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Background A project to assess the existing literature and to benchmark the quality of past guidelines and recommendations on lung cancer screening projects was developed with a particular focus on the assessment of the methodology used in producing them. Methods Each guideline was assessed in the different items and domains with the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument and scored on a seven-point scale. Results Eight guidelines matched the inclusion criteria and were assessed. A multinational collaboration produced three out of five guidelines. The multivariable analysis shows that improved scores of stakeholders' involvement were related to internationally developed guidelines. Improved methodological quality was related to the involvement of scientific societies due to the better rigor of development and editorial independence. Countries with higher expenditure on healthcare produced significantly better guidelines. Conclusions Assessed by the AGREE II criteria, the methodological quality of previous guidelines was relatively low. Nevertheless, the National Comprehensive Cancer Network Guidelines should be recommended as a model for the development of best methodological quality guidelines.

Background We described the results of surgical treatment of empyema, tracing outcomes throughout the passage from the open thoracotomy (OT) approach to video-assisted thoracoscopic surgery (VATS) in a single institute. Methods We retrospectively analyzed the records of 88 consecutive patients treated for Stage 2 and 3 empyema (2010-2019). We divided the study period into three groups: OT period (2010-2013), early VATS (2014-2017, from the introduction of VATS program, until acme of learning curve), and late VATS (2018-2019). Groups were compared to investigate the outcomes evolution. Results Most relevant findings of the study were significant variation in postoperative length of stay (median [interquartile range]: 9 days [7.5-10], 10 [7.5-17.5], and 7 [5-10] for OT period, early VATS, and late VATS, respectively, p = 0.005), hospital admission referral to thoracic surgery interval (7.5 days [4.5-11], 6.5 [3-9], and 2.5 [1.5-5.5], p = 0.003), chest tube duration (5.5 days [5-7.5], 6 [4-6], 4 [3-5], p = 0.003), and proportion of operation performed by residents (3 [15%], 6 [16.7%], 14 [43.6%], p = 0.01). Conclusions Our findings pictured the trajectory evolution of outcomes during introduction and consolidation of VATS treatment of empyema. During the early phase, we observed a decline in some indicators that improved significantly in the late VATS period. After a learning curve, all outcomes showed better results and we entered into a teaching phase.

INTRODUCTION: Robotic-assisted surgery has become the first choice for several conditions since its introduction in clinical practice in 2000. However, the U.S. Food and Drug Administration has recently raised a warning against the use of robotic surgical approaches for the cure and prevention of cancer following the publication of two studies focused on endometrial cancer. We conducted an internal audit to retrospectively analyze our experience to assess the safety and feasibility of robotic-assisted surgery compared to open surgery. METHODS: We selected a 5-year period to guarantee at least 2 years of follow-up (2011-2016) and identified 1139 patients who underwent lobectomy for non-small-cell lung cancer (NSCLC) in our division. The primary data set analyzed included 544 early-stage clinical N0 patients (348 open and 196 robotic surgeries). We compared 131 patients of each group individually matched, with demographic and clinical characteristics almost identical. RESULTS: No difference was observed between the cohorts, either in terms of recurrence-free survival (hazard ratio: 1.09; p = 0.55) or overall survival (hazard ratio: 0.86; p = 0.36). The 5-year recurrence of disease risk and overall survival were 24.9% and 83.2%, respectively, in the open group and 24.6% and 86.1%, respectively, in the robotic group. CONCLUSIONS: These data underline that robotic-assisted lobectomy for early NSCLC is a safe and feasible technique with adequate long-term and progression-free survival compared to open surgery.

We report the first surgical series of patients developing pleural empyema after severe bilateral interstitial lung disease in confirmed severe acute respiratory syndrome coronavirus 2 infection. The empyema results in a complex medical challenge that requires combination of medical therapies, mechanical ventilation and surgery. The chest drainage approach was not successful to relieve the symptomatology and to drain the excess fluid. After multidisciplinary discussion, a surgical approach was recommended. Even though decortication and pleurectomy are high-risk procedures, they must be considered as an option for pleural effusion in Coronavirus disease-positive patients. This is a life-treating condition, which can worsen the coronavirus disease manifestation and should be treated immediately to improve patient’s status and chance of recovery., Since December 2019, several cases of unknown-origin pneumonia started to be diagnosed in Wuhan, China.

Background Acute kidney injury (AKI) frequently occurs in several medical and surgical settings, and it is associated with increased morbidity and mortality. In patients undergoing lung cancer surgery, AKI has not been fully investigated. We prospectively evaluated the incidence, clinical relevance, and risk factors of AKI in patients undergoing lung cancer surgery. Moreover, we estimated the accuracy of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in the prediction of AKI. Methods Patients undergoing lung cancer surgery were included in the study. Plasma NT-proBNP was measured before and soon after surgery. Postoperative AKI was defined according to the Acute Kidney Injury Network (AKIN) classification. Results A total of 2179 patients were enrolled. Of them, 222 (10%) developed AKI and had a more complicated in-hospital clinical course (overall complication rate: 35% vs. 16%; P Conclusions Acute kidney injury occurs in 10% of patients undergoing lung cancer surgery, and it is associated with a high incidence of postoperative complications. The risk of AKI can be accurately predicted by the combined evaluation of preoperative serum creatinine and NT-proBNP.

Primitive aortic sarcomas are rare tumors characterized by resistance to medical treatment and a poor prognosis with high metastatic rates and local recurrences. Surgery remains the mainstay treatment and is based on challenging and technically demanding resections with high rate of major intraoperative and postoperative complications. We report the case of a patient with primitive intimal sarcoma of the aorta, who underwent a descending aortic resection and reconstruction with a prosthetic tube.

OBJECTIVES The aim of this study was to assess the postoperative outcomes of robotic-assisted lobectomy in obese patients to determine the impact of the robotic approach on a high-risk population who were candidates for major pulmonary resection for non-small-cell lung cancer (NSCLC). METHODS Between January 2007 and August 2018, we retrospectively reviewed the medical records of 224 obese patients (body mass index ≥ 30) who underwent pulmonary lobectomy at our institution via robotic-assisted thoracic surgery (RATS, n = 51) or lateral muscle-sparing thoracotomy (n = 173). RESULTS Forty-two patients were individually matched with those who had the same pathological tumour stage and similar comorbidities and presurgical treatment. The median operative time was significantly longer in the RATS group compared to that in the thoracotomy group (200 vs 158 min; P = 0.003), whereas the length of stay was significantly better for the RATS group (5 vs 6 days; P = 0.047). Postoperative complications were significantly more frequent after open lobectomy than in the RATS group (42.9% vs 16.7%; P = 0.027). After a median follow-up of 4.4 years, the 5-year overall survival rate was 67.6% [95% confidence interval (CI) 45.7–82.2] for the RATS group, and 66.1% (95% CI 46.8–79.9) for the open surgery group (log-rank P = 0.54). The 5-year cumulative incidence of cancer-related deaths was 24.8% (95% CI 9.7–43.5) for the RATS group and 23.6% (95% CI 10.8–39.2) for the open surgery group (Gray’s test, P = 0.69). CONCLUSIONS RATS is feasible and safe for obese patients with NSCLC with advantages compared to open surgery in terms of early postoperative outcomes. In addition, the long-term survival rate was comparable to that of the open approach.

Background This study analyzed the short- and long-term outcomes of robotic-assisted thoracic surgery (RATS) for early stage non-small cell lung cancer (NSCLC). Methods From November 2006 to December 2016, we performed 363 RATS procedures. This study retrospectively reviewed 339 patients who underwent RATS for clinical stages I (n = 318) or II (n = 21) NSCLC. Results Twenty-nine patients underwent segmentectomy, 307 lobectomy, and 3 pneumonectomy. Conversion occurred in 22 patients (6.5%): 15 (4.4%) due to technical issues, 4 (1.2%) for oncological reasons, and 3 (0.9%) for bleeding. The median number of N1 and N2 stations resected was 2 and 3, respectively, and the median number of N1 and N2 lymph nodes resected was 9 and 6, respectively. Median operative time was 192 minutes for lobectomy, 172 minutes for segmentectomy, and 275 minutes for pneumonectomy. Median length of hospital stay was 5 days (2–191). The most common postoperative complication was prolonged air leak (12.1%). Major complications occurred in eight patients (2.4%). The 30-day and 90-day operative mortality was 0% and 0.3%, respectively. Two and 5-year cancer-specific survival rate was 96.1% and 91.5%, respectively. Five-year survival rate was 96.2% for patients who underwent segmentectomy, and 89.1% for lobectomy. All three patients who underwent pneumonectomy were alive at 5 years with no disease. Conclusions Besides the well-known short-term outcomes showing very low morbidity and mortality rates, mediastinal lymph node dissection during RATS adequately assesses lymph node stations detecting occult lymph node metastasis and leading to excellent oncologic results. However, these results await longer follow-up studies.

Background: Malignant pleural effusion (MPE) complicates many neoplasms and its incidence is expected to rise in parallel with the aging population and longer survival of cancer patients. Although a clear consensus exists on indwelling catheters in patients with poor performance status, no study has hitherto compared different devices in patients requiring temporary or definitive drainage following talc poudrage. Methods: This is a prospective, two-arm, pilot study on patients with MPE undergoing talc poudrage, comparing two different catheters (PleurX ® versus Pleurocath ® ) positioned because of the inefficacy of the procedure or the high risk of short-term failure. End points of the study were quality of life (QoL), median dyspnea and chest pain assessment by EORTC questionnaires and a 100 mm visual analog scale, total in-hospital length of stay and frequency of serious adverse events. Results: No difference was observed between the two groups in in mean dyspnea and mean chest pain in any questions of the EORTC QLQ-C30 and QLQ-LC13 questionnaires. Duration of the procedure was significantly longer in the PleurX ® group versus the Pleurocath ® group (72±33 versus 44±13 minutes; P=0.03). No difference was observed between the two groups in total length of hospital stay (P=1.00) or complication rate (P=1.00). Conclusions: For the cohort of patients still needing indwelling pleural catheters (PC) after thoracoscopic talc poudrage, PleurX ® is suggested when drain removal is unlikely due to short life expectancy or the high chance of pleurodesis failure. Conversely, Pleurocath ® should be recommended in all other patients as it is faster to place and easier to remove.

Acute kidney injury (AKI) frequently occurs in several medical and surgical settings, and it is associated with increased morbidity and mortality. In patients undergoing lung cancer surgery, AKI has not been fully investigated. We prospectively evaluated the incidence, clinical relevance, and risk factors of AKI in patients undergoing lung cancer surgery. Moreover, we estimated the accuracy of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in the prediction of AKI.Patients undergoing lung cancer surgery were included in the study. Plasma NT-proBNP was measured before and soon after surgery. Postoperative AKI was defined according to the Acute Kidney Injury Network (AKIN) classification.A total of 2179 patients were enrolled. Of them, 222 (10%) developed AKI and had a more complicated in-hospital clinical course (overall complication rate: 35% vs. 16%; P 0.0001), and a longer hospital stay (10 ± 7 vs. 7 ± 4 days; P 0.0001). The incidence of AKI increased in parallel with the extent of lung resection. Among the independent predictors of AKI, serum creatinine (area under the curve [AUC] 0.70 [95% CI 0.67-0.74]) and NT-proBNP (AUC 0.71 [95% CI 0.67-0.74]) provided the highest predictive accuracy, and their combination further significantly improved AKI prediction (AUC 0.74 [95% CI 0.71-0.77]). No difference in AKI prediction was observed between preoperative and postoperative NT-proBNP (P = 0.84).Acute kidney injury occurs in 10% of patients undergoing lung cancer surgery, and it is associated with a high incidence of postoperative complications. The risk of AKI can be accurately predicted by the combined evaluation of preoperative serum creatinine and NT-proBNP.

The aim of this study was to analyse the feasibility and safety of robotic-assisted thymectomy (RoT) in patients with clinically early stage thymoma, investigating clinical and early oncological results. Between 1998 and 2017, we retrospectively reviewed 76 (42.2%) patients who underwent radical thymectomy for clinically early stage thymoma (Masaoka-Koga I and II), identifying all patients who underwent RoT (n = 28) or open thymectomy (OT) with eligibility criteria for robotic surgery (n = 48). Using a propensity-score matched for tumor size (3.9 ± 1.8 cm) and stage (35% stage I, 42% stage IIA, 23% stage IIB), we paired 24 patients who had RoT with 24 patients undergoing OT. RoT was left-sided in 19 (79.2%) patients. None of the patients required conversion to open surgery. OT was via sternotomy in 21 (87.5%) patients and thoracotomy in 3 (12.5%). Mean operating time was shorter in the RoT group (117 ± 40 min) than in the OT (141 ± 46 min) (p = 0.06), even if not statistically significant. Length of stay was significantly shorter in the RoT group (mean 4.0 ± 1.9 days) than in the OT (mean 5.9 ± 1.7 days) (p = 0.0009). No significant difference between the two groups regarding post-operative complications. Five patients died in the OT group after a median follow-up of 6.1 years (only one for recurrence). After a median follow-up of 1.3 years, all patients in the RoT group were alive without disease. RoT is feasible and safe for early stage thymoma with clear advantage compared to OT in term of short term outcomes. A longer follow-up is needed to better evaluate the oncological results.

Objective: The introduction of modern staging systems such as computed tomography (CT) and positron emission tomography/CT (PET/CT) with fluorodeoxyglucose ([ 18 F]FDG) has increased the detection of small peripheral lung cancers at an early stage. We analyzed the behavior of pathological T1 non-small-cell lung cancer (NSCLC) to identify criteria predictive of nodal involvement, and the role of cancer size in lymph node metastases. Methods: We retrospectively analyzed 219 patients with pathological T1 NSCLC. All patients were staged by high-resolution CTand PETas stage I, and underwentanatomical resectionand radical lymphadenectomy. Our data were collected based on pathological nodulesize (0— 10 mm; 11—20 mm; and 21—30 mm); morphological features of lung nodule and FDG uptake of the tumor measured by standardized uptake value (SUV). Results:A total of 190 patients (87%) were pN0, 14 (6%) pN1, and 15 (7%) pN2. No nodal involvement was observed in any of the 62 patients with nodule size less than 10 mm, in 20 out of 120 patients (17%) with nodule size 11—20 mm, and in nine out of 37 tumors (28%) 21—30 mm in size (p = 0.0007). All 55 patients with nodule SUV < 2.0 and all 26 non-solid lesions were pN0 (respectively, p = 0.0001 and p = 0.03). All nodal metastases occurred amongthe group of 132patients with size larger than 10 mm and SUV higher than 2.0 with a 22% rate of nodalinvolvement of (29 patients) (p < 0.0001). Conclusions: The low probability of lymph node involvement in NSCLC

A 57-year-old man was referred to our department from another hospital after major bleeding following thoracoscopic biopsy of an undiagnosed giant mass in the posterior mediastinum. The bleed had been controlled by emergency posterolateral thoracotomy and diagnosis of low grade malignant solitary fibrous tumor of the pleura (SFTP) then obtained, but radical resection was not performed. A chest computed tomography (CT) scan showed a large hypervascular posterolateral mediastinal mass adherent to the mediastinal pleura, the left lung, the thoracic aorta, and close to the esophagus (Figs 1, ​,22). Figure 1 Axial post-contrast computed tomography (CT) images at four different levels of the chest (shown here at the mediastinum window level), disclosed a large left-posterior mediastinal lesion characterized by many intralesional and surrounding vessels, strictly ... Figure 2 Sagittal reformatted computed tomography (CT) image shows the craniocaudal extension of the mass and its extensive contact with the thoracic aorta. We performed redo posterolateral thoracotomy. The mass was then dissected and effectively separated from the esophagus and pericardium. However, the mediastinal pleura of the left lung was widely infiltrated and intrapericardial left pneumonectomy was required to achieve radical en bloc resection (Fig 3). No residual disease was observed at the end of the procedure. Figure 3 Surgical specimen disclosing the radically resected solitary fibrous tumor of the pleura involving the mediastinal surface of the left lung completely resected en bloc by left intrapericardial pneumonectomy. Histological examination confirmed malignant SFTP CD 34 and CD 99 positive, cytokeratin negative, weighing 985 grams without the left lung. Postoperative paramedian left vocal cord paralysis resulting in moderate dysphonia was documented by video laryngoscopy and a speech therapy program was instituted. The patient was discharged two weeks after surgery without any major complication. Two years of follow up, performed by chest CT scan every four months, did not disclose any local or distant relapse. SFTP is a rare, slow-growing tumor whose origin is widely recognized as the mesenchymal cells of submesothelial tissues of the pleura, rather than mesothelial cells.1 The tumor tends to grow into a huge mass before local compression symptoms develop. Angiography or CT scan frequently discloses multiple feeding vessels, including several intercostal, internal mammary, inferior phrenic, and bronchial arteries.2 The ideal treatment of SFTP is based on radical surgical excision that is generally curative in all benign cases and in approximately half of malignant ones.1 Complete resection of giant SFTP may be challenging because of poor exposure, significant blood supply, strong adhesions, and often the direct involvement of nearby structures, however, there is little evidence for alternative management of this particular tumor (radiotherapy and chemotherapy).3 The prognosis for patients with benign SFTP is generally favorable with a five-year overall survival rate ranging from 79 to 100%, however, the risk of recurrence is high after the resection of a malignant sessile SFTP, although long-term survival is possible, ranging from 46 to 100%.4 Adequate pre-operative blood storage is recommended in cases of planned giant SFTP resection, together with a detailed explanation to acquaint patients with details of the therapeutic schedule, including major lung and mediastinal resection.

Objective: The clinical outcome of 180 non-thymomatous myasthenia gravis (MG) consecutive cases surgically treated is reported herein. The original surgical access, consisting of a video-assisted infra-mammary cosmetic incision and median sternotomy, has originally been designed and described by our group. Methods: The in-hospital patients’ charts and the outpatients’ clinic follow-up information of the 180 cases have been extensivelyreviewed.In additionto the strictly surgicalbenchmarkreferral,data on therate of cure of the MG (completestableremission— CSR; pharmacological remission — PR) as indicated by the Myasthenia Gravis Foundation of America (MGFA) have been analysed as recorded at the 12 months after surgery checkpoint. Cosmetic outcome was evaluated as well. Results: Female to male ratio was 156 (86.7%):24 (13.3%). Mean age: 29.1 10.9 years. Preoperative MGFA score: stage I: 4 patients (2.2%); IIa: 57 (31.7%); IIb: 32 (17.8%); IIIa: 41 (23.3%); IIIb: 42 (23.3%); IVa: 2 (1.1%); V: 2 (1.1%). Median operative time was 110 min (70—130 min) and median postoperative hospital stay was 4 days (3—10 days). Postoperative mortality was nil and morbidity occurred in seven patients (3.8%). Final pathology was consistent with: 146 hyperplastic thymus (81.1%); 28 involuted thymus (15.6%) and 6 normal thymus (3.3%). Ectopic thymic tissue was found in 68% of the patients. Mean follow-up was 62.9 34.6 months. A CSR was obtained in 55%; PR in 18.3%; improvement in 39.9%, unchanged in 3.5%, worse in 1.1% and died in 0.5%. Kaplan— Meier estimates of CSR were 34.1% and 75.8% at 5 and 10 years, respectively. The preoperative therapy was the only parameter significantly associated with Kaplan—Meier CSR rates (univariate analysis — p < 0.001). Remarkably, 171 (95%) patients judged their cosmetic results to be excellent or very good.Conclusions:Thymectomy in MG patients via video-assisted infra-mammary cosmetic incision and median sternotomyhas shown to be a useful surgical approach as demonstrated by the good functional and very good aesthetic results, associated with a very low morbidity and no mortality. Patients with preoperative mono-therapy have higher CSR rates. CSRs are durable, as the CSR rate improves with extended follow-up. # 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

OBJECTIVES: Diaphragmatic infiltration by non-small cell lung cancer (NSCLC) is a rare occurrence and surgical results are unclear.We assessed our experience with en bloc resection of lung cancer invading the diaphragm, analysing prognostic factors and long-termoutcomes.METHODS: We analysed a prospective database of patients with NSCLC infiltrating the diaphragm who underwent en bloc resection.Univariateanalysis was performed to identify prognostic factors. Survival was calculated by the Kaplan–Meier method.RESULTS: Nineteen patients (14 men, mean age 64±11 years) were identified. Surgery included nine pneumonectomies, eight lobecto-mies and two segmentectomies. A partial diaphragmatic infiltration was observed in 10 patients (53%) and full-depth invasion in 9 (47%).Diaphragmatic reconstruction was done primarily in 13 patients (68%), and by prosthetic material in 6 (32%). Pathological nodal statusincluded nine N0, four N1 and six N2. The median hospital stay was 7 days (range, 4–36 days). The postoperative mortality rate was 5%(1/19). Two patients (10%) had major complications (acute respiratory distress syndrome and bleeding) and 10 minor complications, ar-rhythmia in 7 (37%) and pneumonia in 3 (16%). The 5-year survival was 30±11%. The median survival and disease-free survival were15±9 months (range, 1–164 months) and 9±7 months (range, 1–83 months), respectively. Factors adversely affecting survival were dia-phragmatic infiltration (50% superficial vs 0% full-depth infiltration; log-rank test, P=0.04) and nodal involvement (43% N0 vs 20% N1–2;log-rank test, P=0.03).CONCLUSIONS: Resection of NSCLC invading the diaphragm is technically feasible and could be a valid therapeutic option with accept-able morbidityand mortalityand long-term survival in highlyselected patients.Keywords: Lung cancer † Surgery † Diaphragm

Palliative airway treatments are essential to improve quality and length of life in lung cancer patients with central airway obstruction. Rigid bronchoscopy has proved to be an excellent tool to provide airway access and control in this cohort of patients. The main indication for rigid bronchoscopy in adult bronchology remains central airway obstruction due to neoplastic or non-neoplastic disease. We routinely use negative pressure ventilation (NPV) under general anaesthesia to prevent intraoperative apnoea and respiratory acidosis. This procedure allows opioid sparing, a shorter recovery time and avoids manually assisted ventilation, thereby reducing the amount of oxygen needed, while maintaining optimal surgical conditions. The major indication for NPV rigid bronchoscopy at our institution has been airway obstruction by neoplastic tracheobronchial tissue, mainly treated by laser-assisted mechanical dissection. When strictly necessary, we use silicone stents for neoplastic or cicatricial strictures, reserving metal stents to cover tracheo-oesophageal fistulae. NPV rigid bronchoscopy is an excellent tool for the endoscopic treatment of locally advanced tumours of the lung, especially when patients have exhausted the conventional therapeutic resources. Laser-assisted mechanical resection and stent placement are the most effective procedures for preserving quality of life in patients with advanced stage cancer.

Introduction: Breast cancer is the leading cause of cancer death among women in the industrialized countries. The incidence of local recurrences after mastectomy and breast-conserving therapy varies between 5% and 40% depending on risk factors and primary therapy. Methods: From April 1999 to April 2011, 40 patients underwent chest wall resection and reconstruction for locally recurrent breast carcinoma with chest wall invasion. The main goal of surgery was local disease control to palliate clinical symptoms. Results: Local radical resection was achieved in 26 patients (65%). One, 2 and 5 year overall survival rates were 94.4%, 82.0% and 68.5%; 1, 2 and 5 year disease-free survival rates were 94.4%, 73.6% and 45.5% respectively.Univariate analysis indicated age (p = 0.002) and synchronous distant metastases (p = 0.020) as factors having a negative impact on overall survival; multivariate analysis disclosed age (p = 0.052) and synchronous metastases (p = 0.059) as factors with a slight negative impact on overall survival. Older age was associated with improved overall survival.Univariate analysis indicated synchronous distant metastases (p = 0.029) and the need of post resectional additional treatments (p = 0.022) as factors adversely conditioning disease-free survival or time to progression; multivariate analysis disclosed the need of post resectional additional treatments (p = 0.036) as the only factor adversely conditioning disease-free survival or time to progression. Conclusions: Chest wall resection and reconstruction for locally recurrent breast cancer is a feasible and safe procedure providing adequate local disease control and an excellent palliation of very disabling symptoms in a selected group of patients.

Background: Extended resections (ER) for lung cancer may improve survival in selected patients. However, analysis on large series is still lacking. We reviewed our experience to identify prognostic factors useful for patient selection. Methods: Between 1998 and 2010, 167 patients with involvement of one or more mediastinal organs underwent operations with the intent to perform ER. At thoracotomy, 42 patients (25%) were considered unresectable (explorative thoracotomy [ET]), and 125 (75%) underwent ER. The types of ER were superior vena cava in 43 patients (34.4%), carina in 33 (26.4%), combined with superior vena cava in 18 (14.4%), with the left atrium in 35 (28%), and with the aorta in 14 (11.2%). We excluded Pancoast tumors and vertebral resections. The minimum follow-up was 6 months. Kaplan-Meier method and log-rank test were used for statistical analysis of survival. Results: There were 136 men (81.4%), with mean age of 63 years (range, 36 to 81 years). Of the 167 patients, induction chemotherapy was administered in 119 (71.3%), including 34 ET patients (81%) and 85 ER patients (68%). Complete resection was achieved in 106 patients (84.8%). The overall 5-year survival was 23% (27% in ER and 13% in ET, p = 0.41). Overall 30-day mortality was 4.8% and morbidity was 34.1%. Factors affecting survival were complete resection (p < 0.01), pStage 0-I-II disease (p < 0.0007), and age younger than 60 years (p < 0.01). Conclusions: ER for lung cancer invading mediastinal organs could improve long-term survival (46% at 5-years in pN0). The best surgical candidates are young patients without lymph nodes involvement who undergo radical resection. Multimodality treatment is suggested in case of mediastinal lymph node involvement. © 2013 by The Society of Thoracic Surgeons.

Introduction: Available information on perioperative blood transfusion practices in oncologic thoracic surgery is scant and outdated. The purpose of this study was to investigate transfusion requirements in patients undergoing curative resection for lung cancer and to identify possible factors predictive of perioperative blood transfusion in our cohort of patients. Methods: From 1st January 2009 to 31st December 2009, 317 patients underwent anatomic pulmonary resection. Patients who received at least 1 unit of red blood cells comprised the "transfused" group. Each case in this group was matched for surgical procedure with a control subject who did not require blood transfusion and was operated on during the same year; these patients comprised the "not transfused" group. Results: A total of 75 patients (23.6%) received at least 1 unit of red blood cells during the perioperative period. Factors conditioning perioperative blood transfusion were: preoperative hemoglobin level (p < 0.0001); procedure duration (p = 0.017); body mass index (p < 0.001); induction therapies (p = 0.017); redo procedure (p = 0.021). Age, sex, histology, stage, ASA score, side, intraoperative blood loss, and fluid infusion did not affect perioperative blood transfusion practices. Conclusions: Preoperative hemoglobin level is the major risk factor for perioperative blood transfusion practices in oncologic thoracic surgery; procedure duration, body mass index, induction therapies, and redo procedure may condition transfusional needs, although they were actually not predictive on multivariate analysis. © 2011 Society of Surgical Oncology.

Malignant pleural effusion is a frequent condition with important prognostic repercussions on duration and quality of life. The neoplasms that more frequently determine pleural effusion are lung and breast cancer and pleural mesothelioma. Lymphomas, tumours of the genitourinary tract and gastrointestinal tract as a group account for a further 25%. Surgical treatment has palliative purposes and finalized to reduction symptoms and to improve quality of life. More frequent clinical presentation is a massive pleural efusion associated to dyspnoea and cough. Pleural aspiration is the first choice treatment but the recurrence rate equals to 100% within 1 month. Repeated pleural aspirations are indicated in those patients that have lower expectation of life. The recurrence risk can be reduced with chemical pleurodesis that allows the adhesion between pleural surfaces. Pleurodesis can be realized by the instillation of several substances by the tube of drainage (slurry) or during thoracoscopy (poudrage). Video Assisted Thoracoscopy (VATS) is a safe and well tolerated technique, a complication rate is lower than 0.5%, VATS can be used to obtain diagnosis and to treat patients with malignant pleural effusion and better expectation of life.

We describe the technique, the benefits and the drawbacks of an original video-assisted thymectomy (VAT), performed through an inframammary cosmetic incision and median sternotomy in myasthenia gravis (MG) patients. This procedure is clinically valuable and cosmetically satisfactory so as to be very well accepted by patients, especially by young women. Minimal-access thymectomy has become increasingly popular as surgical treatment for patients with nonthymomatous myasthenia gravis because of its comparable efficacy, safety, and lesser degree of tissue trauma with conventional open surgery.We report a review/interview of 180 MG patients treated between 1993 and 2005. According to Myasthenia Gravis Foundation of America (MGFA), complete stable remission (CSR) and pharmacologic remission (PR) were calculated at the end of a minimal period of 12 months.A clinical remission was obtained in 41.1% (CR 27.8%, PR 13.3%), who had been followed for at least 12 months from surgery. 95% of these patients judged their cosmetic results to be excellent or good.Thymectomy in MG video-assisted infra-mammary cosmetic incision has shown to be a useful surgical approach as demonstrated by the good functional and very good aesthetic results, associated with a very low morbidity and no mortality.

The treatment of recurrent thymomas remains still controversial.From 1972 to 2006, 265 (114 males and 118 females ) patients with thymoma underwent surgery at Catholic University of Sacred Heart. Twenty of these 265 patients developed a recurrence of the initial thymoma, and they represent the population of the present study.One patient died of sudden death related to respiratory failure. The overall morbidity rate was 33% and the morbidity rate among myasthenic patients was 60%. 10 patients died during the follow-up; 2 of unrelated diseases, 2 of myasthenia gravis, and 6 of tumor growth. The overall actuarial survival rates were 43% and 37% at 5 and 10 years, respectively. Recurrences never appeared in patients with I stage of Masaoka and in type A and AB.Considering the particular spread of thymoma and the encouraging results of the aggressive surgical approach, re-resection should be recommended in respectable recurrent thymomas.

Esophageal carcinoma is often diagnosed at an advanced, non resectable stage. Only early stages show a better prognosis. Surgical treatment represents the gold standard. The various surgical techniques do not seem to affect survival. Based on the severity of esophageal cancer and on poor outcome achievable with surgery alone, multimodality treatments are the most suitable. The possible negative impact on the complication rate after neoadjuvant therapy is still debated. Most randomized trials have not demonstrated as yet an improvement in prognosis in patients undergoing a three-modality treatment. However, patients with complete pathologic response after surgical resection were shown to have a better prognosis. In conclusion, additional randomized trials are required, aimed at evaluating all technical and therapeutic variables which affect prognosis.

In Transhiatal Esophagectomy(THE) two approaches can be used by the surgeon: abdominal and cervical, without thoracotomy. A pioneer of this technique was Orringer, with the largest experience world-wide (1085 patients). THE is associated with a lower morbidity compared with the transthoracic approach, but much controversy exists on whether THE is a suitable operation for cancer, because it is not combined with en-bloc lymphadenectomy. However, overall, there are no statistical differences between the two. Frequently esophageal carcinoma is a systemic disease and thus, the biological behavior and the stage of tumor rather than the technique, play a major role.

The effectiveness of lymph node dissection in the treatment of non-small cell lung cancer is evaluated. The extent of lymphadenectomy in the treatment of NSCLC is still controversial. Although some centers perform only mediastinal lymph node sampling with resection of suspicious lymph nodes, others recommend radical, systematic mediastinal lymph node dissection to improve survival and achieve a better staging. Reports of the literature on the subject are reviewed and the results achieved with the various procedures are analyzed. A personal technique to perform mediastinal lymph node dissection is described.

Large studies have demonstrated that TNM staging system is the most consistent prognostic factor in patients with non small cell lung carcinoma. However, because patients within the same stage may have very different survival, better prognostic information is needed. The recent progress in molecular biology has allowed the analysis of proteins and genes involved in cancer development. To date, more than 150 different prognostic factors affecting survival in patients with lung cancer have been discovered and extensively studied. Despite the encouraging prognostic results in angiogenesis markers, there is not yet a molecular marker validated in large prospective trials that has major independent predictive prognostic value.