Discriminant Profiles of Volatile Compounds in the Alveolar Air of Patients with Squamous Cell Lung Cancer, Lung Adenocarcinoma or Colon Cancer.

The objective of the present work was to analyze volatile compounds in alveolar air in patients with squamous cell lung cancer, lung adenocarcinoma or colon cancer, to prepare algorithms able to discriminate such specific pathological conditions. The concentration of 95 volatile com-pounds was measured in the alveolar air of 45 control subjects, 36 patients with lung adenocarci-noma, 25 patients with squamous cell lung cancer and 52 patients with colon cancer. Volatile compounds were measured with ion molecule reaction mass spectrometry (IMR-MS). An iterat-ed least absolute shrinkage and selection operator multivariate logistic regression model was used to generate specific algorithms and discriminate control subjects from patients with differ-ent kinds of cancer. The final predictive models reached the following performance: by using 11 compounds, patients with lung adenocarcinoma were identified with a sensitivity of 86% and specificity of 84%; nine compounds allowed us to identify patients with lung squamous cell car-cinoma with a sensitivity of 88% and specificity of 84%; patients with colon adenocarcinoma could be identified with a sensitivity of 96% and a specificity of 73% using a model comprising 13 volatile compounds. The different alveolar profiles of volatile compounds, obtained from pa-tients with three different kinds of cancer, suggest dissimilar biological-biochemistry condi-tions; each kind of cancer has probably got a specific alveolar profile.

Risk factors and impact of conversion from VATS to open lobectomy: analysis from a national database.

OBJECTIVE: The objective of the study is to analyse the causes and impact of conversion from VATS to thoracotomy identifying any possible pre-operative risk factors and related consequences. METHODS: Data from patient who underwent VATS lobectomy (VATS-L) for NSCLC at VATS Group participating centres were retrospectively analysed and divided in two groups: patients treated with VATS-L and patients who suffered from conversion. Predictors of conversion were assessed with univariate and multivariable exact logistic regression. Complications were evaluated as dependent variables of conversion in a Cox multivariable logistic regression model. RESULTS: A total of 4629 patients underwent planned VATS-L for NSCLC and of these, 432 (9.3%) required conversion; the most frequent causes were bleeding (30.4%) and fibro-calcified hilar lymph nodes (23.9%). The independent risk factors at multivariable analysis model were sex male (OR 1.458, p < 0.01), age older than 70 years (OR 1.248, p = 0.036) and the clinically node-positive disease (OR 2.258, p < 0.01). The mortality rate was similar, but the percentage of patients who suffered from any complication (41.7% vs 24.4%, p < 0.01), the complication rate (65% vs 32.2%, p < 0.01), chest tube duration (p < 0.01) and the hospitalisation rate (p < 0.01) were higher for patients converted. Atrial fibrillation (OR 1.471, p = 0.019), prolonged air leak (OR 1.403, p = 0.043), blood transfusions (OR 4.820, p < 0.01), sputum retention (OR 1.80, p = 0.027) and acute kidney failure (OR 2.758, p = 0.03) were significantly associated with conversion at multivariable analysis. CONCLUSIONS: Conversion is associated with increased surgical morbidity, blood loss and hospital stay. Sex male, old age and the clinical involvement of lymph nodes were the strongest predictors of conversion.

Correction to: Risk factors and impact of conversion from VATS to open lobectomy: analysis from a national database.

In the "Results" section of the Abstract, the sentence: "The mortality rate was similar, but the percentage of patients who suffered from any complication (41.7% vs 24.4%, p < 0.01), the complication rate (65% vs 32.2%, p < 0.01), chest tube duration (p < 0.01) and the hospitalisation rate (p < 0.01) were higher for patients converted." should read: "The mortality rate was similar, but the percentage of patients who suffered from any complication (41.7% vs 24.4%, p < 0.01), the complication rate (65% vs 32.2%, p < 0.01), chest tube duration (p < 0.01) and length of stay (p < 0.01) were higher for patients converted."

Functional polymorphisms of the microsomal epoxide hydrolase gene: a reappraisal on a early-onset lung cancer patients series.

Microsomal epoxide hydrolase gene (EPHX1) is polymorphic and encodes an enzyme involved in both the activation and detoxification of several tobacco carcinogens. Therefore, a contribution of EPHX1 enzymatic activity on lung cancer risk is possible. A genetic component of early-onset lung cancer has been suggested but variations in enzyme activity and polymorphisms in EPHX1 have seldom been studied in young patients with lung cancer. Primary lung cancer cases of both sexes and under age 45 at diagnosis were considered for this study. Controls fulfilled the following criteria: over 60 years old, smoking history of at least 40 years, no malignancies. Because of these criteria, they are referred to as super controls. The polymorphisms at exons 3 (Tyr113His) and 4 (His139Arg) as well as at the 5'-UTR-290T/G of the EPHX1 gene were genotyped by minisequencing. The association of these three polymorphisms with the development of early-onset lung cancer and the group of the super controls was evaluated by means of 2x2 tables using Yate's X(2) test or Fisher's exact test. Overall, data were obtained from 42 cases and 72 super controls. There was a significant association between early-onset lung cancer and the presence of the EPHX1 exon 4 variant (OR=3.33, 95% CI=1.50-7.41). This was confirmed at the phenotypic level when the data of both patients and super controls were stratified according to the predicted enzymatic activity (X(2) for linear trend=7.23, p=0.007). This analysis of lung cancer in subjects under age 45 supports the hypothesis that EPHX1 polymorphisms may have a role in cancer susceptibility in this age group.

Short and long-term results of sternectomy for sternal tumours.

BACKGROUND: We analyzed our experience in sternal resections (SRs) for primary or secondary neoplasm focusing on technical aspects of reconstruction, post-operative outcomes and long term survival. METHODS: From January 2005 to December 2015, 36 patients (24 males, 67%) underwent surgical excision of primary (chondrosarcoma n=18 patients, 50%; osteosarcoma n=2, 6%; Ewing sarcoma n=1, 3%; other n=2, 6%) or secondary (breast cancer n=7, 19%; kidney carcinoma n=2, 6%) sternal tumour. We performed n=30 partial sternectomy and n=6 total sternectomy with en-bloc resection of the sternocostal cartilages in all patient and extended resection in 7 patients. Stability was obtained with prosthetic material, rigid and non-rigid and a muscular flap: rigid material [Strasbourg Thoracic Osteosynthesis System (STRATOS), MedXpert GmbH] and muscle flap n=11 (30.6%); polytetrafluoroethylene patch and muscle flap n=6 (16.7%); muscle flap alone n=19 (52.8%). RESULTS: The 30-day mortality rate was 0, overall complication rate was 19%. The median ICU stay was 1.5 days and mean hospital stay was 10.6±5.9 days. We obtained a complete (R0) resection in all patients. Overall survival (OS) at 5 and 10 years were 59% and 40%; in the group of primary neoplasm OS rate at 5 and 10 years was 79% and 54%. Disease free survival (DFS) rate at 5 years was 61%. Higher grading was identified as negative prognostic factor. CONCLUSIONS: Wide radical resections of anterior chest wall are basilar in a multimodality treatment for primary or metastatic neoplasm of the sternum. Stabilization with titanium bars and clips provides rigidity of chest wall with good functional results.

Does videomediastinoscopy with frozen sections improve mediastinal staging during video-assisted thoracic surgery pulmonary resections?

BACKGROUND: To assess if video-mediastinoscopy (VM) with frozen sections (FS) combined with a video-assisted thoracic surgery major pulmonary resection (VMPRS) is able to improve VATS mediastinal intraoperative staging. METHODS: From June 2012 to March 2015 a total of 146 patients underwent VMPRS lymphadenectomy. NCCN guidelines were followed for pre-operative staging, including VM with FS in 27 patients (19%). Procedural time, dissected nodal stations, complications related to VM and VATS lymphadenectomy and definitive histology, were evaluated. RESULTS: Operative time for VATS resection with VM (group 1) and VATS pulmonary resection alone (group 2) was 198±64 vs. 167±43 min (P=0.003). Mean/median numbers of dissected nodal stations were 4.93±1.1/5 (range, 4-8) in group 1 and 3.25±0.5/5 (range, 3-8) in group 2 (P<0.001). Group 1 vs. group 2 right-sided lymphadenectomy (n=86) was performed at station 2R/4R in 18 (90%) and 46 (69.7%); at station 3a/3p in 14 (51.8%) and 22 (31%); at station 7 in 18 (90%) and 44 (66.7%); at station 8/9 in 11 (55%) and 24 (36.4%) respectively. On the left side (n=60) group 1 vs. group 2 lymphadenectomy resulted at station 4 in 6 (85.7%) and 38 (71.7%); at station 5/6 in 6 (85.7%) and 26 (49%); at station 7 in 6 (85.7%) and 33 (62.3%), and at station 8/9 in 1 (14.3%) and 18 (34%). There were no early deaths and recurrent laryngeal nerve palsy occurred in 1 (0.8%) in group 2. Pathological upstaging (pN1; pN2) was found in 5 patients (17%) in group 1, and 13 (11%) in group 2 (P=0.23). About FS (n=29), formal paraffin histology resulted in 0% of both, false negative and false positive results. CONCLUSIONS: Based on our experience, the combination "VM with FS followed by VMPRS in sequence", seems to be effective and offers an alternative approach to improve intraoperative mediastinal staging.

Development of a video-assisted thoracoscopic lobectomy program in a single institution: results before and after completion of the learning curve.

BACKGROUND: The development of a video assisted thoracic surgery lobectomy (VATS-L) program provides a dedicated surgical team with a recognized learning curve (LC) of 50 procedures. We analyse the results of our program, comparing the LC with subsequent cases. METHODS: From June 2012 to March 2015, we performed n = 146 VATS major pulmonary resections: n = 50 (Group A: LC); n = 96 (Group B). Pre-operative mediastinal staging followed the National Comprehensive Cancer Network guidelines. All procedures were performed using a standard anterior approach to the hilum; lymphadenectomy followed the NCCN recommendations. During the LC, VATS-L indication was reserved to clinical stages I, therefore evaluated case by case. RESULTS: Mean operative time was 191 min (120-290) in Group A and 162 min (85-360) in Group B (p <0,01). Pathological T status was similar between two Groups. Lymphadenectomy included a mean of 5.8 stations in Group A and 6.6 in Group B resulting in: pN0 disease: Group A n = 44 (88 %), Group B n = 80 (83.4 %); pN1: Group A n = 3 (6 %), Group B n = 8 (8.3 %); pN2: Group A n = 3 (6 %), Group B n = 8 (8.3 %). Conversion rate was: 8 % in group A (n = 4 vascular injuries); 1.1 % in Group B (n = 1 hilar lymph node disease). We registered n = 6 (12 %) complications in Group A, n = 10 (10.6 %) in Group B. One case (1.1 %) of late post-operative mortality (90 days) was registered in Group B for liver failure. Mean hospital stay was 6.5 days in Group A and 5.9 days in Group B. CONCLUSIONS: We confirm the effectiveness of a VATS-L program with a learning curve of 50 cases performed by a dedicated surgical team. Besides the LC, conversion rate falls down, lymphadenectomy become more efficient, indications can be extended to upper stages.

[T4 tracheo-bronchial carcinoma: clinical evaluation of 48 sleeve pneumonectomies]. / Carcinoma tracheobronchiale T4. Bilancio clinico di 48 sleeve pneumonectomies.

The aim of the study was to verify the indications for surgery in T4 tracheo-bronchial carcinomas. Forty-eight tracheal-sleeve pneumonectomies for T4 bronchogenic carcinoma were performed in our unit from 1986 to 2003. The patients were 42 males and 6 females. A postero-lateral thoracotomy was preferred (46 right, 2 left). Bronchial reimplantation was performed additionally (tracheal-sleeve lobectomy) in 2 patients on the right side. The morbidity was 25% and the mortality 6.2% (1 acute respiratory distress syndrome, 1 myocardial infarction, 1 anastomotic fistula). Twenty-three cases were sT4N2M0, 14 sT4N1M0, and 11 sT4N0M0. The sT4N2M0 and sT4N1M0 cases were not associated with more than 3 year survival, despite adjuvant therapies; sT4N0M0 squamous cell carcinomas, on the other hand, had > 40% 10-year survival with no adjuvant therapy. Associated prosthetic replacement of the superior vena cava neither affected the risk nor improved the prognosis. Surgery for T4 tracheo-bronchial carcinoma appears feasible for well differentiated sT4N0 squamous cell carcinomas; at more advanced stages this procedure is no more than a dangerous form of palliation.

Second surgery for recurrence of malignant pleural mesothelioma after extrapleural pneumonectomy.

BACKGROUND: Extrapleural pneumonectomy is a treatment option for malignant pleural mesothelioma (MPM), but disease recurrence is common. Among different therapeutic options for recurrence, we have found no reports for second surgical procedures. METHODS: We retrospectively evaluated the types and outcomes of surgical management of solid recurrences of MPM, in a series of 74 patients treated with extrapleural pneumonectomy over a 20-year period. RESULTS: Of 57 patients for whom follow-up data were available, 11 patients experienced recurrent disease in the form of a solid mass, 1.5 to 12 years after the initial treatment; 8 of these patients had sufficiently good clinical conditions to undergo a second surgery with curative intent. Chest wall resection was performed in 4 cases of parietal recurrence, radical retroperitoneal resection was done in 3 cases of retroperitoneal relapse, and segmental resection of the remaining lung was done in one case of pulmonary metastasis. In this latter case, although computed tomographic images showed a solid mass, at surgery the disease was found to have a serosal nature, precluding the possibility of a curative surgery. Median survival after the second surgery was 14.5 months (range, 6 to 29); no association between survival and site of recurrence, age or disease-free interval was found. CONCLUSIONS: In this series, the second surgery did not offer the expected survival benefit of curative treatment strategies and should therefore be considered palliative. Second surgery may be a treatment option in a subset of patients who experience a solid recurrence of MPM that is symptomatic or near vital organs and who cannot undergo additional radiotherapy.

Treatment for retained [corrected] common bile duct stones during laparoscopic cholecystectomy: the rendezvous technique.

OBJECTIVE: To determine the feasibility and efficacy of the laparoscopic intraoperative rendezvous technique for common bile duct stones (CBDS). DESIGN: Case series. SETTING: Verona University Hospital, Verona, Italy. PATIENTS: A total of 110 patients were enrolled in the study; 47 had biliary colic; 39, acute cholecystitis; 19, acute biliary pancreatitis; and 5, acute biliary pancreatitis with associated acute cholecystitis. INTERVENTIONS: In all patients, CBDS diagnosis was reached by intraoperative cholangiography. Intraoperative endoscopy with rendezvous performed during laparascopic cholecystectomy for confirmed CBDS; for such a procedure, a transcystic guide wire was positioned into the duodenum. Intraoperative endoscopy with rendezvous was performed for retrieved CBDS during a laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: Laparoscopic rendezvous feasibility, morbidity, postprocedure pancreatitis, and mortality. RESULTS: The laparoscopic rendezvous proved to be feasible in 95.5% (105 of 110 patients). The rendezvous failed in 3 cases of successfully performed laparoscopic cholecystectomy, and a conversion of the laparoscopy was needed in 2 cases of successful rendezvous. Two major complications and 2 cases of bleeding were registered after sphincterotomy was successfully performed with rendezvous, and severe acute pancreatitis complicated a traditional sphincterotomy performed after a failed rendezvous. CONCLUSIONS: Rendezvous is a feasible option for treatment of CBDS; it allows one to perform only 1 stage of treatment, even in acute cases such as cholecystitis and pancreatitis. Positioning of the guide wire may allow reduced complications secondary to papilla cannulation but not those of the endoscopic sphincterotomy.

Concomitant pulmonary carcinoma and abdominal aortic aneurysm: therapeutic strategies.

PURPOSE: A diagnosis of concomitant pulmonary carcinoma and abdominal aortic aneurysm is rare (<1% of treated cases). However, such an association makes the therapeutic decisions critical, especially regarding the priority and timing of treatment. This article reports on our experience of 14 cases of concomitant pulmonary carcinoma and abdominal aortic aneurysm. METHODS: From April 1987 to June 2006 we observed 14 cases of concomitant pulmonary carcinoma and abdominal aortic aneurysm. In patients for whom simultaneous treatment was not indicated due to a poor general condition, priority was given to lung cancer except for cases in which the aneurysm needed an urgent approach. Patients observed after 2000 and scheduled for a two-stage treatment were treated with endovascular procedures whenever possible. RESULTS: Only one patient was treated by a simultaneous aneurysmectomy and a left lower lobectomy, while in the other 13 patients two-stage treatment was performed. Lung carcinoma was operated on first in 7 cases but one patient underwent an urgent aneurysmectomy after chest surgery due to a rupture of the aneurysm. Priority was given to an aneurysmectomy in 2 patients. An endovascular approach was performed in 4 patients, thus allowing a pulmonary resection during the same period of hospitalization, 2 days after 2 uneventful endovascular procedures and on the 6th and 7th postoperative days in 2 cases due to an intraoperative rupture of right iliac artery and type I postoperative endoleak, respectively. CONCLUSION: An endovascular exclusion of the aneurysm may therefore be proposed in order to achieve a concomitant treatment of both diseases. Such an approach excludes complications due to a postoperative rupture of the aneurysm when a pulmonary resection would be first performed; moreover, it does not delay the performance of a pulmonary resection when treatment of the aneurysm is considered to have priority.