Use of the hybrid room for thoracic surgery procedures: single-stage localization and removal of non-palpable nodules.

With the widespread availability of lung cancer screening programs, the number of small lung nodules requiring histological characterization has dramatically increased. Because computed tomography-guided fine-needle aspiration may frequently yield false-negative results, excisional biopsy using thoracoscopy is frequently required. Although thoracoscopic procedure has been known to be ideal for nodule resection, the identification of very small, subsolid and deep pulmonary nodules may still be challenging. Precise lesion localization is a key prerequisite to avoid conversion to an unplanned thoracotomy. In the traditional workflow, the localization procedure is performed in the radiology suite, after which the patient is moved to an operating room. With the availability of hybrid operating rooms, a new approach encompassing simultaneous localization and removal of non-palpable lung nodules has become feasible. In this article, we review the procedural workflow of this new technique and discuss its indications and results.

Role of endobronchial ultrasound-guided transbronchial needle aspiration in staging of lung cancer: a thoracic surgeon's perspective.

In potentially resectable non-small cell lung cancer (NSCLC) accurate mediastinal staging is crucial not only to offer the optimal management but also to avoid unnecessary surgery. Mediastinal staging is generally performed by the use of imaging techniques (computed tomography and positron emission tomography). However, the accuracy of radiological imaging in mediastinal staging is suboptimal. Therefore, additional invasive mediastinal staging is frequently required to select patients who can benefit from a neoadjuvant treatment. In recent years, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has progressively replaced mediastinoscopy as a test for invasive mediastinal staging. The considerable potential of EBUS-TBNA as minimally invasive staging method has been understood by pulmonologists since the early 2000s but only recently by thoracic surgeons. The clinical impact of this diagnostic technology has been broadly highlighted in the literature and EBUS-TBNA is currently considered the test of first choice in preoperative nodal staging of NSCLC. We analyze the actual role of EBUS-TBNA in invasive mediastinal staging of NSCLC patients from the thoracic surgeon point of view, with particular emphasis on the performance characteristics of this endoscopic diagnostic method as well as its clinical use within the published guidelines.

Single-Stage Localization and Thoracoscopic Removal of Nonpalpable Pulmonary Nodules in a Hybrid Operating Room.

OBJECTIVE: We report our experience with simultaneous localization and thoracoscopic removal for nonpalpable undiagnosed pulmonary nodules. METHODS: All patients with nonpalpable lesions requiring video-assisted thoracoscopic surgery (VATS) wedge resection underwent localization of the targets and surgical removal in a hybrid operating room. Lesions were considered nonpalpable if they were small (<1 cm), deep (>1 cm from the surface), subsolid, or located within a dystrophic area. In all cases, intraoperative cone-beam computed tomography was performed for nodule localization and targeting, metal hookwires, or coils were alternatively used for intraoperative marking. RESULTS: From April 2016 to November 2019, 39 image-guided VATS (iVATS) were performed. The mean lesion size was 12 ± 6 mm. The mean distance from the deep edge of the lesion to the pleural surface was 24 ± 9 mm. The localization was performed with 20 hookwires and 19 coils. iVATS localization was successful in 36 patients (92.3%). Thirty-seven wedge resections were completed by VATS, 2 (5%) required conversion to thoracotomy. In 9 patients with intraoperative diagnosis of lung cancer, a lobectomy was performed (7 VATS and 2 thoracotomies). Mean length of iVATS localization was 30 ± 13 minutes. Median postoperative length of stay was 4 days (IQR 3 to 5). CONCLUSIONS: iVATS seems to be a helpful tool for simultaneous localization and removal of nonpalpable nodules. A versatile approach using different devices seems advisable for the removal of targets in every clinical scenario reducing VATS conversion rate. Future research is required to compare iVATS with traditional preoperative localization techniques.

Enhanced recovery after surgery: adherence and outcomes in elderly patients undergoing VATS lobectomy.

OBJECTIVES: To evaluate whether ERAS is feasible and beneficial in elderly patients undergoing VATS lobectomy for lung cancer. METHODS: From February 2016 to March 2019, 182 patients were included into a 17-items ERAS pathway. Patients were divided into two groups according to age: Group A (< 75 years) 138 patients and Group B (≥ 75 years) 44 patients. End points were: length of stay (LoS), 30-day morbidity, 90-day mortality, 30-day re-admittance rate, and ERAS-score (number of ERAS objectives achieved). RESULTS: Elderly patients had significantly more chronic renal failure (p = 0.039) and a worse pulmonary function. Mean FEV1% was 101.6% (± 21.0% SD) and 90.8% (± 19.1% SD) and mean FEV1/FVC was 0.75 (± 0.10 SD) and 0.68 (± 0.12 SD) for group A and B, respectively (p = 0.02 and p = 0.01). Median LoS was longer in Group B (6 days) than in Group A (5 days; p = 0.006). Morbidity was higher for elderly patients (A 32.6% vs B 56.8%; p = 0.007), major complication rates were similar (p = 0.782). No post-operative mortality was observed, re-admittance rates were similar (A 7.8% vs B 11.5%; p = 0.548). Mean ERAS-scores were 13.8 (± 1.83 SD) for Group A and 13.4 (± 1.98 SD) for Group B (p = 0.240). Multivariable analysis showed previous major surgery (p = 0.028), COPD (p = 0.027), history of arrhythmic disease (p = 0.015), post-operative complications (p < 0.001), and ERAS-score (p < 0.001) as independent predictive factors of LoS, age did not significantly influence LoS. CONCLUSIONS: Elderly patients adhere to an ERAS protocol similarly to younger ones. ERAS pathway in VATS lobectomy patients seems to be beneficial regardless the age.

The Redax® Coaxial Drain in pulmonary lobectomy: a study of efficacy.

BACKGROUND: Pleural drainage is required after pulmonary lobectomy to evacuate air-leak and fluid. We compared the performance of the new Redax® Coaxial Drain (CD) (Redax, Mirandola, Italy) with a standard chest tube (CT) in terms of fluid and air-leak evacuation. METHODS: Fifty-two patients receiving a 24-F CD under water-seal after pulmonary lobectomy through open surgery or video-assisted thoracic surgery (VATS) were matched according to demographic, clinical and pathological variables with 104 patients receiving a 24-F CT. Fluid evacuation and post-operative day 0 (POD0) fluid evacuation rate, air-leak rate, tension pneumothorax or increasing subcutaneous emphysema, tube occlusion at removal, visual analog scale (VAS) score at rest and during cough, chest drain duration, pleural fluid accumulation or residual pleural cavity after tube removal, post-operative morbidity and mortality rate were recorded and compared between the two groups. RESULTS: No differences were recorded in post-operative morbidity and mortality rates. Fluid drainage rates on POD0 were significantly higher in CD group (73% vs. 48%; P=0.004); air-leak occurrence was similar in both groups and no differences were recorded in terms of tension pneumothorax or increasing subcutaneous emphysema rates; VAS score was lower for CD when compared with CT and it reached significant difference in the subgroups of patients operated on by VATS; no cases of occlusion at removal were recorded in CD patient. CONCLUSIONS: Redax® CD is safe and efficient in air-leak and fluid evacuation; due to its design and constituting material it is superior to standard CTs in terms of fluid evacuation rate and patient post-operative comfort.

Extralobar Pulmonary Sequestration Presenting with Recurring Massive Pleural Effusion in a Young Woman: A Challenging Case.

We report a case of extralobar pulmonary sequestration (ELS) in a young woman, presenting with right recurring massive pleural effusion. The patient initially underwent a diagnostic Video Assisted Thoracic Surgery (VATS) for a suspected diffuse malignancy. After the aspiration of the pleural effusion we observed a highly vascularised cystic mass, with its origin from the right lower lobe. As we tried to retract the right lower lobe, the mass broke with massive bleeding requiring emergency right lateral thoracotomy. The mass was succesfully excised, resembling an extra-lobar pulmonary sequestration. The patient was discharged on post-operative day 5.

Fibrosis pulmonar tardía (neumonía intersticial usual) en un paciente con antecedentes de neumonía asociada a H1N1 no complicada / No disponible

No disponible

Schwannoma del nervio vago mediastínico tratado exitosamente con toracoscopia biportal videoasistida / Mediastinal Vagus Nerve Scwhannoma Succesfully Treated by a Biportal VATS Approach

No disponible

Giant chordoma of the upper thoracic spine with mediastinal involvement: a surgical challenge.

Thoracic chordomas are very rare malignant tumours originating from notochordal remnants. These tumours develop within a vertebral body and enlarge involving the mediastinal compartment. Because of their slow-growing attitude, they become symptomatic only when they invade or compress the spinal cord and/or mediastinal organs. We present a rare case of a thoracic spine chordoma presenting with increasing paraparesis with a huge mediastinal component which was surgically debulked to decompress the spinal cord and medistinal organs.

Metastasis to subsegmental and segmental lymph nodes in patients resected for non-small cell lung cancer: prognostic impact.

BACKGROUND: We investigated the prognostic significance of segmental and subsegmental (level 13 and 14) lymph nodes metastasis in patients with resected non-small cell lung cancer (NSCLC). METHODS: The pattern of lymph nodal metastasis was analyzed in 124 patients with pN1 NSCLC. Long-term outcomes were compared for 390 pN0, 124 pN1, and 82 pN2 consecutive patients submitted to planned pulmonary resection for NSCLC between 2000 and 2006. The pN1 status was stratified into 3 groups according to the highest level of lymph node involvement: level 10 (hilar); level 11+12 (lobar + interlobar); and level 13+14 (segmental + subsegmental). RESULTS: The 5-year overall survival (OS) rates for pN0, pN1, and pN2 patients were 93%, 66%, and 25%, respectively. The highest level of lymph node involvement was a significant prognostic indicator; the 5-year OS rate for level 13+14, level 11+12, level 10 pN1, and pN2 was 81%, 58%, 48%, and 25%, respectively. Significant differences were recorded in long-term outcome when pN0 and pN1 level 13+14, pN1 level 13+14, and pN1 level 11+12, pN1 level 11+12 and pN1 level 10 were compared (p < 0.05). The median number of examined level 13+14 lymph nodes was 2 (range 0 to 6) and 57% pN1 patients had metastasis at level 13+14 lymph nodes. CONCLUSIONS: The highest level of lymph node metastases may be used to stratify outcome of patients with pN1 disease. Routine examination of level 13+14 lymph nodes is to be recommended to correctly identify patients at risk of relapse and predict long-term prognosis.

Non-small cell lung cancer in surgically treated women.

AIM AND BACKGROUND: To determine whether female patients operated on for non-small cell lung cancer (NSCLC) have a survival advantage compared to male patients. METHODS AND STUDY DESIGN: We analyzed data from 1,426 prospectively collected patients submitted to lung resection for NSCLC between 1999 and 2008. RESULTS: Two groups, including 1,014 male and 412 female patients, were compared. Female patients were significantly younger, were more frequently asymptomatic, were less likely to be smokers, had better preoperative respiratory function, had a lower frequency of COPD, and were less commonly affected by cardiovascular comorbidity than men. Adenocarcinoma was more frequently present and early pathological stage (stage IA) more frequently detected in women at diagnosis. The operative mortality was significantly lower among women (1.6% vs 4.6%) (P = 0.012), and women underwent significantly more segmentectomies and fewer pneumonectomies (P = 0.001). The disease-related 5-year survival rate was significantly higher in women (66% vs 51%) (P = 0.0008). At univariate analysis the absence of symptoms at presentation, lower pathological stage, squamous cell type, and female gender were positive factors influencing long-term survival. At multivariate analysis low pathological stage, squamous cell type and female gender were confirmed as independent positive prognostic predictors. Women had a significant survival advantage irrespective of the histological subtype at pathological stage IA, IB, IIB and IIIA disease (P <0.05). CONCLUSIONS: Female gender was confirmed to be a particular subset amongst patients affected by NSCLC and exerted a positive effect on disease-related survival of patients submitted to surgical resection. This important effect of gender should be cautiously kept in mind in analyzing the results of current and future trials for lung cancer therapy.

Use of the proposals of the international association for the study of lung cancer in the forthcoming edition of lung cancer staging system to predict long-term prognosis of operated patients.

PURPOSE: To evaluate the utility of the proposals of the International Association for the Study of Lung Cancer (IASLC) in the forthcoming 7th edition of lung cancer staging system to classify patients submitted to radical surgical resection of non-small cell lung cancer and to compare their value in predicting long-term prognosis with the existing 6th edition of the American Joint Committee on Cancer (AJCC)/Union Internationale Contre le Cancer (UICC) TNM classification. METHODS: Nine hundred twenty-one patients received an anatomic resection and hilar-mediastinal dissection for primary non-small cell lung cancer during the period 1990 to 2005. Histopathologic staging following the actual AJCC/UICC TNM classification were as follows: 207 T1, 562 T2, 148 T3, and 4 T4; 570 N0, 149 N1, 198 N2, and 4 N3; 163 stage IA, 346 IB, 23 IIA, 157 IIB, 224 IIIA, and 8 IIIB. Stages reclassified using the proposals of IASLC for the new staging system were as follows: 101 T1a, 106 T1b, 400 T2a, 103 T2b, 210 T3, and 1 T4; 163 stage IA, 262 IB, 157 IIA, 106 IIB, 230 IIIA, and 4 IIIB. RESULTS: Follow-up was obtained for 836 patients. Mean follow-up was 46.5 +/- 48.9 months. N-status (unchanged between the 2 classifications) was confirmed to be a significant prognostic factor. Significant differences in 10-year disease-related survival were demonstrated between stages IIB and IIIA only (35% vs 14%) of the AJCC/UICC TNM classification and between stages IB and IIA (60% vs 46%) and stages IIB and IIIA (39% vs 15%) of the IASLC proposals for a new classification. DISCUSSION: The proposals of IASLC in the forthcoming 7th edition of the lung cancer staging system are demonstrated to be better able to separate prognostically distinct groups of patients operated for non-small cell lung cancer than the accepted existing 6th AJCC/UICC TNM classification.

Air-leak management after upper lobectomy in patients with fused fissure and chronic obstructive pulmonary disease: a pilot trial comparing sealant and standard treatment.

A pilot trial to compare the efficacy of two different procedures to prevent postoperative air-leak in chronic obstructive pulmonary disease (COPD) patients submitted to upper lobectomy for non-small cell lung cancer. Sixty patients with COPD and lung cancer at the upper pulmonary lobes eligible for lobectomy were enrolled and randomly assigned either to standard treatment (ST) with stapling device or to electrocautery dissection and application of a collagen patch coated with human fibrinogen and thrombin (TachoSil) (experimental treatment [ET]) for the intra-operative completion of their fused fissures. Thirty patients were enrolled in each group during a three-year period. Preoperative characteristics were similar between the two groups. Statistically significant reduction of air-leak was registered in the ET group when overall incidence of postoperative air-leak (55% vs. 96%; P=0.03), postoperative air-leak (mean 1.63+/-1.96 vs. 4.33+/-4.12 days; P=0.0018), chest-drain (mean 3.53+/-1.59 vs. 5.90+/-3.72 days; P=0.0021) and hospital stay duration (mean 5.87+/-1.07 vs. 7.50+/-3.20 days; P=0.01) were considered. The use of TachoSil to prevent postoperative air-leak after interlobar fissure completion in patients with COPD submitted to upper lobectomy seems to be safe and more effective than the ST based on stapling device application.

Large-cell neuroendocrine carcinoma of the lung: a clinicopathologic study of eighteen cases and the efficacy of adjuvant treatment with octreotide.

OBJECTIVE: This study was undertaken to evaluate the efficacy of a new adjuvant protocol with octreotide, alone or in combination with radiotherapy, in radically resected large cell neuroendocrine carcinomas of the lung. METHODS: Between 1990 and 2001, a total of 18 consecutive patients affected by large cell neuroendocrine carcinomas of the lung were operated on. Lobectomy and systemic lymphadenectomy were performed in all cases. Postoperative radiotherapy was performed when stage was higher than Ib. Ten patients with positive results of preoperative indium In-111 pentetreotide scintigraphy received octreotide after the operation. RESULTS: Nine patients (50%) had local recurrences or distant metastases (mean recurrence time 14 months); palliative chemotherapy was given, but all patients died. In 10 cases (55.5%) octreotide alone or in combination with radiotherapy was administered as adjuvant treatment; 9 of these patients (90%) are alive and free of disease ( P = .0007), and the other had liver and brain metastases 21 months after surgery. CONCLUSIONS: Our preliminary results seem to demonstrate the efficacy of octreotide as adjuvant therapy in large cell neuroendocrine carcinomas of the lung when results of preoperative indium In-111 pentetreotide scintigraphy were positive. Further study are required to assess the utility of octreotide in patients with negative results of indium In-111 pentetreotide scintigraphy.