Colorectal Cancer Pulmonary Metastasectomy: When, Why and How.

Colorectal cancer is the third-most-diagnosed cancer in males and in females, representing 8% of estimated new cases, and the third cause of cancer-related death in both sexes, accounting for 9% of cancer deaths in men and 8% in women. About 20% of patients diagnosed with CRC present metastatic disease. Although lung metachronous or synchronous metastatic spread without other involved sites has been reported in only a small proportion of patients, considering that this tumor is frequently diagnosed, the clinical approach to CRC pulmonary metastases represents a major issue for thoracic surgeons and CRC oncologists. Among patients diagnosed with pulmonary metastases from CRC, about 9-12% are eligible for local treatments with radical intent, including surgical resection, SBRT (stereotactic body radiation therapy) and ablation therapy. Due to the lack of randomized controlled trials among different local strategies, there is no definitive evidence about the optimal approach, although surgical resection is considered the most effective therapeutic option in this clinical scenario. Oncological achievement of primary radical resection, the biology of primary tumor and metastatic sites, disease free interval and or progression free survival are independent prognostic factors which make it possible to define a cohort of patients which might significantly benefit from pulmonary metastasectomy.

Pleural mesothelioma in situ: a comprehensive review.

Pleural mesothelioma is a rare and aggressive cancer that affects the pleura. In recent years, there has been increasing interest and attention in detecting and diagnosing early-stage or precancerous forms of mesothelioma because of its severe prognosis and short life expectancy at the time of diagnosis. Mesothelioma in situ represents a clear opportunity to improve and innovate the diagnostic approach and the multimodality treatment of mesothelioma: the diagnosis of pleural mesothelioma at the 'in-situ phase' means early disease detection and thus paves the way to new possible curable strategies. Since 2021, when mesothelioma in situ was finally identified and described as a new histological entity, its diagnosis and management became a challenge and the subject of ongoing research; several aspects remain open and still outstanding as regards diagnostic techniques, time and probability of progression, need for and methods of follow up, aggressive and early surgery. This narrative review aims to provide a comprehensive overview of mesothelioma in situ covering its definition, risk factors, diagnostic criteria, and tricky aspects of early detection. It also highlights its clinical significance, new perspectives, and potential future indications in the context of pleural mesothelioma multidisciplinary management.

Stem cell technology for antitumor drug loading and delivery in oncology.

The main aim of antineoplastic treatment is to maximize patient benefit by augmenting the drug accumulation within affected organs and tissues, thus incrementing drug effects and, at the same time, reducing the damage of non-involved tissues to cytotoxic agents. Mesenchymal stromal cells (MSC) represent a group of undifferentiated multipotent cells presenting wide self-renewal features and the capacity to differentiate into an assortment of mesenchymal family cells. During the last year, they have been proposed as natural carriers for the selective release of antitumor drugs to malignant cells, thus optimizing cytotoxic action on cancer cells, while significantly reducing adverse side effects on healthy cells. MSC chemotherapeutic drug loading and delivery is an encouraging new area of cell therapy for several tumors, especially for those with unsatisfactory prognosis and limited treatment options available. Although some experimental models have been successfully developed, phase I clinical studies are needed to confirm this potential application of cell therapy, in particular in the case of primary and secondary lung cancers.

Mesenchymal Stromal Cell Therapy for Thoracic Surgeons: An Update.

Stem cells are undifferentiated cells presenting extensive self-renewal features and the ability to differentiate "in vitro" and "in vivo" into a range of lineage cells, like chondrogenic, osteogenic and adipogenic lineages when cultured in specific inducing media. Two major domains of clinical applications of stem cells in thoracic surgery have been investigated: regenerative medicine, which is a section of translational research in tissue engineering focusing on the replacement, renewal or regeneration of cells, tissues and organs to re-establish damaged physiologic functions; drug loading and delivery, representing a new branch proposing stem cells as carriers to provide selected districts with anti-cancer agents for targeted treatments.

Management of COVID-19 related tracheal stenosis: The state of art.

Tracheal stenosis (TS) is a debilitating disease promoted by pathologic narrowing of the trachea. The acute respiratory distress syndrome caused by COVID-19 has been demonstrated to trigger enhanced inflammatory response and to require prolonged invasive mechanical ventilation as well as high frequency of re-intubation or emergency intubation, thus increasing the rate and complexity of TS. The standard-of-care of COVID-19-related tracheal complications has yet to be established and this is a matter of concern. This review aims at collecting latest evidence on this disease, providing an exhaustive overview on its distinctive features and open issues, and investigating different diagnostic and therapeutic strategies to handle COVID-19-induced TS, focusing on endoscopic versus open surgical approach. The former encompasses bronchoscopic procedures: electrocautery or laser-assisted incisions, ballooning dilation, submucosal steroid injection, endoluminal stenting. The latter consists of tracheal resection with end-to-end anastomosis. As a rule, traditionally, the endoscopic management is restricted to short, low-grade, and simple TS, whereas the open techniques are employed in long, high-grade, and complex TS. However, the critical conditions or extreme comorbidities of several COVID-19 patients, as well as the marked inflammation in tracheal mucosa, have led some authors to apply endoscopic management also in complex TS, recording acceptable results. Although severe COVID-19 seems to be an issue of the past, its long-term complications are still unknown and considering the increased rate and complexity of TS in these patients, we strongly believe that it is worth to focus on it, attempting to find the best management strategy for COVID-19-related TS.

Post-intubation iatrogenic tracheobronchial injuries: The state of art.

Iatrogenic tracheobronchial injury (ITI) is an infrequent but potentially life-threatening disease, with significant morbidity and mortality rates. Its incidence is presumably underestimated since several cases are underrecognized and underreported. Causes of ITI include endotracheal intubation (EI) or percutaneous tracheostomy (PT). Most frequent clinical manifestations are subcutaneous emphysema, pneumomediastinum and unilateral or bilateral pneumothorax, even if occasionally ITI can occur without significant symptoms. Diagnosis mainly relies on clinical suspicion and CT scan, although flexible bronchoscopy remains the gold standard, allowing to identify location and size of the injury. EI and PT related ITIs more commonly consist of longitudinal tear involving the pars membranacea. Based on the depth of tracheal wall injury, Cardillo and colleagues proposed a morphologic classification of ITIs, attempting to standardize their management. Nevertheless, in literature there are no unambiguous guidelines on the best therapeutic modality: management and its timing remain controversial. Historically, surgical repair was considered the gold standard, mainly in high-grade lesions (IIIa-IIIb), carrying high morbi-mortality rates, but currently the development of promising endoscopic techniques through rigid bronchoscopy and stenting could allow for bridge treatment, delaying surgical approach after improving general conditions of the patient, or even for definitive repair, ensuring lower morbi-mortality rates especially in high-risk surgical candidates. Our perspective review will cover all the above issues, aiming at providing an updated and clear diagnostic-therapeutic pathway protocol, which could be applied in case of unexpected ITI.

European Society of Thoracic Surgeons electronic quality of life application after lung resection: field testing in a clinical setting.

OBJECTIVES: Technology has the potential to assist healthcare professionals in improving patient-doctor communication during the surgical journey. Our aims were to assess the acceptability of a quality of life (QoL) application (App) in a cohort of cancer patients undergoing lung resections and to depict the early perioperative trajectory of QoL. METHODS: This multicentre (Italy, UK, Spain, Canada and Switzerland) prospective longitudinal study with repeated measures used 12 lung surgery-related validated questions from the European Organisation for Research and Treatment of Cancer Item Bank. Patients filled out the questionnaire preoperatively and 1, 7, 14, 21 and 28 days after surgery using an App preinstalled in a tablet. A one-way repeated measures analysis of variance was run to determine if there were differences in QoL over time. RESULTS: A total of 103 patients consented to participate in the study (83 who had lobectomies, 17 who had segmentectomies and 3 who had pneumonectomies). Eighty-three operations were performed by video-assisted thoracoscopic surgery (VATS). Compliance rates were 88%, 90%, 88%, 82%, 71% and 56% at each time point, respectively. The results showed that the operation elicited statistically significant worsening in the following symptoms: shortness of breath (SOB) rest (P = 0.018), SOB walk (P < 0.001), SOB stairs (P = 0.015), worry (P = 0.003), wound sensitivity (P < 0.001), use of arm and shoulder (P < 0.001), pain in the chest (P < 0.001), decrease in physical capability (P < 0.001) and scar interference on daily activity (P < 0.001) during the first postoperative month. SOB worsened immediately after the operation and remained low at the different time points. Worry improved following surgery. Surgical access and forced expiratory volume in 1 s (FEV1) are the factors that most strongly affected the evolution of the symptoms in the perioperative period. CONCLUSIONS: We observed good early compliance of patients operated on for lung cancer with the European Society of Thoracic Surgeons QoL App. We determined the evolution of surgery-related QoL in the immediate postoperative period. Monitoring these symptoms remotely may reduce hospital appointments and help to establish early patient-support programmes.

Uniportal video-assisted thoracic surgery lobectomy: a consensus report from the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS).

OBJECTIVES: Our goal was to report the results of the first consensus paper among international experts in uniportal video-assisted thoracoscopic surgery (UniVATS) lobectomy obtained through a Delphi process, the objective of which was to define and standardize the main procedural steps, optimize its indications and perioperative management and identify elements to assist in future training. METHODS: The 40 members of the working group were convened and organized on a voluntary basis by the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS). An e-consensus finding exercise using the Delphi method was applied to require 75% agreement for reaching consensus on each question. Repeated iterations of anonymous voting continued for 3 rounds. RESULTS: Overall, 31 international experts from 18 countries completed all 3 rounds of questionnaires. Although a technical quorum was not achieved, most of the responders agreed that the maximum size of a UniVATS incision should be ≤4 cm. Agreement was reached on many points outlining the currently accepted definition of a UniVATS lobectomy, its indications and contraindications, perioperative clinical management and recommendations for training and future research directions. CONCLUSIONS: The UVIG Consensus Report stated that UniVATS offers a valid alternative to standard VATS techniques. Only longer follow-up and randomized controlled studies will predict whether UniVATS represents a valid alternative approach to multiport VATS for major lung resections or whether it should be performed only in selected cases and by selected centres. The next step for the ESTS UVIG is the establishment of a UniVATS section inside the ESTS databases.

Surgical and endoscopic treatment for COPD: patients selection, techniques and results.

Chronic obstructive pulmonary disease (COPD) is a very heterogeneous disease characterised by an obstructive lung pattern that constitutes worldwide a major cause of high morbidity and mortality. In the last decades, lung volume reduction surgery (LVRS) has demonstrated to be a potential good alternative to transplantation in patients affected by COPD. The trend toward minimally invasive techniques resulted not only in surgical procedures better tolerated by the patients but also in several endoscopic treatments modality that are rapidly gaining ground.

Transsternal surgical biopsy of a mediastinal mass under local anesthesia.

We describe a minimally invasive transsternal surgical approach to obtain biopsies from retrosternal masses under local anesthesia. This original procedure was carried out in a patient with superior vena cava syndrome because she was unfit to undergo a CT-guided biopsy and at high risk for narcosis. In patients with such features this procedure could be preferable to conventional techniques. The transsternal approach is reliable, produces minimal trauma and no risk of pleural or vessel injury, and is very fast.

Transbronchial needle aspiration in lung cancer patients suitable for operation with positive mediastinal positron emission tomography.

BACKGROUND: The objectives of this study were to analyze our experience with transbronchial needle aspiration as a minimally invasive procedure alternative to mediastinoscopy in the preoperative staging of non-small cell lung cancer patients with positive mediastinal positron emission tomography and to propose a staging algorithm that combines performance characteristics of these three methods. METHODS: Fifty-one patients staged N2 or N3 after positron emission tomography imaging underwent transbronchial needle aspiration. RESULTS: A malignant adenopathy was identified in 26 patients (51%) that were excluded from operation and referred for neoadjuvant chemotherapy or chemoradiotherapy according to the mediastinal status (N2 or N3), as determined on the positron emission tomography image. In the remaining 25 patients (49%), samples were considered adequate negative in 12 patients, inadequate in 11, or inconclusive in 2. These patients underwent mediastinoscopy. Mediastinoscopy showed N2 disease in 19 cases, and the patients received neoadjuvant chemotherapy. In the remaining 6 cases no mediastinal involvement was identified and patients underwent operation. Postoperatively, 5 patients were staged N0 and 1 was staged N2. For transbronchial needle aspiration, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 76%, 100%, 100%, 33%, and 79%, respectively. CONCLUSIONS: Transbronchial needle aspiration avoided a mediastinoscopy in approximately half of lung cancer patients referred for operation with positive mediastinal positron emission tomography, sparing the associated costs and risks of more invasive surgical procedures. The minimally invasive mediastinal staging algorithm that we proposed seems to be efficacious and easily applicable in clinical practice.

Surgical treatment of catamenial pneumothorax: a single centre experience.

We retrospectively reviewed our experience with catamenial pneumothorax (CP) in terms of treatment and follow-up. From 1993 to 2008, ten women presented at our department with CP. CP was right-sided in all patients: seven presented diaphragmatic defects including one endometriosis, five had apical bulla or blebs that in three patients were the only pathological findings. Surgical approach was thoracoscopic with a muscle-sparing thoracotomy when diaphragmatic defects where present. All patients underwent apical resection and apical pleurectomy associated in seven cases with diaphragmatic plication and chemical pleurodesis. After surgery nine patients underwent hormonal treatment: three were put on estrogen-progesterone complex treatment and six received gonadotropin-releasing hormone agonist (GnRH agonist). Recurrence rate was 40% and it was significantly correlated with estrogen-progesterone treatment (P<0.005). The mean follow-up was 52+/-32 months (range 14-168). At the present time, no recurrence has occurred in all women. Occurrence of CP is often underestimated. At the time of surgery the diaphragm should be carefully inspected for defects and/or endometriosis. Standard pleurodesis may not suffice and we suggest apical resection and apical pleurectomy associated with a diaphragmatic procedure when indicated. Hormonal treatment with GnRH agonist seems to improve the outcome.

Pleuropulmonary blastoma in the area of a diagnosed congenital lung cyst.

Pleuropulmonary blastoma is a rare and aggressive neoplasm typically occurring in young children, even in newborns. Onset of the disease can be identified in the area of a previously diagnosed lung cyst. We report a case of a child previously diagnosed as having a right congenital lung cyst who had a pleuropulmonary blastoma developing in the same area. He underwent surgical resection of the neoplasm followed by chemotherapy. After 20 months he is alive and well.

Endobronchial migration of prosthetic patch after congenital diaphragmatic hernia repair.

Surgical repair of congenital diaphragmatic hernia (CDH) can be performed by means of either direct suturing of the diaphragm or positioning of a prosthetic patch. However, half of all prosthetic patches show evidence of reherniation. We describe the case of an 8-year-old girl who presented with prosthesis dislocation and fistulization in the right lower bronchus as a complication of a CDH repair that she underwent when she was 1 year old. Abdominal ultrasound and magnetic resonance imaging suggested a hernia relapse, whereas chest computed tomographic scan failed to identify the diaphragmatic defect. Only fibrobronchoscopy allowed fistulization of the prosthesis into the bronchi to be correctly diagnosed.

Pulmonary resection for non-small-cell lung cancer in patients on hemodialysis: clinical outcome and long-term results.

Patients on hemodialysis (HD) who undergo surgery represent a high risk group requiring careful perioperative management to avoid electrolyte imbalance and hemodynamic instability. The aim of the study was to analyze the postoperative outcome in terms of complications and survival of a group of patients on HD who had undergone pulmonary resection for non-small cell lung cancer (NSCLC). Six patients on HD underwent seven pulmonary resections at our institution from 1998 to 2003. The underlying kidney disease was nephrosclerosis in two patients and glomerulonephritis in four. The mean levels of blood urea nitrogen and serum creatinine were 107 +/- 11.5 mg/dl and 7.9 +/- 0.64 mg/dl, respectively. The mean preoperative PO2 and FEV1 were 77.6 +/- 2.4 mmHg and 2.4 +/- 0.16 liters, respectively. The histologic diagnosis was squamous cell carcinoma in four cases and adenocarcinoma in three. One patient underwent two lung resections in 4 years for two primary lung cancers. Five patients underwent lobectomy, one underwent a wedge resection, and in one case pneumonectomy was performed after neoadjuvant chemotherapy. There was no operative mortality. Postoperatively, atrial fibrillation occurred in two patients associated with sputum retention in both, and two other patients had hyperkalemia (complication rate 57%). One patient died of cardiac complications 27 months after surgery. The remaining five patients are currently alive with no evidence of disease. Patients on HD who undergo lung resection have a high rate of postoperative complications. Although the underlying disease influences long-term survival, radical lung resection in NSCLC patients is recommended in selected cases. Careful metabolic, hematologic, and pharmaceutical management is mandatory during the perioperative period.

Salivary gland-type mixed tumor (pleomorphic adenoma) of the lung.

Primary pleomorphic adenomas of the respiratory tract are rare tumors. They usually originate from the bronchial glands, but may also be unrelated to the bronchial tract and be localized in the pulmonary parenchyma. These salivary-gland type neoplasms have peculiar histological and clinical features: they usually behave as low-grade malignant neoplasms, but may also have more aggressive features. The diagnostic and therapeutic approach in a patient with a pulmonary pleomorphic adenoma is described.