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Malignant pleural effusion (MPE) from patients with advanced non-small-cell lung cancer (NSCLC) has been proven valuable for molecular analysis; however, simultaneous detection of driver fusions in MPE is still challenging. In this study, we investigated the Idylla™ GeneFusion Panel, a stand-alone test in tissue samples, in the evaluation of ALK , ROS1 , RET and MET ex14 skipping mutations in MPE and compared its performance with routine reference methods (Real-time-based and Next-generation Sequencing-NGS). The inclusion criteria for sample selection were as follows: advanced NSCLC harboring ALK , ROS1 , RET fusions or MET exon-skipping alterations and the availability of MPE collected at diagnosis or disease progression. Molecular alterations have been investigated on tissue by fluorescence in situ hybridization (FISH) or Real-time PCR or NGS. For molecular profiling with the Idylla™ GeneFusion, 200 µL of MPE supernatants combined with 50 µL of RNA Later solution were loaded into the Idylla™ cartridge without cfRNA extraction. The Idylla™ GeneFusion Assay performed on MPEs was able to confirm molecular profile, previously diagnosed with conventional methods, in all cases. Our data confirm that MPE are suitable material for investigating fusion alterations. The Idylla™ GeneFusion, although indicated for investigation of tissue samples, offers the possibility of performing a molecular characterization of supernatants without undertaking the entire cfRNA extraction procedure providing a rapid and reliable strategy for the detection of actionable genetic alterations.

Introduction: We report a single-center experience of resection and reconstruction of the heart and aorta infiltrated by lung cancer in order to prove that involvement of these structures is no longer a condition precluding surgery., Methods: Twenty-seven patients underwent surgery for lung cancer presenting full-thickness infiltration of the heart (n = 6) or the aorta (n = 18) and/or the supra-aortic branches (subclavian n = 3). Cardiac reconstruction was performed in 6 patients (5 atrium, 1 ventricle), with (n = 4) or without (n = 2) cardiopulmonary bypass, using a patch prosthesis (n = 4) or with deep clamping and direct suture (n = 2). Aortic or supra-aortic trunk reconstruction (n = 21) was performed using a heart-beating crossclamping technique in 14 cases (8 patch, 4 conduit, 2 direct suture), or without crossclamping by placing an endovascular prosthesis before resection in 7 (4 patch, 3 omental flap reconstruction). Neoadjuvant chemotherapy was administered in 13 patients, adjuvant therapy in 24., Results: All resections were complete (R0). Nodal staging of lung cancer was N0 in 14 cases, N1 in 10, N2 in 3. No intraoperative mortality occurred. Major complication rate was 14.8%. Thirty-day and 90-day mortality rate was 3.7%. Median follow-up duration was 22 months. Recurrence rate is 35.4% (9/26: 3 loco-regional, 6 distant). Overall 3- and 5-year survival is 60.9% and 40.6%, respectively., Conclusions: Cardiac and aortic resection and reconstruction for full-thickness infiltration by lung cancer can be performed safely with or without cardiopulmonary bypass and may allow long-term survival of adequately selected patients., (Copyright © 2023. Published by Elsevier Inc.)

The role of a systematic lymphadenectomy in patients undergoing surgery for clinical stage I lung lepidic adenocarcinoma is still unclear. In the last years, some authors have advocated the possibility to avoid a complete lymph-node dissection in this setting. Results of patients who received systematic hilar-mediastinal nodal dissection for this oncologic condition are here reported. Between 2012 and March 2019, 135 consecutive patients underwent lung resection for clinical stage I lepidic adenocarcinoma, at our institution. Only patients (n = 98) undergoing lobectomy or sublobar resection associated with systematic hilar-mediastinal nodal dissection were retrospectively enrolled in the study. Patients' mean age was 67.8 ± 8.7 years (range 37-84). Three were 52 females and 46 males. Resection was lobectomy in 77.6% (n = 76) and sublobar in 22.4% (n = 22). All the resections were complete (R0). Histology was lepidic predominant adenocarcinoma in 85 cases and minimally invasive adenocarcinoma in 13 cases. At pathologic examination, N0 was confirmed in 78 patients (79.6%), while N+ was found in 20 cases (20.4%), (N1 in 12, 12.2% and N2 in 8, 8.2%). No mortality occurred. Complication rate was 8.2%. At a median follow-up of 45.5 months, recurrence rate was 26.5%. Disease-free 5-year survival was 98.6% for stage I, 75% for stage II and 45% for stage III, p < 0.001. A complete nodal dissection can reveal occult nodal metastases in lepidic adenocarcinoma patients and can increase the accuracy of pathologic staging. N1/N2 disease is a negative prognostic factor for this histology. A systematic lymph-node dissection should be considered even in this setting., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: We investigated whether adjuvant chemotherapy, extent of resection, and immunoistochemical neuroendocrine markers affected survival of patients with the early stage of large-cell neuroendocrine cancer., Methods: This was a retrospective multicenter study including consecutive patients undergoing resection of node negative large-cell neuroendocrine carcinoma. Five-year survival and disease-free survival rate were evaluated by the Kaplan-Meier method and the log-rank test in relation to adjuvant chemotherapy, extent of resection, and immunoistochemical neuroendocrine markers (synaptophysin, chromogranin A, and neuron-specific enolase)., Results: Our study population included 117 patients; 47 (40%) of these received adjuvant chemotherapy. Patients treated with adjuvant chemotherapy had better survival (74% vs. 45%, p = 0.002) and disease-free survival (79% vs. 40%, p = 0.001) in all cases except patients with tumor <20 mm (79.5% vs. 57.4%, p = 0.43). Lobectomy compared to sublobar resection was associated with better survival (67% vs. 0.1%, p < 0.0001) and disease-free survival (65% vs. 0.1%, p < 0.0001) also in patients with tumor <20 mm (79% vs. 28%, p = 0.001). Patients with triple-positive neuroendocrine markers had better survival (79% vs. 35%, p = 0.0001) and disease-free survival (69% vs. 42%, p = 0.0008). Regression analysis showed that tumor size <20 mm, lobectomy, adjuvant chemotherapy, and triple-positive immunistochemical neuroendocrine markers were significant favorable prognostic factors for survival outcomes., Conclusions: Lobectomy seems to be the management of choice in patients with large-cell neuroendocrine cancer <20 mm while adjuvant chemotherapy should be administered only in patients with tumor >20 mm., (© 2022 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Background: Resection of lung cancer infiltrating the aortic arch or the subclavian artery can be accomplished in selected patients with the use of cardiopulmonary bypass (CPB). Direct cross-clamping of the aortic arch and the left subclavian artery without CPB for radical resection of the tumor can be an alternative. This study presents one group's experience with this technique., Methods: Between October 2016 and May 2019, 9 patients (5 male, 4 female) underwent radical resection of lung cancer infiltrating the aortic arch (n = 5) or the left subclavian artery (n = 4) by direct cross-clamping technique at Sapienza University of Rome, Italy. Seven left upper lobectomies, 1 left pneumonectomy, and 1 left upper sleeve lobectomy were performed. Reconstruction of the aortic arch was performed by direct suturing or polyethylene terephthalate (Dacron) patch, whereas the subclavian artery was reconstructed with a Dacron conduit. Three patients received neoadjuvant chemotherapy., Results: Patients' mean age was 64.7 ± 13.3 years (range, 36 to 78 years). Aortic arch resection was partial in all cases (adventitial in 1 and full thickness in 4); left subclavian artery resection was adventitial in 2 patients and circumferential in 2. All the resections were complete. Prosthetic reconstruction was performed in 4 cases. Mean operative time was 130 ± 25.6 minutes; mean vascular clamping time was 28.2 ± 3.2 minutes. No mortality occurred. The major complication rate was 11.1 %. At a mean follow-up of 17 ± 9 months (range, 5 to 29 months), the recurrence rate was 33.3%. Median survival was 20 months., Conclusions: Direct cross-clamping as an alternative to CPB for resection of lung cancer infiltrating the aortic arch or the subclavian artery is a feasible, safe, and reliable procedure in selected patients., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Here, we report our initial experience with subxifoid video-assisted thoracoscopic surgery (SVATS) lobectomy for the management of primary lung cancer, and compared the outcomes of SVATS with those of conventional transthoracic VATS (CVATS) lobectomies to validate its feasibility and usefulness., Methods: The clinical data of consecutive patients undergoing VATS lobectomy via SVATS or CVATS for lung cancer were retrospectively compared. The endpoints were to evaluate the statistical differences in surgical results, postoperative pain (measured with visual analog scale [VAS] scores at 8 hours, Day 1, Day 2, Day 3, at discharge, one month and three months after surgery) and paresthesia (measured at one- month, and three months after surgery). The two groups were compared before and after matching analysis., Results: Our study population included 223 patients: 84 in the SVATS and 139 in the CVATS group. The two groups were not comparable for sex (P = 0.001), preoperative comorbidity as cardiopathy (P = 0.007), BMI value (P = 0.003), left-sided procedure (P = 0.04), tumor stage (P = 0.04), and tumor size (P = 0.002). These differences were overcome by propensity score matching (PSM) analysis that yielded two well-matched groups which included 61 patients in each group. Surgical outcomes including blood loss, hospital stay and complications were similar before and after matching analysis, but SVATS compared to CVATS was associated with longer operative time before (159 ± 13 vs. 126 ± 6.3, P < 0.0001), and after matching analysis (161 ± 23 vs. 119 ± 8.3; P < 0.0001) and significant reduction of postoperative pain during the different time-points (P < 0.001), and paresthesia at one (P = 0.001), and three months (P < 0.0001)., Conclusions: SVATS lobectomy is a feasible and safe strategy with surgical outcomes similar to CVATS lobectomy but with less postoperative pain and paresthesia., Key Points: SIGNIFICANT FINDINGS OF THE STUDY: Subxifoid thoracoscopic lobectomy is a feasible and safe procedure, with potential benefits in terms of postoperative pain and paresthesia compared to conventional thoracoscopic lobectomy Our results showed that surgical outcomes including blood loss, hospital stay, morbidity and mortality are similar but subxifoid thoracoscopy was associated with significant reduction of postoperative pain and paresthesia., What This Study Adds: Subxifoid thoracoscopy is a safe procedure; compared to conventional transthoracic thoracoscopy, it avoids intercostal incisions, and spares nerve trauma, resulting in a reduction of postoperative pain and paresthesia., (© 2020 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Background: Video-Assisted Thoracic Surgery (VATS) lobectomy is now considered the preferred approach at many centers for early stage lung cancer. However, it needs an adequate learning curve, and it may be challenging in non-expert hands. The aim of this study was to evaluate the effectiveness of Transcollation Technology over Traditional Electrocautery to perform hilar and mediastinal dissection during VATS lobectomy., Methods: This is a single-center retrospective study including consecutive patients undergoing VATS lobectomy for lung cancer. Patients were divided in two groups based on whether Transcollation Technology (TT Group) or Traditional Electrocautery (TE Group) was used for hilar and mediastinal lymphadenectomy. Operative time and surgical outcome, including number of transfusions, length of chest drainage, length of hospital stay, morbidity and mortality were registered, and the inter-group differences were statistically analyzed., Results: 53 patients were included in the final analysis. The TT Group (n = 24) compared to the TE Group (n = 29) showed significant shorter operative time (75.2 ± 25.8 min versus 98.1 ± 33.3 min; p = 0.023), and reduction of length of chest tube stay (4.7 ± 0.8 days vs. 6.8 ± 1.1 days, p = 0.013) and length of hospital stay (5.3 ± 1.9 days vs. 6.8 ± 1.1 days, p = 0.007). No intraoperative or major postoperative complications were observed in either groups., Conclusions: Transcollation Technology represents a valid alternative to standard electrocautery instruments during VATS lobectomy. It contributes to reduce the operative time and length of hospital stay. Further larger prospective studies are required to confirm our data.

Mediastinal staging for lung cancer includes both the assessment of mediastinal lymph nodes status before treatment and the postoperative pathological staging obtained by lymph-node removal performed during surgery. In patients with early stage NSCLC, the aim is to exclude with the highest certainty and the lowest morbidity the presence of mediastinal node involvement. Before treatment, mediastinal staging is based on imaging techniques, endoscopic techniques, and surgical procedures. Final pathological staging is based on lymph-node removal performed with lung resection according with different modalities (sampling, systematic dissection, etc.) and various approaches (thoracotomy, VATS, robotic). Data and indications from literature evidences are reported and discussed.

Background: Uniportal video-assisted thoracoscopic surgery (VATS) lobectomy has become a common approach for the treatment of early stage lung cancer. Here, we aimed to establish whether the length of uniportal incision could affect postoperative pain and surgical outcomes in consecutive patients undergoing uniportal VATS lobectomy for early stage lung cancer., Methods: This was a unicenter Randomized Control Trial (NCT03218098). Consecutive patients undergoing uniportal VATS lobectomy for Stage I lung cancer were randomly assigned to a Small Incision group or Long Incision group in 1:1 ratio based on whether patients received a 4 cm or 8 cm incision. The endpoints were to compare the intergroup difference regarding (i) postoperative pain measured by brief pain inventory (BPI) questionnaire (first endpoint); (ii) operative time; (iii) length of chest drainage; (iv) length of hospital stay; (v) postoperative complications; and (vi) pulmonary functional status (secondary endpoints)., Results: A total of 48 patients were eligible for the study. Four patients were excluded; the study population included 44 patients: 23 within the Small Incision group, and 21 within the Long Incision group. The 11 BPI scores between the two groups showed no significant difference. Small Incision group presented higher operative time than Long Incision group (138.69 vs. 112.14 minutes; P = 0.0001) while no significant differences were found regarding length of hospital stay (P = 0.95); respiratory complications (P = 0.92); FEV1% (P = 0.63), and 6-Minute Walking Test (P = 0.77)., Conclusions: A larger incision for uniportal VATS lobectomy significantly reduced the operative time due to better exposure of the anatomical structures without increasing postoperative pain or affecting the surgical outcome., Key Points: A larger incision for uniportal VATS lobectomy significantly reduced the operative time due to better exposure of the anatomical structures without increasing postoperative pain or affecting the surgical outcome. To perform a larger incision could be a valuable strategy, particularly in nonexpert hands or when the patient's anatomy or tumor size make exposure of anatomic structures through smaller incisions difficult., (© 2020 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Background: Tumor with adjacent lobe invasion (T-ALI) is an uncommon condition. Controversy still exists regarding the optimal resection of adjacent lobe invasion, and the prognostic value in relation to fissure integrity at the tumor invasion point. The aims of this paper were to evaluate the prognosis of T-ALI with regard to fissure integrity, and type of resection., Methods: This was a retrospective multicenter study which included all consecutive patients with T-ALI undergoing surgical treatment. Based on radiological, intraoperative and histological findings, T-ALI patients were differentiated into two groups based on whether the fissure was complete (T-ALI-A group) or incomplete (T-ALI-D Group) at the level of tumor invasion point. Clinico-pathological features and survival of two study groups were analyzed and compared., Results: Study population included 135 patients, of these 98 (72%) were included into T-ALI-A group, and 37 (38%) into T-ALI-D Group. T-ALI-D patients had better overall survival than T-ALI-A patients (63.9 ± 7.0 vs. 48.9 ± 3.9; respectively, P = 0.01) who presented with a higher incidence of lymph node involvement (35% vs. 4%; P = 0.004), and recurrence rate (43% vs. 16%; P = 0.01). At multivariable analysis, T-ALI-D (P = 0.01), pN0 stage (P = 0.0002), and pT≤5 cm (P = 0.0001) were favorable survival prognostic factors., Conclusions: T-ALI-D presented a better prognosis than T-ALI-A while extent of resection had no effect on survival. Thus, in patients with small T-ALI-D and without lymph node involvement, sublobar resection of adjacent lobe rather than lobectomy could be indicated., Key Points: The extent of resection of adjacent lobe had no effect on survival while T-ALI-D, pN0 stage, and pT≤5 cm were significant prognostic factors. In patients with small T-ALI-D and without lymph node involvement, sublobar resection of adjacent lobe could be indicated as an alternative to lobectomy., (© 2019 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Objectives: Mechanical trauma occurring during pulmonary resection through both video-assisted thoracic surgery (VATS) or thoracotomy causes profound alterations in cytokines and the cellular network. The aim of this study was to analyse biological changes occurring in both the microenvironment (wound site) and macroenvironment (systemic circulation) following pulmonary lobectomy via the VATS or thoracotomic approach., Methods: From October 2016 to July 2017, 30 patients with clinical Stage I lung cancer were recruited. In 12 cases (the VATS group), surgery was performed through a video-assisted thoracoscopic approach and in 15 cases (the thoracotomy group) through a muscle-sparing minithoracotomy. Following the skin incision, the wound was irrigated with a saline solution (20 ml) and then collected. After the pulmonary resection, the surgical incision was re-irrigated. The number of polymorphonuclears, granulocytes and lymphocytes in the fluids was determined by the fluorescence activated cell sorting (FACS) analysis. Cytokine profiles of interleukin (IL)-6, tumour necrosis factor (TNF)-α, IL-1 and IL-8 from sera and fluids were detected by the enzyme linked immunosorbent assay (ELISA) assay. Functional results were evaluated through spirometry, and pain was assessed using the visual analogue scale., Results: In the postoperative fluids of the VATS group, fewer polymorphonuclears were seen compared to the thoracotomy group (P = 0.001), as well as a decreased percentage of granulocytes (P = 0.01) and a parallel increased lymphocytes fraction (P = 0.001). Only the systemic IL-1β levels were significantly lower in postoperative sera of the VATS group (P = 0.038). No differences were observed regarding other cytokines., Conclusions: The local microenvironment during VATS differs from that of thoracotomy by not producing the same inflammatory phenotype. The clinical efficacy of a less invasive surgical approach is confirmed by a reduced inflammation of the systemic and local districts.

Background: Lung metastases occur in 10% to 20% of patients with colorectal cancer (CRC). Lung metastatic pathways of CRC are poorly known, and the optimal management for recurrent lung metastases remains uncertain., Methods: Long-term oncologic outcomes of 203 patients with CRC lung metastases who underwent metastasectomy were investigated in this multicenter retrospective study. Ninety-two patients (45.3%) with tumor relapse underwent repeated metastasectomy and 11 (5.4%) received a third metastasectomy for a second relapse. Demographic and clinical data, including histologic grade of primary tumor, presence of CRC liver metastases, type of primary tumor resection, number, size, location, and resection type of pulmonary metastases, were evaluated. Overall survival (OS) and disease-free survival were analyzed. Cox regression model was performed to identify variables that influenced OS., Results: One hundred seventy-three patients (85.2%) received a wedge resection, 21 (10.3%) underwent pulmonary lobectomy, and 9 (4.4%) underwent other procedures (pneumonectomy, bilobectomy). The mean follow-up was 39 months (range: 7 to 154 months). One-, 3-, and 5-year global OS from CRC diagnosis was 99%, 80%, and 60%, respectively, and 97%, 60%, and 34% from the first metastasectomy, respectively. Log-rank test between OS (one versus repeated metastasectomy) did not show significant differences (p = 0.659). Cox regression model showed that nodal status (hazard ratio [HR] 17.7, p = 0.008) and administration of adjuvant chemotherapy (HR 0.33, p = 0.026) are risk and protective factors, respectively, for OS., Conclusions: Repeated pulmonary metastasectomy should be offered to patients with metastatic CRC because there are no differences in terms of OS between patients undergoing single and repeated metastasectomy. Adjuvant chemotherapy should be suggested in case of metastatic CRC., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: The advantages of a bronchial sleeve resection are well established. A clear majority of reported cases are of upper lobe sleeve resection. Reimplantation of the upper lobe bronchus after a lower sleeve lobectomy or bilobectomy (the so-called Y-sleeve resection) is infrequent. Related technical peculiarities are the main issues. We present our experience and results in this setting., Methods: Between 1989 and 2015, we performed 28 Y-sleeve resections of the left lower lobe (n = 18) or right middle and lower lobes (n = 10). The lung-sparing reconstructive operation was performed for non-small-cell lung cancer in 23 cases, for bronchial carcinoid tumour in 4 cases and for a cystic adenoid carcinoma in 1 case. Anastomotic reconstruction was performed by interrupted 4-0 absorbable sutures (monofilament material)., Results: All the resections were complete (R0). Postoperative mortality was 3.6%. The rate of major complications was 10.7% (1 myocardial infarction, 1 anastomotic stenosis requiring dilatation and 1 anastomotic fistula). Among the 23 patients with non-small-cell lung cancer (18 men and 5 women; mean age 58 ± 12 years), 8 were Stage I, 9 were Stage II and 6 were Stage IIIa. At a mean follow-up of 46 months, the recurrence rate was 32%. There were 2 loco-regional recurrences. No endobronchial or perianastomotic recurrence occurred. The 3- and 5-year overall and disease-free survival rates of patients with non-small-cell lung cancer were 76.3% and 55.1% and 68.7% and 62.9%, respectively., Conclusions: A Y-sleeve resection with reimplantation of the upper load bronchus is a technically feasible and oncologically adequate operation.

Objectives: Resection of a long pulmonary artery (PA) segment infiltrated by tumour and reconstruction by conduit interposition or wide patch is a challenging but feasible option to avoid pneumonectomy. Our goal was to report the long-term results of our experience with this type of operation using various techniques and materials., Methods: Between 1991 and 2015, 24 patients underwent sleeve resection of a long PA segment or extended resection (>2.5 cm) of 1 aspect of the circumference of the PA associated with lobectomy for centrally located lung cancer. Materials used for conduit reconstruction (20 patients) included pulmonary vein in 12 patients, autologous pericardium in 4, porcine pericardium in 3 and bovine pericardium in 1. Patches used in 4 patients consisted of porcine pericardium (2 patients) and pulmonary vein (2 patients)., Results: Twenty-three patients underwent left upper lobectomy without associated bronchoplasty. One patient underwent bronchovascular left upper sleeve lobectomy. The postoperative morbidity rate was 29.1%. No complications related to the reconstructive procedure occurred. There were no postoperative deaths. Complete patency of the reconstructed PA was shown in all patients by postoperative contrast computed tomography performed every 6 months. Pathological tumour stage ranged from I to IIIA. Five-year overall survival and disease-free survival rates were 69.9% and 52.7%, respectively, at a median follow-up of 41 months., Conclusions: Resection of the long PA segment followed by conduit or wide patch reconstruction is a feasible, safe and effective option to avoid pneumonectomy. Different biological materials can be used to provide adequate tissue characteristics; the choice is made on a case-by-case basis. Long-term results confirm the oncological reliability of this operation., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Few investigators have described en bloc resection of non-small cell lung cancer (NSCLC) invading the aorta., Aim of Study: Analysis of outcome and prognostic factors for en bloc resections of NSCLC invading the aorta., Methods: Thirty-five patients (27 males, 8 females; mean age 63 ± 8.6 years) were operated between 1994 and 2015 in four European Centers., Histology: 12 (34.3%) squamous cell carcinoma, and 6 (17.1%) undifferentiated/large cell carcinoma. The site of aortic infiltration was the descending thoracic aorta in 24 (68.6%) patients, the aortic arch in 9 (25.7%), and the aortic arch and supraortic trunks in 2 (5.7%)., Results: Lung resection consisted of pneumonectomy in 19 (54.3%) patients and lobectomy in 16 (45.7%). Aortic resection management was undertaken by endograft positioning (37.1%), subadventitial dissection (37.1%), cardiopulmonary/aorto-aortic bypass (17.2%), and direct clamping (8.6%). A tubular graft replacement was carried out in five cases, a synthetic patch repair in 6. Mortality was 2.9%, morbidity 37.1%. Patients undergoing pneumonectomy had a significantly higher morbidity rate compared with lobectomy (52% vs 18.7%; P = 0.003), although patients managed with aortic endografting had a lower complication rate. Median overall and disease-free survival rates were 31.3 and 22.2 months, respectively. Gender and site of aortic infiltration were independent prognostic factors., Conclusions: Resection of NSCLC combined with an infiltrated aorta is a challenging procedure that can be performed with reasonable morbidity and mortality in highly selected patients., (© 2017 Wiley Periodicals, Inc.)

Background: The purpose of this study was to compare functional and oncologic outcome of sleeve lobectomy (SL) with that of standard lobectomy (STL) in patients with non-small cell lung cancer., Methods: Between January 2009 and April 2013, 44 consecutive patients undergoing upper SL (29 right side, 15 left side) were prospectively enrolled to be compared with 44 patients with the same side distribution who were randomly selected from patients undergoing upper STL during the study period. Functional and oncologic results of the two groups were compared., Results: Pathologic tumor stage ranged between I and IIIa with similar patient distribution between the two groups. Postoperative complication rates were 20.5% in the SL group and 16% in the STL group. There was no postoperative mortality in either group. Mean postoperative decrease in forced expiratory volume in 1 second at 3 months postoperatively was 17.5% ± 6.2% in the SL group and 19% ± 14.8% in the STL group (p = 0.52). There also was no significant difference (p = 0.15) in mean postoperative decrease in 6-minute walk test (64.3 ± 2.5 m versus 69.1 ± 21.4 m) between the two groups. Evaluation of postoperative changes in quality of life at 3 and 6 months based on a standardized questionnaire (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core Questionnaire) did not show significant differences between the SL group and the STL group (p > 0.05) in terms of global health status, physical functioning, and fatigue. Actuarial survival rates at 3 and 5 years, respectively, were 85.3% and 60.1% in the SL group and 88.7% and 58.2% in the STL group, without significant difference (p = 0.68)., Conclusions: Functional and oncologic results of SL are comparable to those of STL in patients with non-small cell lung cancer., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The relationship between the free margin distance and the recurrence rate and overall survival after R0 wedge resection for non-small cell lung cancer (NSCLC) is still not clear. We retrospectively evaluated the long-term oncologic outcome of patients who had undergone wedge resection for NSCLC to assess the prognostic effect of margin distance in this setting., Methods: Between 2003 and 2013, 243 consecutive patients with a functional contraindication to major lung resection underwent wedge resection with systematic lymph node dissection for clinical stage I NSCLC. The study enrolled 182 patients with pathologic stage I and R0 resection and divided them into three subgroups according to margin distance of less than 1 cm (n = 30), 1 to 2 cm (n = 80), and more than 2 cm (n = 72)., Results: The histologic assessment was adenocarcinoma in 112 patients, squamous cell in 30, and other in 40. Postoperative morbidity was 18.7%, and postoperative mortality was 1.1%. The median follow-up was 31 months (range, 2 to 133 months). The locoregional (lung parenchyma, hilum, mediastinum) recurrence rate was 26.4% (n = 48). The distant recurrence rate was 11% (n = 20). Overall 5-year survival was 70.4%. Disease-free 5-year survival was 51.7%. There was no statistical difference in locoregional (p = 0.9) and distant (p = 0.3) recurrence rate and no difference in overall survival (p = 0.07) when the three groups were compared., Conclusions: Wedge resection is a viable option for the surgical treatment of stage I NSCLC when lobectomy is contraindicated. The distance between the tumor and the parenchymal suture margin does not influence recurrence or the survival rate when an R0 resection is achieved., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Over the years reducing the number of ports during Video-assisted thoracic surgery (VATS) has allowed to accomplish pulmonary lobectomy with a single incision. Endoscopic view and instruments maneuvers issues could be improved by using flexible endoscope. We report our experience of fifteen uniportal VATS (UVATS) using a flexible thoracoscope., Methods: A single incision of about 4-5 cm long was performed at the 5th intercostal space along the anterior axillary line. No additional skin incisions were made. A flexible videoscope and multiple VATS instruments were simultaneously inserted into the uniport. Pulmonary lobectomy with systematic mediastinal lymph node dissection was performed. Verbal pain scores were registered using the visual analog scale from 0 to 10 at the first post-operative day., Results: No post-operative complications or hospital mortality were recorded. Mean operative time was 112.6 min (range 70-200) and mean postoperative hospital stay 3.2 days (range 2-6). Mean pain score was 0.5 (range 0-2)., Conclusions: Single-incision VATS lobectomy using a flexible thoracoscope is a feasible and safe approach.

Background: Few investigators have reported the results of combined resection of lung cancer infiltrating the thoracic aorta; only anecdotal accounts of off-label use of thoracic aortic endografts to facilitate resection of such tumors have been published. In this paper, we describe our experience using this innovative approach in terms of technical details and outcomes., Methods: We retrospectively reviewed data on 9 patients (6 men and 3 women, median age 61 years) with preoperatively suspected thoracic aorta neoplastic invasion, who were operated on after positioning of an endograft and underwent en bloc tumor resection including the aortic wall., Results: All but one cancer were non-small cell lung carcinomas; 4 patients received neoadjuvant chemotherapy, and 7 received adjuvant therapy. Aortic endografting was performed 2 to 17 days before resection of the tumor in 7 patients and as part of a one-stage procedure in 2 patients. The proximal end of the stent graft was deployed in the aortic arch (n = 1) or the descending aorta (n = 8). Lung resections were left pneumonectomies in 4 patients and left lower lobectomies in 5. Five patients underwent additional buttressing of the aortic defect using a synthetic patch (n = 2) or the omentum (n = 3). No cardiopulmonary bypass was required. At the last follow-up, 3 patients had evidence of tumor recurrence (one local and two distant). No endograft-related complications were detected., Conclusions: Thoracic aortic endografting allowed safe en bloc resection of tumors invading the aortic wall, avoiding the need for extracorporeal circulatory support. Such an extended indication for thoracic aortic endografts seems promising and should be considered for selected oncologic cases., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Lobectomy with reconstruction of the bronchus and pulmonary artery is a viable therapeutic option for patients with centrally located non-small cell lung cancer. Preoperative chemotherapy or chemoradiotherapy may represent an additional risk factor for postoperative complications because of increased difficulty in surgical dissection and potential impairment of bronchial healing. Although limited data are available in the literature in this setting, a few published studies have reported the possibility of performing even complex bronchovascular reconstructions after neoadjuvant treatment with no increased morbidity and mortality. This article discusses the main technical details and data from the literature., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The use of an autologous pulmonary vein (PV) conduit for reconstruction of the pulmonary artery (PA) in lung-sparing resections was first described in 2009, but to date only two case reports appeared and no medium-term and long-term results have been reported, to our knowledge. We present the first case series with medium-term follow-up., Methods: Between December 2009 and December 2012, 9 patients undergoing PA sleeve resection for centrally located lung cancer received reconstruction by this technique. Three of these patients underwent induction chemotherapy. The venous graft was obtained from the proximal extraparenchymal portion of the superior PV and was sutured to the proximal and distal PA stumps with the standard anastomotic technique., Results: All 9 patients underwent left upper lobectomy with sleeve resection of the PA without associated bronchoplasty. The postoperative morbidity rate was 33% (1 chylothorax, 1 atrial fibrillation, and 1 parenchymal atelectasis). No adverse events related to the reconstructive procedure occurred. There was no postoperative mortality. Complete patency of the reconstructed PA was shown in all patients by postoperative contrast computed tomography every 6 months. All patients are alive at a mean follow-up time of 32 ± 12.4 months (range, 6 to 42 months). Tumor recurrence has been observed in 2 patients (1 local, 1 systemic). The median survival time is 38 months. The median disease-free survival time is 33 months., Conclusions: Reconstruction of the PA by a PV graft is a feasible and effective option for parenchymal-sparing resections. The PV conduit shows tissue characteristics similar to those of the arterial wall. This technique is safe and is supported by good medium-term results., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Sleeve lobectomy (SL) is considered a valid therapeutic option in untreated, centrally located non-small cell lung cancer (NSCLC) even in patients "fit" for pneumonectomy (PN). Nevertheless, SL feasibility and long-term results after induction therapy (IT) have been only rarely investigated. We herein report the results of a multicenter retrospective study on NSCLC patients who underwent PN or SL after IT for locally advanced NSCLC., Methods: From January 1992 to January 2012, 119 consecutive patients (94 males, 25 females) underwent in three tertiary referral centers either SL (bronchial, arterial, or both) or PN for locally advanced NSCLC after IT (chemotherapy alone or combined chemoradiotherapy). The indication for SL was based on technical feasibility. Clinical and pathologic variables were retrospectively reviewed, and treatment results were assessed and compared in both groups. Survival was calculated by Kaplan-Meier method and compared by the log-rank test as well the Cox regression model., Results: Sleeve lobectomy was performed in 51 patients and PN, in 68 patients. Thirty-day mortality and morbidity rates were 3.9% and 9.8% for SL and 2.9% and 22.1% for PN, respectively. Five-year survival rates were 53.8% after SL and 43.1% after PN, respectively (p = 0.28). Overall recurrence rate was 42.8% after SL and 47.0% after PN (p = 0.34); relapse was locoregional in 22.4% of SL cases and 12.1% after PN, respectively (p = 0.011). The Cox analysis suggested pN status and right side as independent risk factors for death in the SL group (hazard ratio, 1.96; 95% confidence interval, 1.12 to 3.44; p = 0.018; and hazard ratio, 2.96; 95% confidence interval, 1.13 to 8.66; p = 0.047, respectively). As well, pN status and right side were a strong predictor of relapse (hazard ratio, 2.33; 95% confidence interval, 1.17 to 4.64; p = 0.016; and hazard ratio, 2.96; 95% confidence interval, 1.13 to 8.66; p = 0.046, respectively) in SL patients., Conclusions: For locally advanced NSCLC, SL represents a safe and effective surgical option when compared with PN even after IT, with substantially comparable early and long-term results. Nevertheless, further investigations on a large cohort of patients are needed., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Sleeve lobectomy (SL) (lobectomy associated with resection and reconstruction of the bronchus, the pulmonary artery, or both) has proved to be a suitable choice for the treatment of centrally sited non-small cell lung cancer. SL for lung cancer is indicated when a tumor or an N1 lymph node infiltrates the origin of a lobar bronchus, the origin of the lobar branches of the pulmonary artery, or both but not to the extent that a pneumonectomy is required. SL can be performed safely and effectively, even after induction therapy, without an increased complication rate., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: We compared morbidity, mortality, and oncological results of bronchial and/or vascular sleeve lobectomy (SL) with those of pneumonectomy (PN) after induction therapy for lung cancer., Methods: Between 1998 and 2011, 82 patients receiving induction therapy (chemo or chemo-radiotherapy) for non-small-cell-lung-cancer underwent sleeve lobectomy (n = 39) or pneumonectomy (n= 43). Only patients undergoing preoperative chemotherapy (39 in the SL group and 39 in the PN group) were included in the study. SL was bronchial in 21, vascular in 12, and broncho-vascular in six cases, respectively. Clinical stage before induction therapy was IIb in seven patients (1 in PN group; 6 in SL group), IIIa in 66 (36 in PN group; 30 in SL group), and IIIb in five patients (2 in PN group; 3 in SL group), respectively. N3 patients were not included in this series., Results: The rate of downstaged patients (pathological complete response and stage I-II) was 79.5% in the SL group and 53.8% in the PN group (p = 0.01).Postpneumonectomy mortality rate was 2.6 %. There was no postoperative mortality after SL. Complications occurred in 12 patients (30.8%) after PN and in 11 patients (28.2%) after SL (p = 0.6). Three-year and 5-year survival rates were 68 ± 3% and 64 ± 8% in the SL group; and 59.5 ± 5% and 34.5 ± 8% in the PN group (p = 0.02). The difference in terms of recurrence rate (locoregional and distant) between the two groups was not significant (p = 0.2)., Conclusions: SL represents a valid therapeutic option even after induction chemotherapy, providing better long-term survival than PN, with no increase of postoperative complications or recurrence rate. Pathological downstaging is a favorable prognostic factor.

Aim: Pneumonectomy is the standard surgery for resectable locally advanced lung cancer. Objectives of this study were: 1) to assess the overall survival; 2) to evaluate the pulmonary and cardiac function impairment; 3) to monitor quality of life (QoL) in a consecutive series of patients undergoing pneumonectomy, defining the potential risk factors of a poor prognosis., Methods: From January 2003 to March 2010, 71 patients undergoing pneumonectomy for lung cancer or mesothelioma were prospectively enrolled in this study. Twenty-six patients underwent right pneumonectomy (2 of them underwent intrapericardial pneumonectomy), 31 left pneumonectomy (3 of them underwent intrapericardial pneumonectomy), 3 extended pneumonectomy, 3 extrapleural pneumonectomy and 5 patients underwent completion pneumonectomy. Three patients were not included in the study for early postoperative deaths (4.3%). All patients underwent complete preoperative assessment and one year after surgery. QoL was assessed by a questionnaire., Results: One and five-year survival rate was 93% (N.=63) and 20% (N.=14), respectively. Mean values of FEV1 decreased from 2.59±0.75 L to 1.8±0.72 L (P<0.001). One year after surgery all patients showed moderate tricuspid valve insufficiency, PASP significantly higher and right ventricular free wall thickness moderately increased. An increased negative effect was recorded in the QoL scores with P<0.001. Three clinical and surgical parameters were identified as risk or protective factors for the survival outcome., Conclusion: Postoperative mortality (4.3%) and five-year survival (20%) after pneumonectomy seem to be satisfactory. Late cardiopulmonary insufficiency is uncommon and acceptable QoL is still achievable.

Stage T4 non small cell lung cancer (NSCLC) includes an heterogeneous group of locally advanced tumors. Results of surgery alone and of chemo and/or radiotherapy are disappointing with 5-year survival rates under 10%. Although palliative chemo-radiotherapy is the treatment of choice in most cases, radical resection has shown prognostic benefit in selected groups of patients with tumor infiltrating Superior Vena Cava, carina, aorta, left atrium and vertebral bodies. Completeness of resection and absence of mediastinal nodal involvement are fundamental conditions for the long-term success of surgery. Increased postoperative 30-day mortality and 90-day mortality rates have been reported up to 8% and 18% respectively. Neoadjuvant therapy, in the last decades, has shown to improve survival of T4 NSCLC patients undergoing surgery and to increase the number of patients suitable for surgical resection. Surgical resection is not indicated in patients with neoplastic pleural effusion since it is generally related to a worse prognosis in such cases. Conversely, patients with T4 tumor due to neoplastic satellite nodule in the same lobe are good surgical candidates. In some studies, these patients show a significant survival advantage after surgical treatment with respect to patients with other types of T4 tumors, when no mediastinal nodal involvement is associated.