Veno-venous ECMO during surgical repair of tracheal perforation: A case report.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is used extensively in cardiothoracic surgery both for hemodynamic and respiratory support. It has proven to be a valuable tool to maintain adequate oxygenation during tracheal surgery. Airway lesion may be an indication for veno-venous ECMO both in case of conservative management and in case of surgical repair. Here we report the case of a patient with a iatrogenic tracheal injury, successfully operated with the support of veno-venous extracorporeal oxygenation. PRESENTATION OF CASE: A 39-year-old female underwent an elective laparoscopic adhesiolysis. At the end of the procedure, the patient had developed subcutaneous emphysema. A CT-scan showed mediastinal and subcutaneous emphysema and left pneumothorax with a laceration of the membranous portion of the middle third of the trachea. A left pleural drain was inserted and a bronchoscopy showed a 2-cm long tear of the membranous portion in the middle third of the trachea. Veno-venous ECMO was established and surgical repair of the tracheal lesion was performed. Post-operative recovery was uneventful and the patient was discharged on 8th postoperative day. DISCUSSION: The use of Veno-venous ECMO allowed a safe intubation with optimal oxygenation. A selective intubation with a small tube was performed to prevent further tracheal injury and allow an adequate surgical space for tracheal repair. CONCLUSION: The use of ECMO support represents a safe and effective way to manage patients with ITI when surgical repair with minimally invasive ventilation is needed. Since this is a case report larger studies are needed to validate the technique.

Unexpected responses to EGFR inhibition in NSCLC.

The presence of activating mutations of the epidermal growth factor receptor (EGFR)-gene identifies a distinct and clinically relevant molecular subset of non-small-cell lung cancer. It is now well demonstrated that EGFR tyrosine kinase inhibitors (TKIs) gefitinib and erlotinib are superior to standard chemotherapy in this subset of tumors. Nevertheless, in many cases, responses are not durable and last for 6-12 months due to the occurrence of secondary or acquired resistance. Here we present three cases of EGFR-mutant lung adenocarcinomas (ADC), that showed an unexpected response to anti-EGFR small molecules. The first patient presented a continued 89 month-long response to erlotinib in a tumor recurred after surgery and conventional chemotherapy. In the other cases, subclinically persistent tumor in the lung tissue was documented histologically in lung resections performed after partial response to TKI treatment. The persistence of interstitial and endolymphatic tumor cells after TKI treatment might explain the common observation of tumor relapse after TKI discontinuation, and sustain the decision to continue treatment in responsive patients as in our first case.

Surgical treatment of primary pulmonary artery sarcoma.

OBJECTIVE: Primary pulmonary artery sarcoma is a severe and underdiagnosed disease, with the clinical and surgical approach not clearly established. Only a few individual case reports or small series on this topic have been published. The aim of the present study was to report our surgical experience in this field. METHODS: From March 2004 to December 2012, 13 patients underwent surgery for pulmonary artery sarcoma at our institution. In 7 patients, the sarcoma was unilateral (53.8%), and in 6 (46.2%), the tumor had already extended to both lungs. The surgical strategy evolved over the years, but the 2 techniques used were always the same: pneumonectomy in 5 patients and pulmonary endarterectomy in 8. RESULTS: Two patients died in-hospital, both in the pneumonectomy group. The median length of the intensive care unit and hospital stay was 1 day (range, 1-10) and 14 days (range, 11-17) for the pneumonectomy group and 6 days (range, 3-23) and 19 days (range, 10-32) fort the pulmonary endarterectomy group, respectively. The median survival was 26.8 months after pneumonectomy and 6.6 months after pulmonary endarterectomy. CONCLUSIONS: Primary pulmonary artery sarcoma has a poor prognosis. The surgical strategy at our institution included pneumonectomy, for possible radical resection, and palliative endarterectomy, to reduce symptoms and increase the life expectancy. The correct surgical approach must be evaluated individually, according to the tumor presentation, the presence of pulmonary hypertension, and the patient's clinical condition.

Prolonged survival in advanced thymoma: Effectiveness of sequential multiple lines of chemotherapy in an inoperable case.

A standard therapeutic approach for advanced malignant thymoma has yet to be defined given the rarity of this condition. We present a patient with advanced thymoma, evaluated as inoperable at diagnosis due to multiple serosal metastases. The strong constitution and determination of the patient allowed treatment with six distinct and subsequent chemotherapy regimens, all administered on an outpatient basis. A survival of 64 months from diagnosis was achieved. A favorable clinical response was obtained after the first three treatment lines, with the disappearance of all lesions on both computed tomography and positron emission tomography (PET) images. However, this result was not confirmed by surgical exploration of the thorax, undertaken with the aim of radical excision of possible residual disease. The presence of multiple pleural nodules, not evident on the imaging techniques, prevented even limited tumor debulking. The chemotherapy lines administered following detection of the lessions, stabilized the disease for a further 2 years, while a satisfactory quality of life was maintained. Only in the last months did the tumor progress and signs of cardiotoxicity appear, with the latter constituting the eventual cause of death. This case is important since the medical literature does not indicate non-cross-resistant regimens for advanced thymoma following second-line chemotherapy, and the sequence of regimens presented in this case study may serve as a feasible outline program. Moreover, we highlight the known possibility of false-negative PET studies, which can occur despite the claimed glucose avidity of thymoma tissue.