A multicentric evaluation of pediatric lung transplantation in Italy.

BACKGROUND: Pediatric lung transplantation is performed in highly experienced centers due to the peculiar population characteristics. The literature is limited and not representative of individual countries' differences. The purpose of this study was to analyze the Italian experience. METHODS: A multicentric retrospective analysis was performed on 110 pediatric patients (<18 years old) who underwent lung transplantation from 1992 to 2019 at 9 Italian centers. Heart-lung transplantations and lung retransplantations were excluded. RESULTS: The population was composed of 44 male and 66 female patients, with a median age of 15 years. The most frequent indication was cystic fibrosis (83%). One quarter of patients were transplanted in an emergency setting. Median donors' Oto score and age were 1 and 15 years, respectively, with 43% of adult donors. In 17% of patients a graft reduction was performed. Postoperatively, the median duration of mechanical ventilation, intensive care unit, and in-hospital stay were 48 hours, 11 and 35 days, respectively. Thirty-day mortality was 6%, and 1-, 5-, and 10-year survival was 72%, 52%, and 33%, respectively. Risk factors for mortality were Oto score and recipients' body mass index. CONCLUSIONS: The outcomes of pediatric lung transplantation in Italy are comparable with current literature. Particular attention should be paid to the Oto score and recipient body mass index. Conversely, adult donors and graft reductions can be safely used to expand the donor pool.

Is PET/CT Able to Predict Histology in Thymic Epithelial Tumours? A Narrative Review.

BACKGROUND: The usefulness of 18FDG PET/CT scan in the evaluation of thymic epithelial tumours (TETs) has been reported by several authors, but data are still limited and its application in clinical practice is far from being defined. METHODS: We performed a narrative review of pertinent literature in order to clarify the role of 18FDG PET/CT in the prediction of TET histology and to discuss clinical implications and future perspectives. RESULTS: There is only little evidence that 18FDG PET/CT scan may distinguish thymic hyperplasia from thymic epithelial tumours. On the other hand, it seems to discriminate well thymomas from carcinomas and, even more, to predict the grade of malignancy (WHO classes). To this end, SUVmax and other PET variables (i.e., the ratio between SUVmax and tumour dimensions) have been adopted, with good results. Finally, however promising, the future of PET/CT and theranostics in TETs is far from being defined; more robust analysis of imaging texture on thymic neoplasms, as well as new exploratory studies with "stromal PET tracers," are ongoing. CONCLUSIONS: PET may play a role in predicting histology in TETs and help physicians in the management of these insidious malignancies.

The role of sonographic patterns during endobronchial ultrasound-transbronchial needle aspiration for lung cancer staging: a narrative review.

In lung cancer accurate assessment of the mediastinal lymph node status is of paramount importance for the stage assignment as well as crucial for the therapeutic plan. TAC and positron emission tomography (PET) are valuable tools to achieve a preliminary picture of the mediastinal staging but Endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) is considered the first choice for investigating mediastinal lymph nodes as recommended by updated guide-lines. Despite the EBUS-TBNA sensitivity is satisfactory, it is not high enough to exclude mediastinal lymph node metastases; therefore devices and technologies were implemented to increase its sensitivity. The purpose of this narrative review is to describe the tools aimed at correctly interpreting sonographic patterns during EBUS and maximizing the diagnostic accuracy of TBNA. The bibliographic research identified 354 articles potentially related to the purpose of the current review and after accurate reading we selected 21 articles. Eight articles focused on the sonographic features of lymph nodes found during EBUS, 2 papers considered the Doppler patterns and, finally, 18 studies analyzed the advantages of ultrasound elastography. Sonographic features, vascular patterns and ultrasound elastography have proved to be helpful in directing the operator to biopsy the most suspect lymph node, especially in patients with CT-negative and/or PET-negative mediastinum.

Spontaneous diaphragmatic rupture following neoadjuvant chemotherapy and cytoreductive surgery in malignant pleural mesothelioma: A case report and review of the literature.

INTRODUCTION: Diaphragmatic rupture (DR) is an acquired diaphragmatic defect that can cause herniation of abdominal organs into the chest. It is usually a trauma-related lesion, but rarely it can occur spontaneously. Every DR with abdominal herniation should be considered a surgical emergency. PRESENTATION OF CASE: A 61-year-old male patient, with previous exposure to asbestos, was diagnosed of Stage Ib malignant pleural mesothelioma (MPM). He underwent neo-adjuvant chemotherapy (three cycle of cisplatin-pemetrexed combination) and a cytoreductive surgery with pleurectomy/decortication. Post-operative course was characterized by prolonged air-leakage (PAL). After three months, during a follow-up CT-scan, a spontaneous diaphragmatic rupture (SDR) with gastric herniation was detected and treated by a laparascopic diaphragmatic repair and suture. DISCUSSION: Spontaneous diaphragmatic rupture (SDR) is an extremely rare injury of the diaphragm (less than 1% of all DR). In this case, potential predisposing factors for SDR could be: presence of diaphragmatic "locus minoris resistentiae" due to thinning of the diaphragm and increase tissue fragility after neo-adjuvant chemotherapy and diaphragmatic pleural stripping; increased thoraco-abdominal pressure gradient due to PAL and residual pleural space. Thus, we confirmed the feasibility and safety of the laparoscopic approach. CONCLUSION: We highlight the multifactor etiopathology, the challenging diagnosis and the importance of a prompt treatment of SDR.

The European experience.

Traditionally, pulmonary lobectomy has always been considered as the gold standard for the treatment of early stage non-small cell lung cancer (NSCLC); limited resections have been proposed in case of "compromised" patients, with relevant comorbidities. In the last years, the interest in anatomical segmentectomies among surgeons has been progressively growing, even for patients fit for lobectomy, in selected cases. In this article we debate the current trends in the treatment of early stage NSCLC around Europe.

Characterization of the immune microenvironment in malignant pleural mesothelioma reveals prognostic subgroups of patients.

Malignant pleural mesothelioma (MPM) is a rare tumor with an extremely poor prognosis. Its pathogenesis is related to an immune response against asbestos fibers. The T-lymphocytes, including CD8POS and CD4POS cells, are an important part of the MPM immune microenvironment, and likely contribute to the therapy resistance observed in these tumors. Here, we sought to characterize the MPM-specific lymphocytes subpopulations within the tumor immune microenvironment to identify novel clinically relevant immunologic subtypes of tumors. Representative formalin-fixed, paraffin-embedded (FFPE) tissue blocks of 88 MPMs were included in tissue microarrays and subjected to tumor-infiltrating lymphocytes (TILs) quantification and subtyping by immunohistochemistry (IHC) with antibodies specific for CD4, CD8, and CD19. Further, PD-L1 (clone 22C3) expression was assessed by IHC as a combined positive score (CPS). Our data show that PD-L1 expression by tumor cells or the presence of a sarcomatoid component is related to increased stromal TILs presence in MPM. Survival analyses showed that low CD4POS and high CD8POS stromal TILs are associated with poor patients' survival. In MPMs with PD-L1 CPS > 1, stromal CD8HIGH was a poor prognostic factor, akin stromal CD4POS peritumoral TILs correlated with a worse prognosis. Furthermore, we demonstrated that a high CD4POS/CD8POS ratio in the tumor immune microenvironment is an independent prognostic factor for survival. Finally, we provided evidence that the characterization of the stromal immune landscape of MPM predicts responses to chemotherapy in subgroups of MPM. The results of this study provide novel insights into the clinical scenario of immune-related biomarkers in MPM.

VATS segmentectomy: an underused option?

It is well known that the "gold standard" procedure for surgically resectable early-stage non-small cell lung cancer (NSCLC), is pulmonary lobectomy. Even though sublobar resections (SLR), particularly segmentectomy, seem attractive as an alternative to lobectomy in early stage lung cancers, they are still debated procedures. The aim of this study is to answer to the question: "Is VATS lung segmentectomy an underused option?" To obtain an answer to this query, the authors carried out a review of the "state of the art" as follows: (I) performing a non-systematic review of the literature; (II) analyzing the review articles published; (III) looking at the ongoing studies, the results of which have not yet published; (IV) scanning the technical aspect of lung segmentectomy. After completing the multi-step revision, we can conclude that there is a lack of evidence about the oncological value of segmentectomy in early stage NSCLC. Although VATS segmentectomy is feasible and performed by many thoracic surgeons, it's currently not yet world-wide adopted. Among the trials now being recruited in some countries and, aimed to clarify the role of SLR in the treatment of early stage lung cancer, a European prospective randomized study is advocated to implement the scientific knowledge on this issue.

Ribcage kinematics during exercise justifies thoracoscopic versus postero-lateral thoracotomy lobectomy prompt recovery.

OBJECTIVES: The video-assisted thoracic surgery (VATS) approach is encouraged over postero-lateral thoracotomy (PLT) for lobectomy in lung cancer. We compare the ribcage kinematics during exercise before and after both procedures, assuming that VATS, being minimally invasive, could better preserve ribcage expansion. METHODS: Thirty-one patients undergoing lobectomy by means of VATS (n = 20) or PLT (n = 11) were compared presurgery, after chest drainage removal (T1) and 2 months post-surgery (T2) during quiet breathing and incremental exercise. Spirometry, chest pain, ventilatory pattern and expansions of the ribcage (ΔVRC) and abdomen were measured. Furthermore, the expansion of the ribcage and abdomen in the operated (ΔVRC-OP and ΔVAB-OP, respectively) and non-operated (ΔVRC-NO and ΔVAB-NO, respectively) sides was also considered. RESULTS: At T1, in both groups, spirometry worsened and chest pain increased, being higher after PLT. Tidal volume (VT) decreased after PLT because the ribcage expanded less due to reduced ΔVRC-OP. Contrary to this, in VATS, there were no changes in VT and ΔVRC, although ΔVRC-OP was lower, because ΔVRC-NO increased at high level of exercise. At T2, ΔVRC-OP was completely restored after VATS. At high levels of exercise following PLT, although patients still showed reduced ΔVRC and ΔVRC-OP, VT was restored owing to increased ΔVAB-NO. CONCLUSIONS: We demonstrate VATS to have a reduced impact on ribcage kinematics while PLT induced restriction more markedly during exercise and still present 2 months after surgery. Patients adopt 2 different compensatory mechanisms, by shifting the expansion toward the contralateral ribcage after VATS and toward the abdomen after PLT. Our study justifies thoracoscopic lobectomy prompt recovery. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov (NCT02910453).