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Open in new tab Download slide OBJECTIVES Total thymectomy in addition to medical treatment is an accepted standard therapy for myasthenia gravis (MG). Patients with severe generalized MG present life-threatening events, poor prognosis and higher risk of postoperative myasthenic crisis. The aim of our study is to investigate neurological and surgical results in patients with Myasthenia Gravis Foundation of America (MGFA) class IV and V MG following thymectomy. METHODS Data on 76 MG patients with preoperative MGFA classes IV and V who underwent thymectomy were retrospectively collected. Primary end points included short-term surgical outcomes and long-term neurological results including the achievement of complete stable remission and any improvement as defined by MGFA Post-Intervention Status criteria. RESULTS There were 27 (35.5%) males and 49 (64.5%) females; 53 (69.7%) were classified as MGFA class IV and 23 (30.3%) as class V. Thymectomy was performed through sternotomy in 25 (32.9%) patients, Video-assisted thoracic surgery (VATS) in 5 (6.6%) and Robot-assisted thoracic surgery (RATS) in 46 (60.5%). The median operative time was 120 (interquartile range: 95; 148) min. In-hospital mortality was observed in 1 (1.3%) patient and postoperative complications in 14 (18.4%) patients. The median postoperative hospital stay was 4 (interquartile range: 3; 6) days. Pathological examination revealed 31 (40.8%) thymic hyperplasia/other benign and 45 (59.2%) thymomas. Cumulative complete stable remission and improvement probabilities were 20.6% and 83.7% at 5 years and 66.9% and 97.6% at 10 years, respectively. A significant improvement rate was found in patients with age at the time of thymectomy of ≤50 years (P  = 0.0236), MGFA class V (P  = 0.0154) and acetylcholine receptor antibodies positivity (P  = 0.0152). CONCLUSIONS Thymectomy in patients with severe MG yields good perioperative outcomes and satisfactory long-term neurological improvement, especially for patients younger than 50 years, with MGFA class V and anti-AChR+ MG. [ABSTRACT FROM AUTHOR]

A study published in the European Journal of Cardio-Thoracic Surgery challenges conventional practices for chest tube management in lung surgery. Traditionally, chest tube removal has been based on criteria such as fluid drainage volume and duration of air leakage. However, the study proposes a new approach centered around gas flow rate and evaluation of intrapleural pressure. By demonstrating the feasibility and safety of removing chest tubes at higher gas flow rates, the study suggests that the conventional wisdom may need to be reevaluated. The study emphasizes the role of technology, such as digital drainage systems, in revolutionizing postoperative care practices. However, the study's limitations, including a small sample size and single-center nature, must be acknowledged and addressed through further research. The transition to this new paradigm requires a multifaceted approach, including technological advancements, comprehensive training for healthcare providers, and standardized protocols. The study highlights the potential benefits of expedited recovery and reduced hospital stays, but further analysis is needed to assess the impact on quality of life and socio-economic cost. Overall, the study prompts a reevaluation of established norms in chest tube management and emphasizes the importance of evidence-based practice and patient safety. [Extracted from the article]

Open in new tab Download slide OBJECTIVES This study reports the results of an international expert consensus process evaluating the assessment of intraoperative air leaks (IAL) and treatment of postoperative prolonged air leaks (PAL) utilizing a Delphi process, with the aim of helping standardization and improving practice. METHODS A panel of 45 questions was developed and submitted to an international working group of experts in minimally invasive lung cancer surgery. Modified Delphi methodology was used to review responses, including 3 rounds of voting. The consensus was defined a priori as >50% agreement among the experts. Clinical practice standards were graded as recommended or highly recommended if 50–74% or >75% of the experts reached an agreement, respectively. RESULTS A total of 32 experts from 18 countries completed the questionnaires in all 3 rounds. Respondents agreed that PAL are defined as >5 days and that current risk models are rarely used. The consensus was reached in 33/45 issues (73.3%). IAL were classified as mild (<100 ml/min; 81%), moderate (100–400 ml/min; 71%) and severe (>400 ml/min; 74%). If mild IAL are detected, 68% do not treat; if moderate, consensus was not; if severe, 90% favoured treatment. CONCLUSIONS This expert consensus working group reached an agreement on the majority of issues regarding the detection and management of IAL and PAL. In the absence of prospective, randomized evidence supporting most of these clinical decisions, this document may serve as a guideline to reduce practice variation. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Radical resection of thymoma is the most important predictor of survival; despite a complete resection, 10-30% of patients develop a recurrence. The surgical treatment of thymic relapses is an accepted therapeutic approach; however, no clear data are available yet regarding the indication for surgery and the long-term prognosis of this subset of patients. The aim of our work was to review the data of a group of recurrent thymomas treated by surgery, comparing it with non-surgical therapy, and analysing the outcome and the prognostic factors. METHODS: Between 1980 and 2010, 880 patients with thymoma underwent complete macroscopical resection and were followed up for recurrence. Masaoka stage IVa and type C thymic tumours were excluded from the study. A total of 82 (9.3%) patients developed a recurrence, and 52 (63.4%) were reoperated. The other 21 patients, originally operated outside, underwent surgical resection of recurrence. Finally, 73 patients were operated on for recurrent thymoma and 30 received medical treatment. This entire cohort represents the subject of the study. RESULTS: There were 57 (55.3%) males and 46 (44.7%) females. The median time to relapse was 50 months. Sixty-three (61.2%) recurrences were regional, 17 (16.5%) local, 14 (13.6%) distant, 6 (5.8%) regional and distant, and 3 (2.9%) local, regional and distant. No operative mortality was observed. In 50 (68.5%) patients, a macroscopic complete resection was accomplished. The 5- and 10-year overall survival rates from recurrence were 63 and 37%, respectively. Complete surgical resection was associated with a significant better survival when compared with incomplete surgical resection and non-surgical treatment (P < 0.0001). A significant poorer prognosis was observed for multiple versus single relapses (P < 0.0001), Masaoka stage III primary tumour versus Masaoka stage I-II primary tumour (P = 0.02), distant versus loco-regional relapses (P = 0.05) and B3 histotype versus other (P = 0.02). On multivariate analysis, completeness of resection, number of metastases, Masaoka stage of primary tumour and site of relapse were identified as the only independent predictors of prognosis. CONCLUSION: Reoperation for recurrent thymoma is effective and safe, achieving a prolonged survival. Complete macroscopic resection and single recurrence are associated with better prognosis. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Recurrences of thymoma are described in 10-30% of cases up to 10 years after surgical resection. Herein we report our experience with surgical removal of pleural recurrences followed by hyperthermic intrathoracic perfusion chemotherapy (HITHOC). METHODS: We prospectively collected data of patients with pleural recurrence of thymoma who underwent surgery followed by HITHOC. After thoracotomy had been closed, drainages were connected to a dedicated perfusion machine, pleural space was filled with saline solution, progressively heated up to 42.5°C. At this time, chemotherapeutic agents (Doxorubicin and Cisplatin) were injected and perfusion lasted 60 min. RESULTS: In the period 2005-2012, 13 consecutive patients have been treated (8 males, 5 females, mean age 46 years). Initial Masaoka-Koga stage was 2 IIa, 5 IIb, 5 III, 1 IVa. Disease-free interval was 47.2 months on average [standard deviation (SD): 25.5]. Nine patients presented paraneoplastic syndromes (8 myasthenia gravis and 1 red cell aplasia). Complete resection was achieved in all cases except one. HITHOC was successfully performed in all cases and no signs or symptoms of toxicity were recorded in the perioperative period. With a mean follow-up period of 64.6 months (SD: 32.5), 1 patient died for toxicity following systemic chemotherapy, another one died disease-free, 4 patients developed pleural relapses (2 ipsilateral, 2 contralateral) and 1 mediastinal and abdominal nodal metastases. Mean survival was 58 months [SD: 34.4), median survival by the Kaplan-Meier method was not reached while 5-year actuarial survival was 92%. CONCLUSIONS: HITHOC was shown to be feasible and safe. In terms of efficacy, it seems promising but multicentre studies and a longer follow-up period are required to ascertain its effectiveness. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The World Health Organization (WHO) thymoma histological classification clinical value remains a controversy. In this study, we evaluated its prognostic significance in patients with thymoma treated with radical intent. METHODS: Six high-volume Italian Thoracic Surgery Institutions collaborated with their own retrospective anonymized datasets. Demographic, clinical, pathological and treatment data were examined. AWHO histological classification (WHO-HC) collapsed scheme (A/AB and B1/B2 types merged) was proposed and compared with the traditional one. Predictors of survival were assessed using a Cox model with shared frailty. Competing-risk regression models were performed to identify the association between individual factors and freedom from recurrence. RESULTS: Between 1990 and 2011, 750 thymomas were operated on in participating centres. Myasthenia gravis was observed in 363 (48%) patients. A complete resection was achieved in 676 (91%) cases. One hundred and nine patients (15%) had a WHO-HC A type, 166 (22%) AB, 179 (24%) B1, 158 (21%) B2 and 135 (18%) B3. The rate of 5-year OS and cumulative incidence of recurrence for all cases was 91% and 0.11, respectively. Five-year survival rates by WHO-HC in the collapsed scheme were A/AB 93%, early-B 90% and advanced-B 85%. Masaoka stage only was demonstrated to be an independent predictor for survival and recurrence. TheWHO-collapsed scheme showed a trend in influencing recurrence overall survival development (hazard ratio: 1.32; P = 0.16). CONCLUSIONS: Our results show evidence of lack of significance by WHO-HC in influencing prognosis, even though the proposed collapsed scheme revealed a fair stratification of risk to relapses and better correlation with patients' clinical characteristics. [ABSTRACT FROM AUTHOR]

OBJECTIVES The aim of this study was to analyse the results of robotic lobectomy for lung cancer. The evolution of technique and technology was evaluated. METHODS During the period 2004–12, all patients who underwent robotic lobectomy for clinical early-stage lung cancer were retrospectively reviewed. The patients were divided into two groups. Group 1 included 69 patients operated by the first generation of surgical robotic system. Group 2 included 160 patients treated with the latest generation of surgical robotic system. Age, gender, comorbidities, operative time, docking time, conversion rate, morbidity, mortality and length of postoperative stay were compared in both groups. RESULTS The two groups were homogeneous in terms of age, gender and comorbidities. Histopathological analysis showed 41 and 107 adenocarcinomas, 27 and 37 squamous cell carcinomas, 1 and 7 large cell carcinomas, in Groups 1 and 2, respectively, and 5 sarcomatoid carcinomas and 4 carcinoids in Group 2. The pathological stage for Group 1 was Stage I (48 cases), Stage II (17 cases) and Stage III (4 cases). For Group 2, Stage I was found in 115 cases, Stage II in 30 cases and Stage III in 15 cases. The mean operative time was 237 (standard deviation (SD) + 66.9) and 172 (SD ± 39.6) min for Groups 1 and 2 (P = 0.002), respectively. The conversion rates were, respectively, 10.1 and 5.6% (P = 0.21), mortality rates 1.4 and 0% (P = 0.30) and morbidity rates 22 and 15% (P = 0.12). The mean length of postoperative stay was 4.4 (SD ± 3.1) and 3.8 days (SD ± 2.2) (P = 0.26), respectively. CONCLUSIONS This study suggests a positive trend in the outcomes for patients who underwent the upgraded robotic system surgery compared with those treated by the standard system. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Radiofrequency ablation (RFA) of lung tumours has recently received much attention for the promising results achieved. Herein, we report the 5 years experience of a single referral centre in Europe, with particular reference to the mid-term results. Methods: Between October 2001 and June 2005, we performed 88 RFAs of lung tumours, 9 of which were followed by surgical resection. The remaining 79 RFAs, the object of this paper, were performed to treat 64 lesions in 54 patients: 39 males and 15 females with a mean age of 71.7 years (range of 51–89). All patients had clinical or pathological evidence of the neoplastic lesion, which was non-small cell lung cancer (NSCLC) in 40 cases and a metastasis in 24 cases. The mean size of the lesions was 2.4cm (range of 1–5). Ten lesions were re-treated from one to as many as four times. The procedure was always performed under local anaesthesia and conscious sedation. A generator of RF with max power output of 200W was utilised together with a needle with nine deployable electrodes, to achieve a target temperature of 90°C that was maintained for 15–27min according to the size of the lesions. Results: In all cases, except two, the procedure was technically successful. Morbidity consisted in 10 cases (12.7%) of partial pneumothorax, 1 haematoma of the chest wall and 1 pleural effusion. At a mean follow-up of 23.7 months (range of 6–50) we recorded a 61.9% of complete responses, with a higher rate in the metastatic lesions (70.8%) and in those smaller than 3cm (69.7%). Mean (median) overall survival and local progression-free interval were 17.3 (28.9) months and 12.9 (24.1) months, respectively. Conclusions: Efficacy of RFA in the mid-term seems to settle at a promising level, with better results for metastatic lesions and, above all, for lesions smaller than 3cm. Notwithstanding these encouraging results, RFA remains an alternative local therapy only when surgery cannot be performed, especially in NSCLC. [Copyright &y& Elsevier]

OBJECTIVES The aim of this study was to report a single referral centre experience in robotic extended thymectomy for clinical early-stage thymomas, evaluating its safety, feasibility and efficacy, with special regard to oncological outcomes. METHODS Between April 2002 and February 2011, we retrospectively selected all those patients who underwent robotic thymectomy for clinical early-stage thymomas. Operative time, morbidity, mortality, duration of hospitalization and overall and disease-free survival were analysed. RESULTS There were 14 patients (8 males, 6 females) with a mean age of 65.2 years (range 23–81). One patient suffered from myasthenia gravis. The WHO classifications were: A in two cases, AB in four cases, B1 in three cases, B2 in two cases and B3 in three cases. The Masaoka stages were: I in seven cases, IIA in four cases, IIB in two cases and III in one case. The mean operative time was 139 min. No intra-operative complication or death occurred. Conversion to open surgery was required in two cases. Minor complications occurred in two patients (14.2%) due to pleural effusion. The mean hospitalization was 4.0 days. Five patients underwent adjuvant radiotherapy. All patients were alive with no disease recurrence, with a median follow-up of 14.5 months (range 1–98). CONCLUSIONS Robotic thymectomy is a safe and feasible technique, with a short operative time and low morbidity. Even on a small series with short follow-up, robotic extended thymectomy for thymoma appeared to be an effective treatment for early-stage thymomas. [ABSTRACT FROM AUTHOR]