Are the minimally invasive techniques the new gold standard in thymus surgery for myasthenia gravis? Experience of a reference single-site in VATS thymectomy.

The thymus is the primary lymphoid organ responsible for the maturation and proliferation of T lymphocytes. During the first years of our lives, the activation and inactivation of T lymphocytes occur within the thymus, facilitating the correct maturation of central immunity. Alterations in the positive and negative selection of T lymphocytes have been studied as the possible origins of autoimmune diseases, with Myasthenia Gravis (MG) being the most representative example. Structural alterations in the thymus appear to be involved in the initial autoimmune response observed in MG, leading to the consideration of thymectomy as part of the treatment for the disease. However, the role of thymectomy in MG has been a subject of controversy for many years. Several publications raised doubts about the lack of evidence justifying thymectomy's role in MG until 2016 when a randomized study comparing thymectomy via sternotomy plus prednisone versus prednisone alone was published in the New England Journal of Medicine (NEJM). The results clearly favored the group of patients who underwent surgery, showing improvements in symptoms, reduced corticosteroid requirements, and fewer recurrences over 3 years of follow-up. In recent years, the emergence of less invasive surgical techniques has made video-assisted or robotic-assisted thoracoscopic (VATS/RATS) thymectomy more common, replacing the traditional sternotomy approach. Despite the increasing use of VATS, it has not been validated as a technique with lower morbidity compared to sternotomy in the treatment of MG. The results of the 2016 trial highlighted the benefits of thymectomy, but all the patients underwent surgery via sternotomy. Our hypothesis is that VATS thymectomy is a technique with lower morbidity, reduced postoperative pain, and shorter postoperative hospital stays than sternotomy. Additionally, VATS offers better clinical improvement in patients with MG. The primary objective of this study is to validate the VATS technique as the preferred approach for thymectomy. Furthermore, we aim to analyze the impact of VATS thymectomy on symptoms and corticosteroid dosage in patients with MG, identifying factors that may predict a better response to surgery.

Treatment and intention-to-treat propensity score analysis to evaluate the impact of video-assisted thoracic surgery on 90-day mortality after anatomical resection for lung cancer.

OBJECTIVES: The aim of this study was to know the treatment effect of video-assisted thoracic surgery (VATS) on 90-day mortality after anatomical lung resection based on a nationwide cohort. METHODS: This is a multicentre prospective cohort of 2721 anatomical resections for lung cancer from December 2016 to March 2018. Treatment and intention-to-treat (ITT) analyses were performed after inverse probability score weighting and different propensity score matching algorithms. Covariate balance was assessed by standardized mean differences. The estimators reported were the average treatment effect, the average treatment effect on the treated and odds ratios after conditional logistic models with 95% confidence intervals. The unconfoundedness assumption was evaluated by sensitivity analysis for average treatment effect (c-dependence) and average treatment effect on the treated (Γ). RESULTS: VATS was the initial approach in 1911 patients (70.2%), though 273 cases (14.3%) had to be converted to thoracotomy. Ninety-day mortality rates were: treatment analysis (VATS 1.16% vs open 3.9%, P < 0.001), ITT analysis (VATS 1.78% vs open 3.36%, P = 0.012). After inverse probability score weighting and propensity score matching, in the treatment analysis, VATS meant absolute risk reductions between 2.25% and 2.96% and relative risk reductions between 65% and 70% [OR = 0.34 (95% confidence interval 0.15-0.79), all P-values <0.004). However, all the estimators turned out to be non-significant in the ITT analyses. A high sensitivity to unobservable confounders was proved (c-dependence 0.135, Γ = 1.5). CONCLUSIONS: VATS can reduce the risk of 90-day mortality after anatomical lung resection. However, the implications of conversion to thoracotomy, comparing ITT versus treatment analysis, and the potential impact of hidden bias should deserve further attention in the future.

Efectividad de la interrupción de la transmisión nerviosa de la cadena simpática torácica bilateral con clip para el tratamiento de la hiperhidrosis palmar y/o axilar severa y el rubor facial / Effectiveness of bilateral clipping of the thoracic sympathetic chain for the treatment of severe palmar and/or axillary hyperhidrosis and facial flushing

Introducción: El tratamiento estándar de la hiperhidrosis palmar o axilar y el rubor facial es la sección de la cadena simpática torácica. La interrupción de la transmisión nerviosa de la cadena simpática torácica bilateral con clip, conocida como "pinzamiento", constituye una alternativa con la opción de revertir el procedimiento en caso de sudoración compensatoria intolerable. Métodos: Estudio prospectivo para evaluar: a) resultados del «pinzamiento» en pacientes con hiperhidrosis palmar o axilar y rubor facial, y b) determinar la mejoría obtenida tras la retirada del clip en pacientes con sudoración compensatoria intolerable Se incluyó a 299 pacientes (598 procedimientos) diagnosticados de hiperhidrosis palmar (n = 110), palmar o axilar (n = 78), axilar (n = 35) y rubor facial (n = 76), tratados mediante «pinzamiento» videotoracoscópico de 2007 a 2015. Resultados: Ciento veintiocho varones y 171 mujeres con una edad media de 28 años. En 290 casos (97,0%) pudo darse el alta dentro de las primeras 24 h. En un 92,3% el procedimiento fue efectivo (99,1% hiperhidrosis palmar, 96,1% hiperhidrosis palmar o axilar, 74,3% hiperhidrosis axilar y 86,8% rubor facial). Nueve pacientes (3%) presentaron complicaciones menores. En 137 pacientes (45,8%) apareció sudoración compensatoria: moderada 113 (37,8%), severa 16 (5,3%) e intolerable 8 (2,7%). Se retiró el clip en estos 8 pacientes, mejorando los síntomas en 5 (62,8%), con efecto mantenido sobre la hiperhidrosis en 4 de ellos. Conclusiones: El «pinzamiento» de la cadena simpática torácica es una técnica efectiva y segura. En caso de sudoración compensatoria incapacitante, esta técnica permite la retirada del clip y la reversión de los síntomas en un porcentaje notable de pacientes

Introduction: Division of the thoracic sympathetic chain is the standard treatment for severe palmar and/or axillary hyperhidrosis and facial flushing. Clipping is an alternative option which allows the block to be reverted in cases of intolerable compensatory sweating. Methods: This is a prospective study performed to assess: a) results of clipping of the thoracic sympathetic chain in patients with palmar and/or axillary hyperhidrosis and facial flushing; and b) to determine the improvement obtained after removal of the clip in patients with unbearable compensatory sweating. We included 299 patients (598 procedures) diagnosed with palmar hyperhidrosis (n=110), palmar and/or axillary hyperhidrosis (n=78), axillary hyperhidrosis (n=35), and facial flushing (n=76), who underwent videothoracoscopic clipping between 2007 and 2015. Results: 128 men and 171 women were treated, with mean age of 28 years. A total of 290 patients (97.0%) were discharged within 24 hours. The procedure was effective in 92.3% (99.1% in palmar hyperhidrosis, 96,1% in palmar and/or axillary hyperhidrosis, 74.3% in axillary hyperhidrosis, and 86.8% in facial flushing). Nine patients (3%) presented minor complications. Compensatory sweating developed in 137 patients (45.8%): moderate in 113 (37.8%), severe in 16 (5.3%) and unbearable in 8 (2.7%). The clip was removed in these 8 patients; symptoms improved in 5 (62.8%), with sustained effect on hyperhidrosis in 4 of them. Conclusions: Clipping of the thoracic sympathetic chain is an effective and safe procedure. If incapacitating compensatory sweating develops, this technique allows the clips to be removed with reversion of symptoms in a considerable number of patients

Effectiveness of bilateral clipping of the thoracic sympathetic chain for the treatment of severe palmar and/or axillary hyperhidrosis and facial flushing. / Efectividad de la interrupción de la transmisión nerviosa de la cadena simpática torácica bilateral con clip para el tratamiento de la hiperhidrosis palmar y/o axilar severa y el rubor facial.

INTRODUCTION: Division of the thoracic sympathetic chain is the standard treatment for severe palmar and/or axillary hyperhidrosis and facial flushing. Clipping is an alternative option which allows the block to be reverted in cases of intolerable compensatory sweating. METHODS: This is a prospective study performed to assess: a) results of clipping of the thoracic sympathetic chain in patients with palmar and/or axillary hyperhidrosis and facial flushing; and b) to determine the improvement obtained after removal of the clip in patients with unbearable compensatory sweating. We included 299 patients (598 procedures) diagnosed with palmar hyperhidrosis (n=110), palmar and/or axillary hyperhidrosis (n=78), axillary hyperhidrosis (n=35), and facial flushing (n=76), who underwent videothoracoscopic clipping between 2007 and 2015. RESULTS: 128 men and 171 women were treated, with mean age of 28 years. A total of 290 patients (97.0%) were discharged within 24hours. The procedure was effective in 92.3% (99.1% in palmar hyperhidrosis, 96,1% in palmar and/or axillary hyperhidrosis, 74.3% in axillary hyperhidrosis, and 86.8% in facial flushing). Nine patients (3%) presented minor complications. Compensatory sweating developed in 137 patients (45.8%): moderate in 113 (37.8%), severe in 16 (5.3%) and unbearable in 8 (2.7%). The clip was removed in these 8 patients; symptoms improved in 5 (62.8%), with sustained effect on hyperhidrosis in 4 of them. CONCLUSIONS: Clipping of the thoracic sympathetic chain is an effective and safe procedure. If incapacitating compensatory sweating develops, this technique allows the clips to be removed with reversion of symptoms in a considerable number of patients.

Neumotórax espontáneos de repetición como presentación del síndrome de Birt-Hogg-Dubé / Recurrent Spontaneous Pneumothorax as a Manifestation of Birt-Hogg-Dube Syndrome

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Lung cancer diagnosis by trained dogs.

OBJECTIVES: Early lung cancer (LC) diagnosis is key to improve prognosis. We explored here the diagnostic performance of a trained dog to discriminate exhaled gas samples obtained from patients with and patients without LC and healthy controls. METHODS: After appropriate training, we exposed the dog (a 3-year-old cross-breed between a Labrador Retriever and a Pitbull) to 390 samples of exhaled gas collected from 113 individuals (85 patients with LC and 28 controls, which included 11 patients without LC and 17 healthy individuals) for a total of 785 times. RESULTS: The trained dog recognized LC in exhaled gas with a sensitivity of 0.95, a specificity of 0.98, a positive predictive value of 0.95 and a negative predictive value of 0.98. The area under the curve of the receiver-operating characteristics curve was 0.971. CONCLUSIONS: This study shows that a well-trained dog can detect the presence of LC in exhaled gas samples with an extremely high accuracy.

Carcinoide tímico asociado a síndrome de neoplasia endocrina múltiple tipo I / Thymic Carcinoid Associated With Multiple Endocrine Neoplasia Syndrome Type I

Los carcinoides tímicos son una entidad poco frecuente que puede asociarse a enfermedades endocrinológicas como el síndrome de Cushing o el síndrome de neoplasia endocrina múltiple tipo I (MEN1). Suponen el 4% de los tumores del mediastino anterior y se caracterizan por tener un comportamiento muy agresivo. Presentamos el caso de un paciente diagnosticado de síndrome MEN1 a quien durante el seguimiento de su enfermedad se detectó una imagen torácica compatible con carcinoide tímico. Tras intervenirle quirúrgicamente mediante timectomía ampliada a grasa peritímica, se confirmó el diagnóstico clínico. A los 14 meses de seguimiento se halló en las pruebas de imagen una lesión sospechosa de recidiva local, motivo por el que fue reintervenido. El informe anatomopatológico de dicha intervención fue de fibrosis rádica. Así mismo, presentamos una revisión del manejo diagnóstico y terapéutico actual en pacientes con síndrome MEN1 diagnosticados de carcinoide tímico(AU)

Thymic carcinoids are a rare entity that may be associated with endocrine diseases like Cushing's syndrome or multiple endocrine neoplasia syndrome type I (MEN1). These tumors represent 4% of anterior mediastinal tumors and are characterized by their very aggressive behavior. We present the case of a patient with a previous MEN 1 diagnosis in whom, during the follow up of his disease, a thoracic image compatible with thymic carcinoid was detected. After an extended thymectomy that included peri-thymic fat resection, the clinical diagnosis was confirmed. A follow-up examination 14 months later revealed a suspicious lesion that suggested local recurrence, therefore the patient was reoperated on. The pathology report of this surgery indicated post-radiation fibrosis. Likewise, we present a review of the current diagnostic and therapeutic management of patients with MEN1 syndrome who are diagnosed with thymic carcinoid(AU)

Thymic carcinoid associated with multiple endocrine neoplasia syndrome type I.

Thymic carcinoids are a rare entity that may be associated with endocrine diseases like Cushing's syndrome or multiple endocrine neoplasia syndrome type I (MEN1). These tumors represent 4% of anterior mediastinal tumors and are characterized by their very aggressive behavior. We present the case of a patient with a previous MEN 1 diagnosis in whom, during the follow up of his disease, a thoracic image compatible with thymic carcinoid was detected. After an extended thymectomy that included peri-thymic fat resection, the clinical diagnosis was confirmed. A follow up examination 14 months later revealed a suspicious lesion that suggested local recurrence, therefore the patient was reoperated on. The pathology report of this surgery indicated post-radiation fibrosis. Likewise, we present a review of the current diagnostic and therapeutic management of patients with MEN1 syndrome who are diagnosed with thymic carcinoid.

Tumor del seno endodérmico primario de pulmón. Una rara entidad anatomopatológica / Pulmonary Pure Yolk-Sac Tumor. A Rare Anatomopathological Entity

La localización intratorácica más frecuente para los tumores germinales no metastáticos, es el mediastino anterior. Los tumores de células germinales primarios de pulmón son una excepción en la literatura limitándose a algunos casos de coriocarcinomas y raros casos de tumores del seno endodérmico. En este artículo, se presenta un caso de tumor del seno endodérmico primario de pulmón de características atípicas en cuanto a la manera de diagnostico y al tratamiento practicado(AU)

The most frequent location for non-metastatic germ cell tumors is the anterior mediastinum. Primary lung germ cell tumors are an exception in medical literature being limited to just a few cases of choriocarcinomas and rare cases of yolk-sac tumors. In this paper, we report a case of a pulmonary yolk-sac tumor with atypical characteristic as regards its diagnosis and treatment(AU)

Pulmonary pure yolk-sac tumor. A rare anatomopathological entity.

The most frequent location for non-metastatic germ cell tumors is the anterior mediastinum. Primary lung germ cell tumors are an exception in medical literature being limited to just a few cases of choriocarcinomas and rare cases of yolk-sac tumors. In this paper, we report a case of a pulmonary yolk-sac tumor with atypical characteristic as regards its diagnosis and treatment.