Malignant Solitary Fibrous Tumours of the Pleura Are Not All the Same: Analysis of Long-Term Outcomes and Evaluation of Risk Stratification Models in a Large Single-Centre Series.

Introduction: Malignant solitary fibrous tumours of the pleura (mSFTP) are extremely rare diseases (<5% of all pleural neoplasms) with unpredictable behaviour. Surgery remains the standard of care for these tumours; however, estimating patient prognosis and planning follow-up remain challenging. Several risk stratification models have been proposed, but a classification with diagnostic and prognostic potential has not been well standardised yet. The aim of this study was to analyse the clinicopathological data of mSFTP to investigate their prognostic features and to compare the performance of three risk stratification models proposed in the literature. Methods: Observational retrospective cohort study on all proven cases of mSFTP surgically resected with radical intent between 2000 and 2019 in a single centre. Demographic, surgical and pathological data were examined. All patients were risk-stratified by using three prediction models: modified Demicco, De Perrot and Tapias. Overall survival (OS) and disease-free survival (DFS) were analysed. Results: There were 21 men and 13 women (median age, 67 years, range, 23-83 years). Twenty-one patients (62%) were symptomatic. The median follow-up was 111 months (range, 6-258 months). The 5-year OS and DFS were 81.2% and 77.4%, respectively. Nine patients (26.5%) experimented recurrences. At univariate analysis, the presence of necrosis (p = 0.019), nuclear atypia (p = 0.006), dimension greater than 11.5 cm (median value of our cohort) (p = 0.037) and relapse/disease progression (p = 0.001) were independent prognostic factor of worse OS. The administration of adjuvant treatment was a protective independent factor for survival (p = 0.001). Radicality of resection (p = 0.005); tumour dimension (p = 0.013), presence of necrosis (p = 0.041) and nuclear atypia (p = 0.007) and pleural pattern (p = 0.011) were independent prognostic factors of worse DFS. Analysing the three risk stratification models, the Tapias score was revealed as the best index to predict both OS (p = 0.002) and DFS (p = 0.047) in patients with mSFTP. Conclusions: Using the risk stratification model proposed by Tapias, patients with the highest risk of recurrence could be identified at the time of surgery to establish a more frequent imaging surveillance and longer follow-up. The role of adjuvant treatment in mSFTP therapy has not been established yet, but further analysis on patients with a high risk of recurrence, stratified according to risk models, along with biomolecular panels may tailor future post-surgical therapies.

Hybrid treatment of T3 chest wall lung cancer lobectomy.

Nowadays the treatment of patients with non-small cell lung cancer (NSCLC) that invades the chest wall is still questioned. The classic approach is a lobectomy that requires chest wall resection through thoracotomy, but thanks to the progress in the field of thoracoscopic surgery, this procedure can be performed by video-assisted thoracoscopic surgery (VATS). Major advances have been made in recent years both in the surgical technique associated with thoracoscopy and in the instrumentation available today. This has allowed the use of thoracoscopic technique even in advanced disease. To choose to perform complex surgery in assisted video surgery, considerable experience is needed to avoid making mistakes and giving up a better approach for the patient only for any technical difficulties. Thoracoscopy is not currently the preferred intervention for patients with chest wall invasion because there are insufficient studies on the feasibility of lobectomy with thoracoscopic wall resection, although the thoracoscopic approach has reduced mortality and morbidity in lung cancer cases not in advanced stage. We discuss our experience in three patients using hybrid approach with assisted video thoracoscopic lobectomy and a chest wall en-block resection with an alternative method of estimating thoracic wall resection that uses assisted video surgery and hypodermic needles (minimally invasive posterior approach).

Uniportal Videothoracoscopic Surgery: Our Indications and Limits.

OBJECTIVE: We present our experience with uniportal videothoracoscopic surgery (VATS-U), examining its indications, limits, and results. METHODS: Since January 2009, 66 patients underwent VATS-U for the following indications: pneumothorax (n = 25), lung nodule (n = 15; n = 10 with preoperative radiolocalization), wedge biopsy (n = 15), hyperhidrosis (n = 10), and chest wall schwannoma (n = 1). The conversion rate to conventional video-assisted thoracic surgery (VATS), postoperative pain, complications, residual paraesthesia, and hospitalization were analyzed. Operative time, postoperative pain, and paraesthesia were retrospectively compared with a cohort of 172 cases of conventional multiportal VATS, performed in the same period. RESULTS: Conversion to traditional VATS was necessary in two cases (pulmonary nodule, n = 1; pneumothorax, n = 1). The mean pain score was 0.8, the mean operation time was 42 minutes, and 10 patients had postoperative paraesthesia that lasted a mean of 7 days. No postoperative complications were reported, and the mean postoperative hospital stay was 3 days (range, 1-6 days). The comparison between the VATS-U and the standard multiportal VATS group showed in the VATS-U group a lower but not statistically significant pain score and paraesthesia as well as a lower and statistically significant operative time. CONCLUSIONS: Uniportal videothoracoscopic surgery has a wide range of indications: lung apex resections and pleurodesis for spontaneous pneumothorax treatment; pulmonary nodule assessment with or without preoperative localization; lung biopsy for interstitial diseases; unilateral or bilateral sympathectomy to treat hyperhidrosis; benign chest wall tumor evaluation. The limits of this technique are linked to pleural adhesions or lung nodules in difficult positions. In our experience, VATS-U results in minimal postoperative pain, allowing for fast functional recovery and a consequent short hospital stay; thus, we suggest that VATS-U is a valid alternative to traditional multiportal VATS for indications beyond cosmetic benefits. Prospective randomized trials are necessary to validate the advantages of uniportal VATS.

Carinal resection.

Carinal resections and reconstructions, with or without lung resection, are challenging operations that may be indicated in less than 1% of operable patients with NSCLC or benign lesions involving the carina. These operations are completed in only a few centers worldwide, likely because of their technical complexity and the general opinion about their limited patient benefit. However, good survival results can be expected in pN0 or pN1 patients so that, in experienced hands, these operations are effective options. The risk of postoperative complications can be minimized by several intraoperative and postoperative precautions.

Development and validation of a new outcome score in subglottic stenosis.

BACKGROUND: We prospectively evaluated a clinical and endoscopic score, the tracheal endoscopic clinical score (TECS), developed as a disease-specified outcome measure in adult patients undergoing operation for subglottic stenosis. We also performed a retrospective chart review to identify preoperative and intraoperative risk factors for worse TECS. METHODS: The TECS includes endoscopic (vocal cord and glottic function, anastomotic healing, and patency) and interview (respiration, voice, swallow) variables, and was administered at 6-month follow-up. Endoscopic and subjective domains were weighted to obtain a continuous TECS index ranging from 0 (best) to 1 (worse). The TECS and preoperative variables relationships were evaluated by univariate and multivariate analysis. RESULTS: We collected data (January 2009 to December 2010) from 30 patients (mean age, 48.3±19 years) undergoing subglottic resection and primary reconstruction. Stenosis etiology was postintubation (n=8), idiopathic (n=2), tracheostomy (n=18), and malignant (n=2). Surgery included Pearson operation with (n=7) or without (n=23) a Liberman-Mathisen cricoplasty. Mean length of resected trachea was 30.5±13.5 mm, and mean hospital stay was 7.4 days. Mortality rate was 1 patient (3.3%). The univariate analysis showed positive correlation between 6-month TECS and degree of stenosis (McCaffrey and Cotton scale 0 to 4) stage 4, tracheostomy or T-tube at surgery, bottleneck-type transition stenosis, and resection length. At multivariate analysis, the presence of tracheostomy, bottleneck-type transition stenosis and resection length were indicators of worse postoperative functional result. CONCLUSIONS: The TECS seems to be a valid and simple instrument to identify preoperative variables predicting worse results and to assess postoperative outcome. Validation on larger series is necessary.