Postoperative irradiation in stage II thymomas: is it worth it?-shedding some light in the guidelines' gray zone.

Thymomas are rare, indolent tumors. Early stages (I-II) benefit from surgical treatment, while locally advanced diseases (stages III-IV) usually require a multidisciplinary approach. The role of postoperative radiotherapy (PORT) on anterior mediastinum for radically resected Masaoka-Koga stage II thymomas remains controversial. This study aims to determine the impact of PORT on the disease-free survival (DFS) of stage II thymomas. We retrospectively collected the clinical and oncologic data [age, sex, myasthenia gravis (MG) prevalence, Masaoka-Koga stage, World Health Organization (WHO) histologic subtype] of those patients who underwent radical exeresis in our Unit between January 2000 and December 2020. Kaplan-Meier estimates of DFS were then performed. Our study included 195 patients (M/F = 98/97). Almost all patients were affected by MG (90.7%) and most of them were operated by median sternotomy (93.3%). Thymoma stage was IIa in 87 cases (44.6%) and IIb in 108 cases (55.4%). The most represented histologic subtype was AB (27.7%), followed by B2 (24.6%), A (19%), B1 (14.9%) and B3 (13.8%). PORT was performed in 113 patients (58%, 39 stage IIa and 74 stage IIb). During the surveillance, 8 patients (4.1%) presented pleural recurrences and no local relapses. DFS was comparable in stage IIa and IIb patients, independently from PORT administration (p = .395 and p = .858, respectively). Moreover, PORT did not affect DFS considering the histologic subtypes (p = .304 for A and AB thymomas, p = .608 for B1, B2 and B3 thymomas). In our wide series, PORT administration didn't show any additional benefit on DFS. Therefore, based on our experience, patients with stage II thymoma who underwent radical surgery should not undergo any local adjuvant treatment.

Endobronchial ultrasound-transbronchial needle aspiration: effectiveness and accuracy in non-small cell lung cancer staging.

INTRODUCTION: Endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) has a cardinal role in the diagnosis and staging of non-small cell lung cancer (NSCLC), providing an accurate nodal staging in a less invasive way than surgical biopsy. The aim of this study was to assess the diagnostic accuracy of EBUS-TBNA in the pre-operative NSCLC mediastinal staging, as well as to evaluate EBUS-TBNA specificity and sensibility in our cohort. METHODS: We retrospectively analyzed data of NSCLC patients who underwent EBUS-TBNA followed by major pulmonary resection between January 2020 and December 2022. EBUS-TBNA was performed in patients with NSCLC (central T ≤ 3 cm, peripheral/central T > 3 cm), following the ESTS guidelines. The target nodes were selected on the basis of their radiologic/metabolic characteristics. Each procedure was conducted together with rapid on-site cytological evaluation (ROSE). RESULTS: Twenty-five patients were included (M/F = 17/8). At least three needle passages on each target lymph node were performed. No complications during or after the procedures occurred. We found a 100% correspondence between ROSE on the sampled nodes and postoperative pathologic findings. An upstaging occurred in three cases (12%) because of the involvement of stations 5 and 6 (not accessible via EBUS), while the only case of downstaging (N2 → N0, 4%) was probably due to intercurrent neoadjuvant chemotherapy. In all cases, EBUS-TBNA has proved to achieve a diagnostic procedure on the target nodes. CONCLUSIONS: EBUS-TBNA is a safe and effective procedure that offers high sensitivity and specificity when performed together with ROSE, which improves the accuracy of sampling. Doubt on nodal stations 5 and 6 involvement should be settled by other techniques.

TNM Staging System in Thymoma: A Critical Appraisal?

Thymomas are rare tumors of the anterior mediastinum with peculiar clinical and pathological features. They have been deeply analyzed by pioneer authors, who strictly linked their name to the main pathological and staging classifications. Before the latest edition of the WHO classification of thymic epithelial tumors, the history of thymoma pathological classification inherited the name of the pathologists who systematically addressed the issue, from Levine-Rosai to Muller-Hermelink. Similarly, the thymoma staging system is intimately related to the name of two surgeons, Masaoka and Koga, who historically dealt with this disease. More recently, the traditional tumor-nodes-metastasis (TNM) system has been developed for the staging of this condition, in a rational attempt to put thymomas in conformity with the other solid tumors. The efforts of the International Thymic Malignancies Interest Group (ITMIG) and the Thymic Domain of the Staging and Prognostic Factors Committee (TD-SPFC) of the International Association for the Study of Lung Cancer (IASLC) resulted in the TNM classification of thymic tumors, which have been included in the eighth edition of the American Joint Committee on Cancer's (AJCC) Cancer Staging Manual. Herein, we report a narrative review of the evolution of the thymic epithelial tumors (TET) staging system and present a critical appraisal of the actual TNM classification compared with the historical Masaoka-Koga classification, with special focus on the proposal for the ninth edition of the TNM, expected in 2024.

Surgical treatment of tracheal stenosis during Covid-19 era: a single-center experience and lessons learnt on the field.

SARS-CoV2 outbreak led to several healthcare system challenges, especially concerning respiratory support to Covid-19 patients. In the first 2 years of pandemic (2020-2021), we assisted to a marked increase of post-invasive mechanical ventilation (IMV) tracheal stenosis incidence, many of them requiring surgical treatment, namely resection and primary end-to-end anastomosis. Our aim is to describe our experience during the abovementioned biennium, focusing on postoperative outcomes of patients who have had Covid-19 ("post-Covid"). We retrospectively collected pre-, intra- and postoperative data on all patients who underwent tracheal surgery for benign stenosis in our Unit from May 2020 to October 2021, including previous Covid-19. Comparison between "post-Covid-19" and "non-Covid-19" groups' outcomes was then performed. Patients were 9 males and 6 females, and mean age was 57.4 ± 13.21 years. Nine patients had previous Covid-19 (60%). All patients underwent multidisciplinary preoperative evaluation. Almost every operation was conducted by cervicotomy, and the mean length of the resected specimen was 23.9 ± 6.5 mm. Postoperative complications were: dysphonia (3 cases), wound infection (1), bleeding (1), ab-ingestis pneumonia (1), anastomosis dehiscence (2), and stenosis recurrence (1). Thirty-day mortality rate was 6.7% (1 patient). No significant differences between "post-Covid-19" and "non-Covid-19" groups were identified. Pathology revealed, in 5 "post-Covid-19" patients, signs of vasculitis or perivascular inflammatory infiltrate. Tracheal stenosis' surgical treatment has always been known as a challenging procedure because of high perioperative morbidity and mortality rates. Our experience shows that previous Covid-19 and ongoing pandemic did not significantly affect perioperative outcomes of patients who underwent tracheal resection and primary end-to-end anastomosis in a high-volume Center and after multidisciplinary workup.

Unradical Surgery for Locally-Advanced Thymoma: Is it time to evolve Perspectives?

OBJECTIVES: Nearly-one-third of thymomas are locally-advanced at diagnosis. The traditional dogma that surgery is justified in case a complete resection can be achieved has remained unmovable until today. This study aimed to investigate feasibility and oncologic efficacy of incomplete resection for locally-advanced thymomas in a contest of multimodality therapy. MATERIALS AND METHODS: A retrospective analysis was conducted using data of prospectively maintained thymomas database in a single high-volume centre. Data on 285 consecutive patients undergoing surgery for stage III and IVa thymomas between 1995 and 2019 were reviewed. Patients who underwent incomplete resection with curative-intent (removal of at least 90% of tumour burden) were included. Long-term outcomes and predictors of cancer-specific survival (CSS) and progression-free survival (PFS) were analyzed. Secondary endpoint was to assess adjuvant therapy efficacy. RESULTS: The study included 79 patients, 60 with microscopic residual tumour (76%, R1) and 19 with macroscopic residual disease (24%, R2). Masaoka-Koga stage was: III in 41 patients (52%) and IVa in 38 (48%). Histology was B2-thymomas (n = 31, 39.2%) followed by B3 (n = 27, 34.2%). Five- and 10-years CSS was 88% and 80%. Seventy patients (90%) underwent adjuvant treatment; they showed CSS comparable to radical resected patients (5-years: 89.1% vs 98.9%, respectively; 10-years: 81.8% vs 92.7%, respectively, p = 0.43). The site of residual disease, Masaoka-Koga stage and WHO histology did not affect prognosis. Stepwise multivariable analysis confirmed adjuvant therapy as a favourable CSS prognostic factor (HR, 0.51; 95% CI, 0.33-0.79, p = 0.003). Stratifying by subgroups, R2-patients who received postoperative chemo(radio)therapy (pCRT) showed a significantly better prognosis than R2-patients treated by consolidation radiotherapy alone (10-years CSS: 60%, p < 0.001). CONCLUSION: In locally-advanced thymomas, whenever a radical surgery cannot be achieved, incomplete resection has proved to be effective in a contest of multimodality strategy, independently of WHO histology, Masaoka-Koga stage and site of residual disease.

Intraoperative prevention and conservative management of postoperative prolonged air leak after lung resection: a systematic review.

Background: Prolonged air leak (PAL) due to an alveolar-pleural fistula (APF) is the most common complication after lung surgery. PAL is associated with an increased risk of morbidity and mortality, a longer chest tube duration, hence a prolonged hospitalization. Management of PAL may be challenging, and the thoracic surgeon should be aware of the possible therapeutic strategies. Methods: A systematic literature review was performed in PubMed, Cochrane Library, EMBASE, Ovid and Google Scholar. Title, abstract and full-text screening was performed, followed by structured data extraction, methodological quality assessment and Cochrane risk of bias assessment. Inclusion criteria were: case-control studies/randomized controlled trials (RCTs) comparing the new tested method with the standard of care to manage PAL after lung surgery; PAL due to APF; at least 10 patients; English-written papers. Results: A total of 942 initial papers from literature search, resulted in 43 papers after the selection. This systematic review found that the use of intraoperative measures as surgical sealants or pleural tenting, as well as a proper management of the chest drain and the use of blood patch or sclerosant agents seem to reduce postoperative air leaks incidence and/or duration and length of chest drain stay and hospitalization. Conclusions: Different measures have been described in literature to manage or prevent postoperative PAL. Most of them seem to be safe and efficient if compared to the "wait and see" strategy, even if large comparative studies that standardize the intra- and post-operative management of APF after lung resection are lacking and, actually, hard to conceptualize. However, there is a large consensus on the value of a preoperative PAL-risk stratification and on the necessity of tailoring PAL management or prevention's strategy and its timing on each patient's features.

Cold coagulation in thoracoscopic treatment of primary pneumothorax: a comparison with apicectomy.

OBJECTIVES: Primary spontaneous pneumothorax is a common disease, whose surgical treatment is still enigmatic in terms of timing and technique. Herein, we reported our experience with the parenchymal-sparing technique via cold coagulation (CC), in comparison to stapler apicectomy (SA). METHODS: We retrospectively collected data of all patients with apical blebs or <2 cm bullae treated with minimally invasive surgery for recurrent or persistent spontaneous pneumothorax, from 2010 to 2020. Two different surgical techniques were used: SA and the parenchymal-sparing CC of the apex. Perioperative and long-term results were analysed and compared. RESULTS: Out of 177 patients enrolled, 77 patients (CC group) underwent cold-coagulation of the apex while 100 patients (SA group) were treated with SA. Two groups were comparable in terms of age, surgical indication, intraoperative findings and affected side. CC group had a mean operative time of 43.2 min (standard deviation ± 19.5), shorter than SA group with 49.3 min (standard deviation ± 20.1, P-value: 0.050). Complication rate was significantly different between 2 groups, 5 (7%) and 16 (16%), for the CC and SA groups, respectively (P: 0.048), even if not in terms of prolonged postoperative air leak (P: 0.16). During the follow-up, 13 homolateral recurrences were reported: 2 (3%) in group CC and 11 (11%) in group SA; with a significant difference (P: 0.044). All reinterventions (postoperative prolonged air leak and recurrences) required an SA. CONCLUSIONS: Parenchymal-sparing technique through CC of apical blebs and bullae is an effective treatment for primary spontaneous pneumothorax and guarantees a good immediate lung sealing, despite stapling still represents the choice treatment in complex cases.

An asymptomatic giant AB thymoma in a patient with Down syndrome: a case report.

Background: Mediastinal mass management may represent a real challenge for all the physicians who deal with it. Mediastinum, in fact, contains different vital structures which are often involved by growing neoplasms with increasing severity. Therefore, up to 60% of the patients with mediastinal mass are symptomatic, according to the structure involved. Different neoplasms may arise essentially from all mediastinal organs, whereas thymic epithelial tumors and lymphomas represent more than 90% of mediastinal tumors. Case Description: We report the first case described of a giant asymptomatic mediastinal mass in a 43-year-old male affected by Down syndrome (DS), turned out to be a thymoma, treated exclusively and successfully with radical surgery. Despite the absence of any symptoms, the giant thymoma infiltrated the diaphragm, the pericardium, the upper lobe of the left lung together with the left phrenic nerve resulting in the compression of heart and great vessels. Conclusions: To date, this is the first description of a thymic malignancy in a patient with DS, that usually is characterized by a low-incidence of solid tumor except for germ-cells ones. Surgery has been extremely challenging, due the clinical condition of the patient together with the tumor features; nevertheless, oncological radicality criteria were completely fulfilled. After four years from surgery, the patient is alive and still disease-free, highlighting the importance of radical surgery.

New Insights in Pleural Mesothelioma Classification Update: Diagnostic Traps and Prognostic Implications.

The 2021 WHO Classification of Tumors of the Pleura has introduced significant changes in mesothelioma codification beyond the three current histological subtypes-epithelioid, sarcomatoid and biphasic. Major advances since the 2015 WHO classification include nuclear grading and the introduction of architectural patterns, cytological and stromal features for epithelioid diffuse mesothelioma. Mesothelioma in situ has been recognized as a diagnostic category. Demonstration of loss of BAP1 or MTAP by immunohistochemistry, or CDKN2A homozygous deletion by FISH, is valuable in establishing the diagnosis of epithelioid mesothelioma. Recent emerging data proved that grading and histological subtypes have prognostic implications and may be helpful to patient risk stratification and clinical management. Nevertheless, the latest mesothelioma classification increases the already non-negligible diagnostic pitfalls, especially concerning differential diagnosis of pre-invasive tumors. In this review, recent changes in histologic classification of mesothelioma and advances in molecular markers are presented and their relation to diagnostic challenges and prognostic implications is discussed.

Hyperthermic Intrathoracic Chemotherapy for Malignant Pleural Mesothelioma: The Forefront of Surgery-Based Multimodality Treatment.

INTRODUCTION: Malignant Pleural Mesothelioma (MPM) is characterized by an aggressive behavior and an inevitably fatal prognosis, whose treatment is still far from being standardized. The role of surgery is questionable since a radical resection is unattainable in most cases. Hyperthermic IntraTHOracic Chemotherapy (HITHOC) combines the advantages of antitumoral effects together with those of high temperature on the exposed tissues with the aim to improve surgical radicality. MATERIAL AND METHODS: this is a narrative review on the role of HITHOC in the management of MPM patients. To provide data on the beginnings and the historical evolution of this technique, we searched the available literature by selecting the more exhaustive papers on this topic. RESULTS: from 1994 to date different authors experimented HITHOC following a cytoreductive surgery in MPM, obtaining in most cases a good local control and a better overall survival associated to very low complication rate. CONCLUSIONS: HITHOC may be considered as a safe, feasible and effective procedure although there is a high heterogeneity between different protocols adopted worldwide. More structured studies are needed to reach a unanimous consensus on this technique.

Hypertermic Intrathoracic Chemotherapy (HITHOC) for thymoma: a narrative review on indications and results.

OBJECTIVE: With this narrative review, we retraced the history of hypertermic intrathoracic chemotherapy (HITHOC) since the beginning, analyzing literature on operative technique, feasibility and efficacy of this treatment. Moreover, we report the fifteen-year experience of our center in this relatively new technique, for what concerns both early postoperative results and long-term oncological outcomes. BACKGROUND: Thymomas are frequently misdiagnosed and recognized in advanced stage, often with pleural dissemination, especially when not associated to Myasthenia Gravis that allows an early diagnosis during the initial assessment. Moreover, the natural history of locally advanced thymoma is characterized by a high rate of pleural or pericardial relapses. Surgery has always been considered a milestone in thymoma's treatment, even in case of serous dissemination or relapses, although his role as exclusive therapy does not guarantee an acceptable local disease control. In case of disseminated disease, different multidisciplinary protocols have been experimented, from chemotherapy to radiation therapy, alone or associated to surgery, in order to increase overall and disease-free survival, but the breakthrough happened in the early 90s with the introduction of HITHOC following surgery. Combination of surgery and HITHOC resulted in less toxic than systemic chemotherapy and providing a good local disease control in patients with stage IVa thymomas or thymoma's pleural recurrences. METHODS: We searched PubMed for relevant literature, up to January 2020, on hypertermic intrapleural chemotherapy for thymomas (TPR or DNT), selecting only those reporting information about HITHOC protocol used, postoperative course and oncological outcomes. CONCLUSIONS: HITHOC is a safe and feasible procedure, with a very low complication rate and negligible systemic effects of chemotherapeutic agents, effective in controlling both TPR and DNT, in particular as regards local disease-free survival. KEYWORDS: Hypertermic intrathoracic chemotherapy (HITHOC); thymoma; intracavitary chemotherapy; hyperthermia; redo-surgery.

Prognostic factors for survival in advanced thymomas: The role of the number of involved structures.

BACKGROUND AND OBJECTIVES: The Masoka-Koga and tumor node metastases staging systems for thymoma are based on structures involved, but the prognostic role of the number of infiltrated/involved structures is still debated. We analyzed the prognostic role of involved structures and their combinations in locally advanced thymomas patients. METHODS: Data on 174 surgically treated locally advanced thymoma patients from 1/01/1990 to 31/12/2015 were reviewed. Clinical and pathological characteristic, involved structures, number of involved structures and different combinations were correlated to cancer specific survival (CSS) using Kaplan-Meier product-limit method. RESULTS: Five and 10-year CSS was 92% and 87%. Masaoka Stage 3 (p < 0.001), absence of pericardial involvement (p = 0.001), number of involved structures (p = 0.018), R0 (p < 0.001) and adjuvant radiotherapy (p = 0.008) were favorable prognostic CSS factors. A significant better prognosis was present in ≤2 involved structures vs >2 involved structures (5- and 10-year CSS: 95% and 93% vs. 80% and 51%). Multivariable analysis confirmed as independent prognostic factor R0 (p = 0.033, hazard ratio [HR]: 0.093, 95% confidence interval [CI] 0.010-0.827) and number of involved structures (p = 0.046, HR: 0.187, 95% CI: 0.036-0.968). In Masaoka Stage 3, patients with ≤2 involved structures had a significant better CSS than patients with >2 (10-year CSS: 98% vs. 73%, p = 0.008). CONCLUSIONS: The number of involved structures and the concomitant involvement of the pericardium seems to be associated with a poor prognosis in surgically treated advanced thymoma patients.

The International Thymic Malignancy Interest Group Classification of Thymoma Recurrence: Survival Analysis and Perspectives.

INTRODUCTION: The International Thymic Malignancy Interest Group (ITMIG) classifies thymoma recurrences on the basis of the topographic location, but its effectiveness in prognosis prediction has not been well investigated yet. Aims of this study are to analyze survival outcome of patients surgically treated for thymoma recurrence according to the ITMIG recurrence classification and to investigate possible alternatives. METHODS: From January 1, 1990, to January 7, 2017, data on 135 surgically treated patients for thymoma recurrence from three high-volume centers were collected and retrospectively analyzed. Patients were classified according to the ITMIG classification as local, regional, and distant. The ITMIG classification and alternative classifications were correlated to overall survival (OS). RESULTS: According to the ITMIG classification, recurrence was local in 17 (12.5%), regional in 97 (71.8%), and distant in 21 (15.7%) patients, with single localization in 38 (28.2%) and multiple localizations in 97 (71.8%). The 5- and 10-year OS were 79.9% and 49.7% in local, 68.3% and 52.6% in regional, and 66.3% and 35.4% in distant recurrences, respectively, but differences were not statistically significant (p = 0.625). A significant difference in survival was present considering single versus multiple localizations: 5- and 10-year OS of 86.2% and 81.2% versus 61.3% and 31.5% (p = 0.005, hazard ratio = 7.22, 95% confidence interval: 0.147-0.740), respectively. Combining the localization number with the recurrence site, ITMIG locoregional single recurrence had a statistically significant better survival compared with patients with ITMIG locoregional multiple recurrence or ITMIG distant recurrence (p = 0.028). Similarly, a significant difference was present considering intrathoracic single versus intrathoracic multiple versus distant recurrence (p = 0.024). CONCLUSIONS: The ITMIG classification for thymoma recurrence did not have significant survival differences comparing local, regional, and distant recurrences. Integrating this classification with the number of the localizations may improve its effectiveness in prognosis prediction.

Thymectomy in Myasthenic Patients With Thymoma: Killing Two Birds With One Stone.

BACKGROUND: Thymoma and myasthenia gravis share several pathogenetic aspects including the role of surgery as a therapeutic option. Extended thymectomy is associated with excellent survival and good local control, especially in early stages, and its role for the neurologic disease has been recently validated. The aim of this study is evaluating oncologic and neurologic outcomes of myasthenic patients with thymoma who underwent extended thymectomy. METHODS: We retrospectively collected surgical, oncologic, and neurologic data of all myasthenic patients with thymoma who underwent extended thymectomy at our department from January 1994 to December 2016. Clinical and pathologic data, neurologic remission rate, and overall survival and disease-free interval were analyzed. RESULTS: In all, 219 patients underwent extended thymectomy. The B2 histotype was the most represented thymoma (24.2%), and the most prevalent pathologic Masaoka stage was IIB (37.9%). The overall survival and disease-free survival were statistically different between early stage and advanced stage. During the surveillance, 33 patients (15.1%) had recurrences, treated in 21 cases with iterative surgery. Regarding neurologic outcomes, 75 patients (34.2%) reached a complete stable remission, 84 (38.4%) a pharmacologic remission, 51 (23.3%) had an improvement of their symptoms, and in 9 patients (4.1%) myasthenia was unchanged or worsened. CONCLUSIONS: Surgery is a cornerstone in the treatment of patients with both thymoma and myasthenia gravis. Extended thymectomy, as proposed by Masaoka, offers considerable oncologic outcomes with an excellent survival and low recurrence rate of thymoma; moreover, surgery leads to remarkable neurologic results.

Surgical treatment of pleural recurrence of thymoma: is hyperthermic intrathoracic chemotherapy worthwhile?

OBJECTIVES: Recurrence of thymoma is described in 10-30% of cases after surgical resection. Iterative surgery for thymoma pleural relapses (TPRs) is often part of a multimodal treatment. Hyperthermic intrathoracic chemotherapy (HITHOC) following macroscopic radical surgery is an option that combines the effects of mild hyperthermia with those of chemotherapeutic agents. We evaluated the effectiveness of surgery + HITHOC, compared with surgery alone, in the treatment of TPR. METHODS: We retrospectively collected data of all patients who underwent surgery for TPR in our centre from 2005 to 2017. Relapses were treated by partial pleurectomy with radical intent, followed by HITHOC when not contraindicated. Patients were divided into 2 groups: surgery + HITHOC and surgery alone. We collected demographic and clinical data and analysed postoperative results together with oncological outcomes. RESULTS: Forty patients (27: surgery + HITHOC, 13: surgery alone), mean age 49.8 (±13.7) years, were included in this study. There were no perioperative deaths. We experienced 33.3% perioperative morbidity in the surgery + HITHOC group compared with 23.1% in the surgery alone group (P = 0.71). The overall survival rate was comparable between the 2 groups (P = 0.139), whereas the local disease-free interval was 88.0 ± 15 months in the surgery + HITHOC group and 57 ± 19.5 months in the surgery alone group (P = 0.046). The analysis of factors affecting the outcomes revealed that radical surgery is related with a better survival rate whereas the local disease-free interval was significantly influenced by HITHOC. CONCLUSIONS: The safety and feasibility of HITHOC in the treatment of TPR are already known, even if it should be reserved for selected patients. Surgery + HITHOC seems to be associated with a longer local disease-free time compared to surgery alone.

Chest wall reconstruction with a novel titanium mesh after partial sternectomy for chondrosarcoma.

Primitive malignant sternal tumours are extremely rare and represent less than 1% of all chest wall tumours. A combination of radical surgery and accurate reconstruction is mandatory to ensure adequate stability and to reduce paradoxical movement. To date, this is one of the few reports on a successful sternal reconstruction using a rigid titanium mesh to restore the skeletal integrity, which was then covered by bilateral muscular flaps.

Nerve-Sparing Surgery in Advanced Stage Thymomas.

BACKGROUND: Phrenic nerve infiltration has been described in as many as 33% of advanced thymomas; en bloc resection causes diaphragmatic loss of function, with detrimental effects on pulmonary function. We report the outcomes of selected patients operated on for invasive thymoma with a nerve-sparing technique. METHODS: From 1990 to 2015 we used nerve-sparing surgery with the intention to treat all patients with advanced stage thymomas without preoperative evidence of hemidiaphragmatic palsy, but with macroscopic evidence of phrenic nerve involvement. All patients underwent adjuvant radiotherapy (45 to 60 Gy) with or without chemotherapy. Long-term outcomes and the pattern of recurrence were retrospectively analyzed. RESULTS: Among 140 patients with stage III and IVa operated on during the study period, 19 women and 18 men with a median age of 52 years received a nerve-sparing resection. Myasthenia gravis was associated in 25 cases. In 12 patients, phrenic palsy was observed postoperatively, and eventually 4 of them recovered. Recurrence was found in 10 patients (7 stage IVa, 3 stage III) requiring additional therapies. Three patients died of cancer-related causes, with an overall survival of 265.4 months and a disease-free survival of 233.2 months. CONCLUSIONS: Phrenic nerve preservation in cases of invasive thymomas is feasible and may warrant an acceptable local control of disease, if associated with radiotherapy. According to these results, this technique could be proposed to all patients with invasive thymoma, especially in those affected by severe comorbidities or with a poor performance status.

N2 lung cancer is not all the same: an analysis of different prognostic groups.

OBJECTIVES: The International Association for the Study of Lung Cancer (IASLC) recently proposed a change in the staging system for N2, based on the metastatic station number: N2a1 (a single metastatic station with no hilar involvement), N2a2 (a single metastatic station with hilar involvement) and N2b (multiple metastatic stations). The aim of our study was to validate the IASLC proposal in a cohort of patients with pathological N2 disease. METHODS: All patients with pathological T1-T2 N2 non-small-cell lung cancer who were operated on between 2006 and 2010 in our department were enrolled. The patients had lobectomy, bilobectomy or pneumonectomy without induction therapy; patients with any type of extended resection were excluded. All patients had adjuvant treatment. The impact of the new IASLC proposal on the overall and disease-free survival rates was then analysed. RESULTS: Ninety-three patients were selected. The median follow-up period and overall survival time were 92 and 28.8 months, respectively. According to the new IASLC proposal, we observed 22 cases of N2a1, 54 N2a2 and 17 N2b. Patients with N2a1 had a significantly better overall survival than those with N2a2 and N2b (P = 0.041); the difference between N2a2 and N2b was not significant (P = 0.19). Patients with N2a1 squamous cell carcinoma had a significantly better overall survival than those with other histological diagnoses (P = 0.046). The disease-free interval was longer in patients with N2a1 than those in other groups (P = 0.021). CONCLUSIONS: Our experience partially validates the IASLC proposal; the introduction of quantitative criteria for N staging might improve stratification of patients and the assignment to the correct therapeutic path.