The Prognostic Role of the Number of Involved Structures in Thymic Epithelial Tumors: Results from the ESTS Database.

BACKGROUND: The role of the number of involved structures (NIS) in thymic epithelial tumors (TETs) has been investigated for inclusion in future staging systems, but large cohort results still are missing. This study aimed to analyze the prognostic role of NIS for patients included in the European Society of Thoracic Surgeons (ESTS) thymic database who underwent surgical resection. METHODS: Clinical and pathologic data of patients from the ESTS thymic database who underwent surgery for TET from January 2000 to July 2019 with infiltration of surrounding structures were reviewed and analyzed. Patients' clinical data, tumor characteristics, and NIS were collected and correlated with CSS using Kaplan-Meier curves. The log-rank test was used to assess differences between subgroups. A multivariable model was built using logistic regression analysis. RESULTS: The final analysis was performed on 303 patients. Histology showed thymoma for 216 patients (71.3%) and NET/thymic carcinoma [TC]) for 87 patients (28.7%). The most frequently infiltrated structures were the pleura (198 cases, 65.3%) and the pericardium in (185 cases, 61.1%), whereas lung was involved in 96 cases (31.7%), great vessels in 74 cases (24.4%), and the phrenic nerve in 31 cases (10.2%). Multiple structures (range, 2-7) were involved in 183 cases (60.4%). Recurrence resulted in the death of 46 patients. The CSS mortality rate was 89% at 5 years and 82% at 10 years. In the univariable analysis, the favorable prognostic factors were neoadjuvant therapy, Masaoka stage 3, absence of metastases, absence of myasthenia gravis, complete resection, thymoma histology, and no more than two NIS. Patients with more than two NIS presented with a significantly worse CSS than patients with no more than two NIS (CSS 5- and 10-year rates: 9.5% and 83.5% vs 93.2% and 91.2%, respectively; p = 0.04). The negative independent prognostic factors confirmed by the multivariable analysis were incomplete resection (hazard ratio [HR] 2.543; 95% confidence interval [CI] 1.010-6.407; p = 0.048) and more than two NIS (HR 1.395; 95% CI 1.021-1.905; p = 0.036). CONCLUSIONS: The study showed that more than two involved structures are a negative independent prognostic factor in infiltrative thymic epithelial tumors that could be used for prognostic stratification.

Thymomectomy plus total thymectomy versus simple thymomectomy for early-stage thymoma without myasthenia gravis: a European Society of Thoracic Surgeons Thymic Working Group Study.

OBJECTIVES: Resection of thymic tumours including the removal of both the tumour and the thymus gland (thymothymectomy; TT) is the procedure of choice and is recommended in most relevant articles in the literature. Nevertheless, in recent years, some authors have suggested that resection of the tumour (simple thymomectomy; ST) may suffice from an oncological standpoint in patients with early-stage thymoma who do not have myasthenia gravis (MG) (non-MG). The goal of our study was to compare the short- and long-term outcomes of ST versus TT in non-MG early-stage thymomas using the European Society of Thoracic Surgeons thymic database. METHODS: A total of 498 non-MG patients with pathological stage I thymoma were included in the study. TT was performed in 466 (93.6%) of 498 patients who had surgery with curative intent; ST was done in 32 (6.4%). The completeness of resection, the rate of complications, the 30-day mortality, the overall recurrence and the freedom from recurrence were compared. We performed crude and propensity score-adjusted comparisons by surgical approach (ST vs TT). RESULTS: TT showed the same rate of postoperative complications, 30-day mortality and postoperative length of stay as ST. The 5-year overall survival rate was 89% in the TT group and 55% in the ST group. The 5-year freedom from recurrence was 96% in the TT group and 79% in the ST group. CONCLUSION: Patients with early-stage thymoma without MG who have a TT show significantly better freedom from recurrence than those who have an ST, without an increase in postoperative morbidity rate.

Left systematic mediastinal lymph node dissection.

Sampling, or systematic mediastinal lymph node dissection, is the standard-of-care surgical treatment for early stage non-small cell lung cancer, according to guidelines from the European Society of Thoracic Surgeons. Lymph node status defines disease status and patients' prognosis. In this  video tutorial, a radical ipsilateral mediastinal lymph node dissection in a man suffering from a left, centrally located lung adenocarcinoma is presented. Systematic mediastinal lymph node dissection constitutes a high-quality metric for the efficacy of the surgical procedure and is essential to achieving adequate staging and treatment.

Lobectomy due to Pulmonary Vein Occlusion after Radiofrequency Ablation for Atrial Fibrillation.

Radiofrequency ablation is an effective treatment for atrial fibrillation. Pulmonary vein stenosis/occlusion is one of its rare complications. Herein, the case of a 50-year-old man with hemoptysis and migratory pulmonary infiltrations after transcatheter radiofrequency ablation for atrial fibrillation is presented. Initially, pneumonia, interstitial pulmonary disease, or lung cancer was suspected, but wedge resection revealed hemorrhagic infiltrations. Chest computed tomography pulmonary angiography detected no left superior pulmonary vein due to its total occlusion, and left upper lobectomy was performed. Post-ablation pulmonary vein occlusion must be strongly suspected in cases of migratory pulmonary infiltrations and/or hemoptysis.

Chest drainage systems in use.

A chest tube is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air in the case of pneumothorax or fluid such as in the case of pleural effusion, blood, chyle, or pus when empyema occurs from the intrathoracic space. It is also known as a Bülau drain or an intercostal catheter. Insertion of chest tubes is widely performed by radiologists, pulmonary physicians and thoracic surgeons. Large catheters or small catheters are used based on each situation that the medical doctor encounters. In the current review we will focus on the chest drain systems that are in use.

Effectiveness of brain natriuretic peptide in predicting postoperative atrial fibrillation in patients undergoing non-cardiac thoracic surgery.

A best evidence topic was written according to a structured protocol. The question addressed was whether plasma brain natriuretic peptide (BNP) levels could effectively predict the occurrence of postoperative atrial fibrillation (AF) in patients undergoing non-cardiac thoracic surgery. A total of 14 papers were identified using the reported search, of which 5 represented the best evidence to answer the clinical question. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. All studies were prospective observational, and all reported a significant association between BNP and N-terminal (NT)-proBNP plasma levels measured in the immediate preoperative period and the incidence of postoperative AF in patients undergoing either anatomical lung resections or oesophagectomy. One study reported a cut-off value of 30 pg/ml above which significantly more patients suffered from postoperative AF (P < 0.0001), while another one reported that this value could predict postoperative AF with a sensitivity of 77% and a specificity of 93%. Another study reported that patients with NT-proBNP levels of 113 pg/ml or above had an 8-fold increased risk of developing postoperative AF. These findings support that BNP or NT-proBNP levels, especially when determined during the preoperative period, if increased, are able to identify patients at risk for the development of postoperative AF after anatomical major lung resection or oesophagectomy. The same does not seem to be true for lesser lung resections. These high-risk patients might have a particular benefit from the administration of prophylactic antiarrhythmic therapy.

Paracetamol and ibuprofen block hydrothorax absorption in mice.

OBJECTIVES: Non-steroidal anti-inflammatory agents (NSAIDs) and paracetamol alter pleural permeability, hindering pleural fluid recycling. The aim of this study was to investigate the effect of different analgesic and anti-inflammatory agents on fluid recycling in an induced hydrothorax model in mice. METHODS: Hydrothorax was induced in C57BL/6 mice by injecting 500 µl phosphate-buffered saline-bovine serum albumin 1% isosmotic in the right hemithorax. Paracetamol (1 g/kg), ibuprofen (250 mg/kg) and parecoxib (2 mg/kg) were administered systematically by intraperitoneal injections. Each drug group included eight mice, which were sacrificed at 2 h and 4 h, respectively, after injections. The remaining hydrothorax volume and total cells contained were determined. RESULTS: Regarding the paracetamol and ibuprofen groups, the remaining hydrothorax volume was greater than in the control group (350 ± 61, 348 ± 62 and 270 ± 51 µl, respectively, P = 0.042) when mice were sacrificed within 2 h. Similar observations were made in groups sacrificed after 4 h (202 ± 45 and 198 ± 44 vs 107 ± 56 µl, respectively, P = 0.002). In the parecoxib group, the remaining hydrothorax volume was 122 ± 53 µl (P = 0.038 versus paracetamol and ibuprofen, P > 0.05 versus control group). At the same time, the absorption rate in the paracetamol and ibuprofen groups was lower than in the parecoxib and control groups (P = 0.033). In the parecoxib group, the absorption rate was lower than that in the control group after 2 h (P = 0.042). In the paracetamol and ibuprofen groups, the total cell count and the macrophage and the neutrophils counts were increased, compared with the control and parecoxib groups (P = 0.025, 0.028 and 0.032, respectively). CONCLUSIONS: Paracetamol and ibuprofen acutely hinder pleural fluid recycling by lowering the fluid absorption rate (higher remaining hydrothorax volume), while they increased total white cell counts. COX-2s presented lower remaining hydrothorax volume without acutely increasing the absorption rate. These findings could present some relevance to the administration of painkillers in patients with pleural effusion after thoracotomy.

The management of the advanced colorectal cancer: management of the pulmonary metastases.

Pulmonary metastases from colorectal cancer present as systemic manifestation of the disease. As a general principle, the presence of metastases predispose to a poor prognosis. However, the application of some criteria of "operability" permitted the surgical resection resulting in prolonged survival (reported 5-year survival up to 50%), in better quality of life and in the cure of some patients. When the primary tumor site is controlled, and the metastatic disease is limited in lungs without extrapulmonary location (except for resectable or resected hepatic lesion) surgical removal is indicated. As significant prognostic factors in metastasectomies have been reported the synchronous or metachronous caracter of the metastases, the disease free survival, the complete removal of the metastases, the thoracic lymph node invasion, the CEA level before metastasectomy and 1 month after, the solitary vs. multiple pulmonary metastatic locations, the induction chemotherapy, the histological type and differentiation grade, as well as the vascular emboli in histopathological examination. Thorough preoperative evaluation of the patient includes oncological assessment and respiratory functional tests. Alternatively, when the patient is not a good surgical candidate, radiofrequency ablation is an option. Many surgical accesses have been validated, as posterolateral or lateral or even posterior thoracotomy, sternotomy, clamshell incision, and thoracoscopic techniques that offer the advantages of less pain, fast recovery, and less morbidity. Though thoracoscopic metastasectomies have been questioned concerning to the completeness of metastatic removal, no statistical difference in survival has been revealed in many series comparing thoracotomy to thoracoscopic techniques. As a conclusion, there are many advances in the management of pulmonary metastases from colorectal cancer during last decade, the results have been essentially optimized, the role of surgery has been established, and the multimodality approach has been recognized as the cornerstone of a successful outcome.

Isolated sternal fractures treated on an outpatient basis.

AIM: The aim of this study is to investigate the need for admission of patients with isolated sternal fracture (ISF) by prospectively and randomly discharging or admitting them. METHODS: Patients with ISF after the completion of investigations were randomly discharged or admitted. Investigations performed included lateral chest x-ray; chest computed tomography; electrocardiogram; cardiac ultrasound; definition of C-reactive protein; and cardiac enzymes, such as creatine phosphokinase, myocardial branch of creatine phosphokinase, and troponin I (cardiac specific). These investigations were repeated after 6 hours in the admission and the next day in both groups. RESULTS: Forty-two patients were included in the study. Twenty-one were admitted, whereas 21 were discharged. Electrocardiogram and ultrasound were normal in both groups upon presentation and the next day. Creatine phosphokinase and myocardial branch of creatine phosphokinase, although elevated at presentation, were normal the next day and similar in both groups. There was no morbidity, need for surgery, or mortality in both groups during a 6-month follow-up. CONCLUSIONS: Patients with ISF can be discharged safely as soon as investigations are completed. Extensive myocardial assessment is not needed on the posttraumatic period. Myocardial involvement seems unlikely in patients with ISF, who can be treated with oral analgesics.

Nonsteroidal anti-inflammatory drugs alter the human mesothelial pleural permeability via ion cellular transportation by inhibiting prostaglandin synthesis.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are used in clinical practice as analgesics or anti-inflammatory drugs. Studies have implicated them in participating in permeability throughout various tissues such as the kidneys and lungs. OBJECTIVE: The effect of NSAIDs on the pleural permeability and the underlying mechanisms whereby this effect is mediated were investigated. METHODS: Parietal pleural specimens were obtained from patients subjected to thoracic surgery and were mounted in Ussing chambers. Solutions containing paracetamol, acetylsalicylic acid, diclofenac, lornoxicam, parecoxib and ibuprofen were added in the chambers facing the pleural and the outer-pleural surface. Prostaglandin E(2) was similarly used to investigate prostaglandin synthesis involvement at low and high doses. Amiloride- and ouabain-pretreated specimens were used in order to investigate ion transportation involvement. Transmesothelial resistance (R(TM)) was determined as a permeability indicator. RESULTS: Paracetamol, acetylsalicylic acid, diclofenac, lornoxicam and ibuprofen increased R(TM) on the pleural and outer-pleural surface, inhibited by amiloride and ouabain. Parecoxib had no effect on the R(TM). Prostaglandin decreased R(TM) on the pleural and outer-pleural surface inhibited by amiloride, ouabain and ibuprofen. CONCLUSION: NSAIDs, except parecoxib, induce a rapid decrease of the pleural permeability by inhibiting cellular transportation, an effect that is mediated by prostaglandin synthesis inhibition.

Thymoma and myasthenia gravis: clinical aspects and prognosis.

Myasthenia gravis is present in a significant proportion of patients with thymoma. We investigated particular features of the clinical behavior of thymoma and its relationship to myasthenia in a retrospective study of 79 patients who underwent thymectomy for thymoma during the last 20 years. The presence of myasthenia gravis, Masaoka stage, World Health Organization histotype, myasthenia response, and survival were analyzed. The mean age of the patients was 56.1 ± 12.4 years, and 39 had myasthenia gravis. A significantly higher proportion of patients with myasthenia was found in B2 and B3 histotypes compared to A, AB, and B1. Among myasthenic patients, 33.3% had no response, 50% had a partial response, and 16.7% achieved complete remission. During the follow-up period, 16 (21.1%) patients died. Mean survival was 4.8 ± 1.4 years for patients with no myasthenia response, whereas those with a partial or complete myasthenia response had significantly better survival.

Ectopic hepatocellular carcinomas developed in the chest wall and skull.

A 68-year-old man presented with a suppurating mass on his skull and a palpable mass on his right upper thoracic wall. Computed tomography revealed a round mass, 70 mm in diameter, invading the right pleural cavity, and a second tumor infiltrating the skull through the left parietal bone. Both masses were resected simultaneously. Histopathology showed that both tumors were hepatocellular carcinomas.

Transternal repair of a giant Morgagni hernia causing cardiac tamponade in a patient with coexisting severe aortic valve stenosis.

BACKGROUND: Foramen of Morgagni hernias have traditionally been repaired by laparotomy, laparoscopy or even thoracoscopy. However, the trans-sternal approach should be used when these rare hernias coexist with other cardiac surgical diseases. CASE PRESENTATION: We present the case of a 74 year-old symptomatic male with severe aortic valve stenosis and global respiratory failure due to a giant Morgagni hernia causing additionally cardiac tamponade. The patient underwent simultaneous repair of the hernia defect and aortic valve replacement under cardiopulmonary bypass. The hernia was repaired through the sternotomy approach, without opening of its content and during cardiopulmonary reperfusion. CONCLUSIONS: Morgagni hernia can rarely accompany cardiac surgical pathologies. The trans-sternal approach for its management is as effective as other popular reconstructive procedures, unless viscera strangulation and necrosis are suspected. If severe compressive effects to the heart dominate the patient's clinical presentation correction during the cardiopulmonary reperfusion period is mandatory.