. 81 % and 68 %, respectively (p < 0.001). CONCLUSIONS: Long-term survival is based on histological completeness of surgical treatment. Octreotide scintigraphy and SPECT document N (1) and N (2) precisely.

Lung transplantation by continuous perfusion in an experimental auto-transplant animal model.

OBJECTIVE: The aim of this study was to evaluate the preservation of the lung using the cold flushing technique in association with continuous perfusion of the organ during static hypothermic storage. METHODS: In the first phase, the hearts and lungs of 5 New Zealand rabbits were removed three hours after establishing brain death. The left lungs were each conserved in 200 ml of low-potassium UW solution at 10 degrees C for 3 hours of cold ischemia (control group I). The right lungs were also placed in cold storage but were perfused continuously for three hours with low-potassium UW solution at 10 degrees C (group II). In the second phase, ten rabbits underwent a right lung auto-transplant. Lungs were conserved using two techniques. Histoenzymatic and pathological tests were performed: lung function was evaluated. RESULTS: In the first phase the histopathological examination carried out at the end of storage revealed fewer ischemic alterations in the second group compared to the first. In the second phase a significant hypoxia was observed in group I when both lungs and the right lung only were perfused. The histopathological examination revealed ischaemia/reperfusion lesions in both groups though mainly in group I and a good level of ATPase activity in group II though these results were not significant. CONCLUSIONS: Cold flushing of the pulmonary artery and continuous perfusion during static hypothermic storage appears to guarantee a better partial arterial pressure of oxygen in this model of auto-transplant compared to the classical cold storage method.

[Translaryngeal tracheostomy using the Fantoni technique: report of 104 cases]. / La trachéotomie translaryngée selon la technique de Fantoni: à propos de 104 observations.

OBJECTIVE: Surgical tracheostomy morbidity led the authors to investigate new election techniques. The aim of this retrospective study was to assess the translaryngeal tracheostomy (TLT), complications and cost. METHODS: From January 1998 to January 2001, 104 patients were treated with TLT modified: 69 males (66.3%) and 35 females (33.7%), average age 52.6 +/- 9.5 years. The original pathologies were: traumatical (36), neurological (37), surgical (9), heart (4), respiratory (18). The average time between intubation and execution of TLT was 4.2 +/- 1.3 days. RESULTS: Fifty four patients died (52%) and 50 patients lived (48%). Two complications (1.9%) occurred in those who survived: a breaking of the guidewire in traction. Extraction of the tracheostomy tube by clamp, a haemorrhage in 2nd post-operative day due to a thyroid vessel lesion. The haemostasis was performed by classical tracheostomy. The average number of days to decannulation was 25 +/- 1 days. CONCLUSIONS: TLT reduces trauma or trachea and neighbouring structures. This technique is safe and easy. TLT is an effective method, in non-urgent situations, in children and adults, as well as in brachytypes and the obese.

Is video-assisted thoracic surgery justified at first spontaneous pneumothorax?

OBJECTIVE: The fundamental role of video-assisted thoracic surgery (VATS) in the treatment of spontaneous pneumothorax is generally acknowledged today. This study intends to evaluate whether VATS is justified at the onset of a first spontaneous pneumothorax through analysis of parameters tested on two group of patients treated respectively with pleural drainage and VATS. PATIENTS/METHODS: The study includes 70 patients affected by first spontaneous pneumothorax divided into two groups of 35 patients for the purpose of therapeutic treatment. The first group underwent pleural drainage while the second underwent VATS. Parameters analyzed were as follows: (1) prolonged air leaks (more than 6 days); (2) time required for pleural drainage; (3) time of hospital stay; (4) management costs; (5) recurrences (follow-up at 12 months). RESULTS: Prolonged air leaks occurred in four patients (11.4%) in the first group and two patients (5.7%) in the second; recurrences occurred in eight patients in the first group (22.8%), and only one in the second group (2.8%). Mean time for drainage and hospitalization was, respectively, 9 and 12 days in patients with pleural drainage against 3.9 and 6 days of those using VATS. Average management costs per patients including hospitalization was calculated at $2,750.00 per patient for the first group compared with $1,925.00 for the second group. CONCLUSIONS: The use of VATS at first spontaneous pneumothorax is justified in the interest of both patients and health administrations as demonstrated by the number of recurrences in patients in the first group and economy savings resulting from use of VATS.

A comparative study of Euro-Collins, low potassium University of Wisconsin and cold modified blood solutions in lung preservation in acute autotransplantations in the pig.

OBJECTIVE: The aim of the study was to assess the quality of lung preservation offered by Euro-Collins solution (EC), Cold Modified Blood solution (CMB) and low potassium University of Wisconsin solution (UWLP). METHOD: Fifteen right lung auto-transplantations (five for each solution) in the pig (Large White) were performed after 2 h of cold ischaemic storage in physiological solution at 4 degrees C. Right lung biopsies were performed before ischaemia and 30 min after reperfusion, for histoenzymatic, histopathological and electron microscope studies. RESULTS: After reperfusion, significant alterations were observed in the haemodynamics with only the right lung perfused; pulmonary arteriolar resistance increased by a factor of 5 in the EC group, by a factor of 4 in the CMB group and by a factor of 1.2 in the UWLP group; the right ventricular ejection fraction fell by 60% in the EC group, by 50% in the CMB group and by 31% in the UWLP group. Haemodynamic impairment was lower in the UWLP group (P<0.05; P<0.001) as was ischaemic-reperfusion injury (P<0.05). Oedema was observed in the EC group and extensive alveolar wall damage in the CMB group. Hypoxaemia was observed in all groups but the differences in the degree of hypoxaemia were not significant. CONCLUSIONS: The authors concluded that UWLP solution was the most effective of the three in this transplant model.

[Current role of open window thoracostomy]. / Attuale ruolo dell'open window thoracostomy.

The Open Window Thoracostomy (OWT) surgical method find its origin in the treatment of chronic tuberculous empyemas, in the cases where the drainage alone not permitted a sufficient cleaning of pleural cavity. In the recent years the indications for the execution of this method are extended also to metapneumoniae and post-pneumonectomy empyemas (for benign and malignant pathology), with or without bronco-pleural fistula, when these pathologies produces a general severe decline in the patient (septic shock). This method permit to effect a daily cleaning of a pleural cavity, through the introduction of a sterile gauzes imbued of specific antibiotic, reducing at least the purulent infection effects's previously present and favouring the reduction of the same cavity, in prevision of other reconstructive operations (thoracoplasty). Generally not many beloved by surgeons and patients (for the difficult management, aesthetic outcomes, the long stay in hospital), the OWT can often reestablish a dangerous situation, especially in the patients with a risk of septic shock. This study aims to analyse present indications, problems and therapeutics outcomes of this method, through the evaluation of 27 cases of OWT treated in the Department of Thoracic Surgery University of L'Aquila between the 1984 and the 1998.

[Tumors of the chest wall]. / I tumori della parete toracica.

The aim of this work was to evaluate the different surgical repair procedures and to discuss their technical applications according to the indications. From april 1989 to november 1999 we observed 18 patients, 12 males (66.7%) and 6 females (33.3%) presenting tumors of the chest wall. All patients were submitted preoperatively to a general respiratory check-up, and to an assessment of loco-regional and metastatic lesions. In 13 patients (72.2%), on the basis of topographical and morphological characteristics of the mass, we performed a transthoracic needle biopsy under scanner monitoring. The exeresis, in 6 patients (33.3%), implied a large resection of osteo-muscular structures. In 10 patients (55.6%), the benign nature of lesion, required extirpation solely of the tumor. In 2 patients (11.1%), owing to the extensive infiltration of the primary neoplasm, solely complementary treatment was carried out. Reconstruction of the thoracic wall was performed using associated myoplasty in all cases. In 3 subjects a prosthesis was installed; in 1 case a costal transposition association is necessary. Histological observation of the excised material revealed 16 primary tumors, 12 benign (75%) and 4 malignant (25%). Transthoracic needle biopsy under scanner monitoring confirmed the diagnosis in 100% of the cases operated. Fourteen patients (87.5%) are alive 73 +/- 35 months after intervention, without resumption of the disease. Two patients died (12.5%) VIII and VI months following the operation. Two patients not operated, died after VI and V months. Appropriate choice of techniques and of repair materials allowed valid oncological, aesthetical and functional results independently from the extent of the parietal defect.

[Chest wall tumors. Report of 17 cases]. / Tumeurs de la paroi thoracique. A propos de 17 observations.

The aim of this work was to evaluate the different approaches to surgical repair of the thoracic wall and to discuss technical indications. From June 1987 to June 1997, we cared for 17 patients, 14 males (82.3%) and 3 females (17.7%) with parietal neoplasia. All patients underwent a preoperative respiratory work-up to identify tumoral extension. In 6 patients, the morphology and location of the tumor led to CT-guided transthoracic needle aspiration. Tumoral excision in 14 patients (82.3%) included wide resection of osteomuscular structures. Reconstruction of the thoracic wall associated myoplasty in all cases. A prosthesis was installed in 5 cases and a rib transposition in 2. Pathology examination of the surgical specimen revealed 13 primary tumors (76.5%) and 4 secondary tumors (23.5%) CT-guided transthoracic needle aspiration confirmed the diagnosis in 82.2% of the cases. Twelve patients (70.5%) were alive and recurrence free at 85.6 +/- 40 months after surgery. Five patients died (29.5%) 12.2 +/- 10.1 months after surgery. There was one case of prosthesis infection (5.8%). The appropriate choice of the surgical technique and repair materials gave satisfactory oncological, esthetic and functional results independently of the extent of the parietal defect.

[Therapeutic approach in non-postoperative pleural empyema]. / L'approccio terapeutico nell'empiema pleurico non post-chirurgico.

The Authors carried out an retrospective analysis on 81 patients, 67 men and 14 women, suffering from non post-surgical thoracic empyema, to evaluate the different therapeutic procedures and respective indications. The unsuccessful response to the preserving approach (intercostal drainage and pleural lavage twice a day with specific antibiotics or antiseptics) in 56 cases, induced the Authors to carry out a video-thoracoscopy (VAT), that allowed them to define the infection stage and subsequent treatment (the carrying on of a pleural drainage-lavage in 32 cases, the transcurrent pleural irrigation in 10 cases, the open window thoracostomy followed by myoplasty in 6 cases with bronchopleural fistula, the decortication with associated pleural exeresis in 6 cases with bronchopleural fistula, the decortication with associated pleural exeresis in 6 cases, the streptokinase in pleural cavity in 2 cases). There were registered totally 3 deaths (3.7%). The Authors in conclusion assert that the VAT, carried out after the unsuccessful preserving treatment, allows the evaluation of the infection stage and consequently suggests therapy.

[Chondro-costal abnormalities of anterior wall of the chest: operative indications and surgical technique]. / Le malformazioni condro-costali della parete anteriore del torace: indicazioni operatorie e tecnica chirurgica.

The aim of this study is to evaluate the utility of surgical treatment in patients with pectus excavatum (PE) or pectus carinatum (PC). Fifteen patients underwent surgical treatment because of their psycological and anatomical condition, more serious in 6 patients (5 with PE and 1 with PC). The degree of these chest wall deformities was evaluated as resulting from CT scan of the thorax, by the ratio between the transversal and the front/back diameters, according to Haller. The Authors recommend surgical operation in the post-puberal age up to 21 years because of good results obtained using Ravitch approach (only 1 case of partial relapse of PE), even though modified in PE cases with the application of flat steel prosthesis and in PC cases for uncutting the perichondral beds. The choice of surgical procedure derives, in our opinion, from the correction of these anatomic deformities and from the greater sense of improved cosmesis that might result.

Diagnostic and therapeutic approaches for masses in the posterior mediastinum.

Between January 1980 and December 1997 twenty-one patients with a mass in the posterior mediastinum came under our observation. All of the patients underwent chest radiography, bronchoscopy, respiratory function tests, perfusional and ventilatory radionuclide scans, a computed tomography (CT) of the chest and blood gas analysis. In cases involving neurogenic tumours magnetic resonance imaging (MRI) was used. Ten patients underwent CT guided transthoracic needle biopsy. The excision was performed by means of a thoracotomy in 12 cases (57.1%) and by video assisted thoracoscopy surgery (VATS) in the other 9 (42.9%); no deaths were recorded. Eleven neurilemmomas, two bronchogenic cysts, two paragangliomas, two neuroepitheliomas, one neurogenic sarcoma and three esophageal duplications were found. The authors believe an accurate pre-operative assessment of the lesion can be obtained using CT and MRI. The video assisted thoracoscopy (VAT) is a useful method of diagnosis and treatment as it can be converted into VATS if the lesion is benign or cystic. Thoracotomy is necessary when the mass is malignant or when there is adhesion to or invasion of surrounding tissues.

Mucinous cystadenoma of the lung.

A 56-year-old male patient came under our observation when a peripheral round mass in his right lung which he had since 1991 and which was believed to be a bronchogenic cyst, showed a volumetric enlargement of 2 cm. After performing a lobectomy of the middle lobe, the histopathological examination revealed the presence of a mucinous cystadenoma of borderline malignancy.

[Use of magnetic resonance in the study of mediastinal diseases]. / Impiego della RM nello studio della patologia mediastinica.

Clinical research on 75 cases of mediastinal masses has been carried out with the aim of evaluating the diagnostic value of Magnetic Resonance (MR). Results which have been achieved point to a remarkable potentiality of MR especially in the characterization and spatial definition of the masses and in the study of the spinal canal. These results, as well as the non-invasivity of the procedure, lead us to consider MR as an investigation of primary importance in the diagnostic assessment of mediastinal pathology.