Robotic-Assisted Resection of Rare Mitral Valve Hemangioma.

Cardiac hemangiomas are extremely rare tumors accounting for only 1.5%-2.5% of all cardiac tumors. According to most recent literature, only 13 mitral valve hemangiomas have been reported. A 78-year-old man was undergoing routine transthoracic echocardiography monitoring for an ascending aortic dilation when a vegetation on the mitral leaflet was incidentally detected. This lesion presented as a 0.5- × 0.6-cm mobile mass arising from the medial aspect of the A2 cusp. Despite the asymptomatic nature of the aforementioned lesion, resection was pursued given presumed diagnosis of papillary fibroelastoma and concern for risk of stroke. The mass was resected using minimally invasive robotic approach, and final pathology was consistent with hemangioma.

Routine Use of Preoperative Neck Ultrasound in Primary Hyperparathyroidism Identifies Coexisting Thyroid Disease and Improves Parathyroid Localization.

BACKGROUND: In Jan 2018, we began routinely obtaining neck ultrasound (US) with 123I/99Tc-sestamibi (MIBI) for parathyroid gland localization and to identify thyroid pathology in the setting of primary hyperparathyroidism (1HPT). The aim of this study is to assess if routine neck US is a useful adjunct to 123I/99Tc-MIBI in 1HPT. METHODS: Patients undergoing surgery for 1HPT with both 123I/99Tc-MIBI and US at our institution after implementation of routine US were reviewed. Biopsy and surgical management of thyroid pathology was evaluated. 123I/99Tc-MIBI and US results were compared to intraoperative findings to determine sensitivity and positive predictive value (PPV) for parathyroid localization. RESULTS: From January 2018 to September 2019, there were 423 patients (mean, 61 years) that met inclusion criteria (80% women). Thyroid nodules were found on US in 57%, mean size 1.3 + 0.8 cm. Fine needle aspiration (FNA) was performed in 87 patients with nodules (36%). 35 patients (8.5%) required total or partial thyroidectomy for diagnoses/treatment. Papillary thyroid cancer (PTC) was found in 3.5% of the cohort with micro-PTC 53% and PTC 1-2 cm 40%. A successful parathyroid operation for 1HPT was achieved in 98.6% of patients. Positive predictive value for localization of abnormal parathyroid glands was 97% when US and 123I/99Tc-MIBI had concordant findings. DISCUSSION: Routine use of US in 1HPT commonly identifies nodules that are benign or low-risk PTC. Ultrasound is less sensitive for parathyroid localization but when used with 123I/99Tc-MIBI, concordant imaging has a high PPV.

Use of pharmacogenetic data to guide individualized opioid prescribing after surgery.

BACKGROUND: Despite the current strategies aimed at avoiding opioid overprescription by implementing institutional guidelines, the use of opioids after surgical procedures remains highly variable. It is well known that opioids are activated by the cytochrome p450 CYP2D6 enzyme to exert pharmacologic effect. Individual variation in CYP2D6 activity affects drug metabolism, and genotyping can be performed to predict an individual's ability to metabolize CYP2D6 substrates. We postulate that the pharmacogenomic identification of patients with different opioid metabolism capacity may allow for the individualization of postsurgical opioid prescription. METHODS: This study was generated by the unison of data from 2 prior initiatives taking place at our Institution. In the first study, patients undergoing 1 of 25 elective surgical procedures were prospectively identified as part of a quality initiative and surveyed by phone 21 to 35 days after hospital discharge to complete a 29-question survey regarding opioid utilization and pain experience. Additional chart abstraction was conducted to obtain prescribing data and pain scores during the hospitalization. The second study was the Mayo Clinic Right Drug, Right Dose, Right Time study protocol, in which 5 pharmacogenes, including CYP2D6, were genotyped for 1,000 Mayo Clinic Biobank participants. The goal of this study was to implement preemptive pharmacogenomics in an academic health care setting and to generate data for further pharmacogenomic research. Patients were classified by their predicted CYP2D6 activity based on their CYP2D6 genotype. RESULTS: Of the 2,486 patients with prospective opioid utilization data, 21 had pharmacogenetic data available and were included in the analysis. These patients were classified according to their activity as opioid metabolizers, with 10 patients (48%) classified as intermediate, 4 patients (19%) as intermediate to normal, and 7 patients (33%) as normal or extensive. Compared with the intermediate to normal and intermediate phenotypes, normal or extensive patients had the highest percentages of preoperative opioid naivety and recorded pain scores throughout the surgical experience. The percentage of unused opioids for intermediate, intermediate to normal, and normal or extensive categories was 79%, 63%, and 46%, respectively. Moreover, of the 14 patients declaring the highest level of satisfaction for their pain control after discharge, 60% belonged to intermediate, 100% to intermediate to normal, and 57% to the normal or extensive group. CONCLUSION: This study outlines a possible correlation between genetically controlled metabolism and opioid requirements after surgery. In this setting, an increased CYP2D6 enzymatic activity was associated to a greater opioid consumption, lesser amount of unused opioids, and a lower satisfaction level from opioid prescription.

Breathprinting and Early Diagnosis of Lung Cancer.

The electronic nose (e-nose) is a promising technology as a useful addition to the currently available modalities to achieve lung cancer diagnosis. The e-nose can assess the volatile organic compounds detected in the breath and derived from the cellular metabolism. Volatile organic compounds can be analyzed to identify the individual chemical elements as well as their pattern of expression to reproduce a sensorial combination similar to a fingerprint (breathprint). The e-nose can be used alone, mimicking the combinatorial selectivity of the human olfactory system, or as part of a multisensorial platform. This review analyzes the progress made by investigators interested in this technology as well as the perspectives for its future utilization.

Bipolar sealing devices in video-assisted thoracic surgery.

Intraoperative bleeding is one of the main severe complications in complete video-assisted thoracic surgery (c-VATS) and post-operative air-leaks prevention still represents an important challenge. Usually, hemostasis is often difficult and unsafe when the VATS approach is performed and the potential role of bipolar sealing devices is still undefined, as proven by limited experiences reported in the literature. By introducing endostaplers in VATS surgery, it was possible to perform safe thoracoscopic resections of lung. On the other hand, several diathermy techniques have been proposed to reduce intraoperative blood loss in surgery. In particular, standard bipolar technology has proven to effect coagulation in small vessels. The aim of this study is to compare bipolar electro thermal devices to endostapler in VATS lung resections concerning intraoperative bleeding and post-operative air leaks.

Segmentectomy versus lobectomy for stage I non-small cell lung cancer: a systematic review and meta-analysis.

BACKGROUND: In recent years, many factors have revamped the interest in segmentectomies as preferred procedure for stage I non-small cell lung cancer (NSCLC). The aim of this systematic review and meta-analysis is to compare the outcomes of segmentectomy versus lobectomy regarding overall survival (OS) in the surgical treatment of stage I NSCLC, as stated in the conclusions of the largest studies conducted in this field and reported to date. METHODS: The searching strategy was developed in EMBASE, MEDLINE and Cochrane CENTRAL from 1990 until December 2016. The meta-analysis was performed with the combination of the reported survival outcomes of the individual studies using a random effect model. The OS of the lobectomy group was compared with the segmentectomy group alone. The hazard ratio (HR) and standard error were extracted or calculated for each study using the Kaplan-Meier method. RESULTS: Regarding the results, most of these studies were based on the retrospective data. The size of the cohorts varied from 17 to 11,520, with a total number of 24,542 patients. The pooled HR was 1.04 [95% confidence interval (CI), 0.92-1.18; P=0.50]. CONCLUSIONS: The survival in the segmentectomy group was not inferior to patients treated with lobectomy. In conclusion, the current meta-analysis disclosed that segmentectomies produce similar survival compared to lobectomy for patients with stage I NSCLC. To establish the role of segmentectomy in early NSCLC, more evidence is needed, in particular, a large numbered, prospective, randomised trials, which should dissolve the uncertainties and the questions raised by retrospective data.

Suction or Nonsuction: How to Manage a Chest Tube After Pulmonary Resection.

Despite several randomized trials and meta-analyses, the dilemma as to whether to apply suction after subtotal pulmonary resection has not been solved. The combination of a poorly understood pathophysiology of the air leak phenomenon and the inadequate quality of the published randomized trials is actually preventing thoracic surgeons from abandoning an empirical management of chest drains. Even digital systems do not seem to have made the difference so far. Based on the evidence of the literature, the authors propose a new air leak predictor score (ALPS) as a contributing step toward appropriateness in using intraoperative sealants, opting for an external suction and managing and chest tubes.

Does prophylactic ligation of the thoracic duct reduce chylothorax rates in patients undergoing oesophagectomy? A systematic review and meta-analysis.

A systematic review of English and non-English articles using OVID MEDLINE (1980-2014) was performed to evaluate the potential value of prophylactic ligation of the thoracic duct in preventing chylous leakage after oesophagectomy for cancer. Search terms included [Oesophagectomy OR esophagectomy] AND [chylothorax] AND [thoracic duct ligation]. Only those papers that directly compared the incidence of chylothorax in patients who underwent prophylactic ligation [ligation group (LG)] with that in those who had conservative treatment were selected [preservation group (PG)]; all the articles presenting original data and supplying sufficient information on the chylothorax rate after oesophagectomy were included. Independent extraction of articles was performed by two authors using predefined data fields, including study quality indicators. The PRISMA guidelines were carefully adhered to. A total of 5254 subjects were included in the 7 clinical studies examined into the current meta-analysis. Of these, 2179 patients underwent prophylactic ligature of the thoracic duct (LG group) and 3075 had preservation of the thoracic duct (PG group). A significant difference in terms of chylothorax rate [odd ratios (ORs) 0.47 in favour of LG, 95% confidence interval (CI) 0.27-0.80] was noted between the LG group and the PG group. According to our meta-analysis and taking into account-specific caveats, prophylactic ligation of the thoracic duct could be considered as an effective preventative measure to reduce the incidence of postoperative chylothorax.

BIONOTE e-nose technology may reduce false positives in lung cancer screening programmes†.

OBJECTIVES: Breath composition may be suggestive of different conditions. E-nose technology has been used to profile volatile organic compounds (VOCs) pattern in the breath of patients compared with that of healthy individuals. BIOsensor-based multisensorial system for mimicking NOse, Tongue and Eyes (BIONOTE) technology differs from Cyranose® based on a set of separate transduction features. On the basis of our previously published experience, we investigated the discriminating ability of BIONOTE in a high-risk population enrolled in a lung cancer screening programme. METHODS: One hundred individuals were selected for BIONOTE based on the attribution to the high-risk category (i.e. age, smoking status, chronic obstructive pulmonary disease status) of the University Campus Bio-Medico lung screening programme. We used a measure chain consisting of (i) a device named Pneumopipe (EU patent: EP2641537 (A1):2013-09-25) able to catch exhaled breath by an individual normally breathing into it and collect the exhalate onto an adsorbing cartridge; (ii) an apparatus for thermal desorption of the cartridge into the sensors chamber and (iii) a gas sensor array which is part of a sensorial platform named BIONOTE for the VOCs mixture analysis. Partial least square (PLS) has been used to build up the model, with Leave-One-Out cross-validation criterion. Each breath fingerprint analysis costs €10. RESULTS: The overall sensitivity and specificity were 86 and 95%, respectively, delineating a substantial difference between patients and healthy individuals. CONCLUSIONS: Our preliminary data show that BIONOTE technology may be used to reduce false-positive rates resulting from lung cancer screening with low-dose computed tomography in a cost-effective fashion. The model will be tested on a larger number of patients to confirm the reliability of these results.

Validation of the new IASLC/ATS/ERS lung adenocarcinoma classification: a surgeon's perspective.

The conclusions from the new IASLC/ATS/ERS lung adenocarcinoma classification portend important clinical consequences. The interpretation of the histological, biomolecular and radiological correlates of this classification not only allows for the definitive abandonment of the bronchoalveolar carcinoma definition but provides surgeons with significant clues to better understand the adenocarcinoma subsets and their surgical management. Indeed, the information will benefit surgeons who are fully involved in the lung cancer CT screening programs as well as in the diagnostic and therapeutic pathways of both early and locally advanced lung cancer. Moreover, intriguing perspectives are disclosing on the inclusion of the surgical modality among the ones used in the oligometastatic disease status. On the other hand, the new adenocarcinoma classification also emphasizes the need for surgeons working in a multidisciplinary environment to be thoroughly cognizant of the ever evolving lung cancer biomolecular knowledge and, in particular, of the potentially druggable somatic mutations in line with the modern professional profile of the so-called "surgeon scientist".

Spindle cell lipoma: a rare tumor of the mediastinum.

Spindle cell lipoma (SCL) is a rare mediastinal tumor hard to be differentiated from myxoid liposarcoma. We report a patient with an expanding fat density in the aorto-pulmonary window and with a previous history of invasive melanoma of the left pectoralis and subsequent pulmonary metastases successfully treated with chemotherapy. Preoperative diagnosis of the mediastinal lesion was difficult but crucial to determine further therapeutic plan.

Primary intrapulmonary malignant peripheral nerve sheath tumor mimicking lung cancer.

Malignant peripheral nerve sheath tumors (MPNSTs) are sarcomas originating from the cells constituting the nerve sheaths such as Schwann cells, perineural cells or fibroblasts. They represent approximately 5-10% of all soft tissue sarcomas. They have been rarely observed in the lung. We describe a rare case of primary lung MPNST in an elderly male patient, in which surgical approach has obtained a good control of the disease. Immuno-histochemical and molecular analyses have been required on the surgical specimen due to inadequate possibility of recognition through morphology alone.