Case Report: Invasive fungal infection after anti-CD19 CAR-T cell therapy. Implication for antifungal prophylaxis.

CAR-T therapy has revolutionized the treatment of relapsed/refractory B-cell malignancies. Patients who are receiving such therapy are susceptible to an increased incidence of infections due to post-treatment immunosuppression. The need for antifungal prophylaxis during the period of neutropenia remains to be determined. The clinical outcome of a 55-year-old patient with relapsed/refractory DLBCL who received axicabtagene ciloleucel is described here. The patient developed CRS grade II and ICANS grade IV requiring tocilizumab, prolonged use of steroids and anakinra. An invasive pulmonary aspergillosis arose after 1 month from CAR-T reinfusion, resolved with tracheal sleeve pneumonectomy. The patient is now in Complete Remission. This case suggests that antifungal prophylaxis should be considered. We have now included micafungin as a standard prophylaxis in our institution.

Management of pulmonary ground-glass opacities: a position paper from a panel of experts of the Italian Society of Thoracic Surgery (SICT).

OBJECTIVES: A significant gap in our knowledge of how to manage pulmonary ground-glass opacities (GGOs) still exists. Accordingly, there is a lack of consensus among clinicians on this topic. The Italian Society of Thoracic Surgery (Società Italiana di Chirurgia Toracica, SICT) promoted a national expert meeting to provide insightful guidance for clinical practice. Our goal was to publish herein the final consensus document from this conference. METHODS: The working panel of the PNR group (Pulmonary Nodules Recommendation Group, a branch of the SICT) together with 5 scientific supervisors (nominated by the SICT) identified a jury of expert thoracic surgeons who organized a multidisciplinary meeting to propose specific statements (n = 29); 73 participants discussed and voted on statements using a modified Delphi process (repeated iterations of anonymous voting over 2 rounds with electronic support) requiring 70% agreement to reach consensus on a statement. RESULTS: Consensus was reached on several critical points in GGO management, in particular on the definition of GGO, radiological and radiometabolic evaluation, indications for a non-surgical biopsy, GGO management based on radiological characteristics, surgical strategies (extension of pulmonary resection and lymphadenectomy) and radiological surveillance. A list of 29 statements was finally approved. CONCLUSIONS: The participants at this national expert meeting analysed this challenging topic and provided a list of suggestions for health institutions and physicians with practical indications for GGO management.

Current Practices in the Management of Pulmonary Ground-Glass Opacities: A Survey of SICT Members.

BACKGROUND: Several gray areas and controversies exist concerning the management of pulmonary ground-glass opacities (GGOs), and there is a lack of consensus among clinicians on this topic. One of the main aims of the Italian Society of Thoracic Surgery is to promote education and research, so we decided to perform a survey on this topic to estimate current trends in practice in a large sample of thoracic surgeons. METHODS: A total of 160 thoracic surgeons responded, namely, completed our questionnaire (response rate, 53%; 160 of 302). The survey was composed of 36 questions divided into six subsections: (1) demographic characteristics of the respondents; (2) terminology and taxonomy; (3) radiologic and radiometabolic evaluation; (4) diagnostic approach and indications for surgery; (5) surgical management; and (6) radiologic surveillance. RESULTS: We observed some divergence of opinion regarding the definition of mixed GGOs, the role of 18F fluorodeoxyglucose positron emission tomography and computed tomography scans, indications for nonsurgical biopsy, intraoperative techniques for localizing GGOs, indications for surgery, extension of lung resection and lymph node dissection according to the radiologic scenario, use of intraoperative frozen section analysis, and radiologic surveillance of pure GGOs. CONCLUSIONS: This topic warrants more investigation in the future. An upcoming consensus conference of Italian Society of Thoracic Surgery experts (also open to experts in other specialties) could provide updated indications for GGO management based on the literature, expert opinions, and the results of the present survey.

Experimental Robotic Pulmonary Lobectomy With the TELELAP/ALFX System in the Ovine Model.

A new robotic telesurgical device (TELELAP/ALFX) is used for the first time to execute an anatomical pulmonary resection (lobectomy) plus mediastinal lymph node dissection in the ovine model. This integrated operative system has 2 innovative peculiarities: (a) tactile perception (engineered to give the operator a tactile feedback similar to that experienced when handling thoracoscopy instruments) and (b) eye-tracking (immediate synchronization of the surgeon's eyes movements with that of the robotic camera). Herein, we report a lower right pulmonary lobectomy under complete robotic assistance (TELELAP/ALFX). Standard endoscopic staplers were used in all the major maneuvers (bronchial as well as vascular resections and fissural completion) introduced through a utility 4-cm-sized incision. The specimen was placed in an endoscopic retrieval bag and removed through a service minithoracotomy. With the limitations because of interspecies differences in anatomical landmarks, a mediastinal lymph nodal dissection was also completed. The operative time was acceptable (~180 minutes) with blood loss of 100 mL. In conclusion, according to this first all experimental experience we may deem the TELELAP/ALFX system completely apt to perform major anatomic pulmonary resections and the regulatory process to run trials in humans are under way.

Techniques of right extended pneumonectomy.

Tracheal sleeve pneumonectomy is considered the operation of choice for tumors involving the right tracheobronchial angle, even though the procedure is burdened by a high rate of perioperative morbidity and mortality. In this report, we present our experience with two different techniques to avoid sleeve pneumonectomy: the tangential tracheal suture and the tracheoplasty.

A new technique of diaphragmatic patch fixation in extrapleural pneumonectomy.

Extrapleural pneumonectomy (EPP) is an established surgical treatment for malignant mesothelioma; this operation is, however, burdened by a high rate of perioperative morbidity, mostly related to the surgical procedure. Diaphragmatic patch dehiscence is a potentially serious complication often related to the difficulty in placement of the fixing stitches, especially in the costo-phrenic angle. We present our experience with the use of titanium-plate support for an easy and safe positioning of the diaphragmatic patch.

[Intralobar pulmonary sequestration: a case report]. / Sequestrazione polmonare intralobare: a proposito di un caso.

The authors report a case of intralobar pulmonary sequestration diagnosed accidentally in a 64-year-old woman. The patient subsequently underwent surgery. The authors were prompted by this fairly rare case to describe and discuss its anatomopathological, clinical, diagnostic and therapeutic aspects.