Lymph Node Involvement and the Surgical Treatment of Thymic Epithelial and Neuroendocrine Carcinoma.

BACKGROUND: Thymic epithelial and neuroendocrine carcinomas are rare malignancies, and only a few prognosticators are defined. Surgery is the mainstay of treatment, and complete resection contributes to superior outcome. Systematic lymph node dissection is not routinely performed in thymic malignancies. The aim of this study was to assess the impact of histologically confirmed lymph node metastases on the outcome after thymectomy. METHODS: We identified 53 patients with thymic epithelial or neuroendocrine carcinomas who underwent surgical resection at our center between 1999 and 2016. The clinical follow-up was retrospectively collected, and the impact of clinicopathologic factors on overall survival was analyzed. RESULTS: Ninety-one percent of the patients were treated taking a multimodal approach. Median overall survival was 11.3 years. Lymph node metastases were identified in 16 patients (30.2%; 11 pN1 and 5 pN2). Lymph node metastasis was associated with inferior overall survival (hazard ratio [HR] 3.03, 95% confidence interval [CI]: 1.03 to 8.87, p = 0.044). Masaoka-Koga stage (4 versus 1 to 3) was another significant prognosticator (HR 7.01, 95% CI: 2.52 to 19.50, p = 0.0002). Organ metastases were present in 18 patients at the time of thymectomy and were associated with inferior outcome (HR 5.8, 95% CI: 2.04 to 16.79, p = 0.001). CONCLUSIONS: This retrospective, single-center analysis demonstrates a high rate of lymph node metastasis in resectable thymic neuroendocrine tumors or carcinomas. Positive lymph nodes are associated with an inferior outcome. Prospective studies are warranted to explore whether this outcome can be improved by systematic lymphadenectomy and adjuvant therapies. Nevertheless, lymphadenectomy provides optimal staging and should be a routine part of surgery for patients with thymic malignancies.

Effectiveness of Robotic Lobectomy-Outcome and Learning Curve in a High Volume Center.

BACKGROUND: Robotic surgery has been developed as a sophisticated tool to expand possibilities in minimal invasive surgery. The learning curve for this method is short in various surgical fields; however, limited data exist on the learning curve in robotic thoracic surgery. METHODS: This study analyzes a single center experience of robotic lobectomies using a prospectively kept database. Perioperative data and outcome of patients during the learning curve were compared with patients operated with increased institutional experience. The learning curve was defined as the initial 20 lobectomies. RESULTS: Sixty-four robotic lobectomies were performed between January 2014 and February 2017. Indications, preoperative lung functions, comorbidities, patient age, and tumor stage were comparable between patients operated during the learning curve and thereafter. The mean operative time could be significantly reduced after the learning curve (286 ± 86 vs. 211 ± 62 minutes; p = 0.0003). The conversion rate dropped from 4 of 20 (20%) during the learning curve to 2 of 44 (4.5%, p = 0.07) thereafter. Chest tube duration (4.3 ± 2.9 vs. 3.8 ± 2.1 days) and hospital stay (8.3 ± 3.4 vs. 7.9 ± 4.5 days) were not different in the two phases. The number of resected lymph nodes increased from 11.2 ± 6.8 to 13.9 ± 6.5 (p = 0.0797). Lymph node upstaging was achieved in 8 (12.9%) cases. Ninety-day mortality was 0%, and 2-year overall survival was 83%. CONCLUSIONS: Robotic thoracic surgery can be safely performed and trained with low complication rates and contributes to the extension of minimal invasive thoracic surgery. The initial learning curve in our experience is overcome after 20 cases. However, to become proficient in more advanced procedures and to further reduce operative time, additional training is required. Prospective studies are required to clearly determine the role of robotic surgery in comparison to the video-assisted thoracoscopic surgery (VATS) procedures.

Pulmonary metastasectomy for sarcoma-Essen experience.

BACKGROUND: Pulmonary metastasectomy is an established treatment modality for patients with soft as well as bone tissue sarcomas. Aim of this study is to describe the Essen experience in the surgical management of patients with pulmonary sarcoma metastases. METHODS: This is a retrospective single center analysis of perioperative outcome of patients undergoing pulmonary metastasectomy for sarcoma metastases from 1997-2017 and a summary of published papers on this topic. RESULTS: During the observation period 327 patients (49.23% female) underwent pulmonary metastasectomy for metastases of extrathoracic sarcomas in curative intent. The number of resected metastases was 1-3 in 283 cases (86.54%), 4-9 in 31 cases (9.48%) and 10 or more lesions in 14 cases (4.28%). Wedge resections or precision excisions with laser or electrocautery were performed in 278 cases (85.02%), anatomical segmental resections in 16 patients (4.89%) and lobectomies in 33 patients (10.09%). Bilateral procedures were performed in 98 cases (29.96%). Lymphadenectomy was performed in 122 patients. Positive lymph nodes were found only in 6 cases. All of these cases were patients with soft tissue sarcoma as primary tumor. Preoperative neoadjuvant treatment was performed in 79 patients (24.15%) with chemotherapy, in 54 patients (16.51%) with radiochemotherapy and in 10 patients (3.05%) with radiotherapy. Major postoperative complications were observed in 2.75% of all patients. Thirty-day mortality was 0%. CONCLUSIONS: Pulmonary metastasectomy in sarcoma patients is a feasible and safe treatment strategy even in patients with bilateral metastases and multiple lesions. Thoracic lymph node metastases are rare and did not influence survival in our cohort.

Pulmonary manifestation of a condition resembling Kasabach-Merritt syndrome in a woman with abdominal angiomatosis associated with consumptive coagulopathy--surgical management: a case report.

INTRODUCTION: Kasabach-Merritt syndrome is a benign condition characterized by hemangiomatosis, severely disseminated intravascular consumption coagulopathy, and thrombocytopenia. The mortality rate increases from 12% to 30% in hemorrhagic cases. In general, the symptoms primarily manifest in the gastrointestinal tract, the skin, and the subcutaneous tissue. There is no publication about pulmonary manifestation of angiomatosis in combination with vascular malformation and hemoptysis. This is the first description of a Kasabach-Merritt syndrome-like condition in the lung. CASE PRESENTATION: We present the case of a 29-year-old German woman with angiomatosis and associated pulmonary vascular malformation in her lower left lobe with a Kasabach-Merritt syndrome like condition. It was detected after hemoptysis. We also present our case observations and management. CONCLUSION: In a case of angiomatosis with an associated pulmonary lobar vascular malformation, lobectomy can be safely performed to prevent life-threatening bleeding.

Surgery of primary lung cancer with oligometastatic m1b synchronous single brain metastasis: analysis of 37 cases.

BACKGROUND: At the time of diagnosis, lung cancer has often metastasized already. Brain metastases, however, are associated with a poor prognosis (median survival of less than 1 year). We evaluated the changes of the median survival after resection of the cerebral metastases and primary non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: Between January 1999 and December 2009, 37 patients (22 men, 15 women; median age: 55.64 years; age range: 38-72 years) underwent surgery for primary NSCLC after craniotomy and removal of the synchronous single brain metastasis. The overall survival was evaluated and risk factors identified. RESULTS: Mediastinal lymph node involvement was excluded with mediastinoscopy in 26 of the 37 patients. Postoperative N-stage was N0, N1, and N2 in 16 (43%), 10 (27%), and 11 (30%) patients, respectively. Histology was squamous cell carcinoma in 10 (27%), adenocarcinoma in 20 (54%), and large cell carcinoma in 7 (19%). The employed type of resection was anatomical segmentectomy in 6 and lobectomy in 31 patients. The 30-day mortality was 0% and postoperative complications occurred in 12 patients only (32%). The overall 1 and 2 years survival were 62 and 24%, respectively. None of the factors age, sex, tumor histology, primary location of the tumor, type of resection, adjuvant chemotherapy, or nodal status affected survival in the univariate analysis. CONCLUSIONS: The oncologic lung resection of NSCLC after the resection of a single brain metastasis can be implemented without an increased risk of complications or mortality. Despite the stage IV disease, the median survival appears encouraging.