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Thymomas are rare, indolent tumors. Early stages (I-II) benefit from surgical treatment, while locally advanced diseases (stages III-IV) usually require a multidisciplinary approach. The role of postoperative radiotherapy (PORT) on anterior mediastinum for radically resected Masaoka-Koga stage II thymomas remains controversial. This study aims to determine the impact of PORT on the disease-free survival (DFS) of stage II thymomas. We retrospectively collected the clinical and oncologic data [age, sex, myasthenia gravis (MG) prevalence, Masaoka-Koga stage, World Health Organization (WHO) histologic subtype] of those patients who underwent radical exeresis in our Unit between January 2000 and December 2020. Kaplan-Meier estimates of DFS were then performed. Our study included 195 patients (M/F = 98/97). Almost all patients were affected by MG (90.7%) and most of them were operated by median sternotomy (93.3%). Thymoma stage was IIa in 87 cases (44.6%) and IIb in 108 cases (55.4%). The most represented histologic subtype was AB (27.7%), followed by B2 (24.6%), A (19%), B1 (14.9%) and B3 (13.8%). PORT was performed in 113 patients (58%, 39 stage IIa and 74 stage IIb). During the surveillance, 8 patients (4.1%) presented pleural recurrences and no local relapses. DFS was comparable in stage IIa and IIb patients, independently from PORT administration (p = .395 and p = .858, respectively). Moreover, PORT did not affect DFS considering the histologic subtypes (p = .304 for A and AB thymomas, p = .608 for B1, B2 and B3 thymomas). In our wide series, PORT administration didn't show any additional benefit on DFS. Therefore, based on our experience, patients with stage II thymoma who underwent radical surgery should not undergo any local adjuvant treatment., (© 2024. Italian Society of Surgery (SIC).)

Introduction: Endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) has a cardinal role in the diagnosis and staging of non-small cell lung cancer (NSCLC), providing an accurate nodal staging in a less invasive way than surgical biopsy. The aim of this study was to assess the diagnostic accuracy of EBUS-TBNA in the pre-operative NSCLC mediastinal staging, as well as to evaluate EBUS-TBNA specificity and sensibility in our cohort., Methods: We retrospectively analyzed data of NSCLC patients who underwent EBUS-TBNA followed by major pulmonary resection between January 2020 and December 2022. EBUS-TBNA was performed in patients with NSCLC (central T ≤ 3 cm, peripheral/central T > 3 cm), following the ESTS guidelines. The target nodes were selected on the basis of their radiologic/metabolic characteristics. Each procedure was conducted together with rapid on-site cytological evaluation (ROSE)., Results: Twenty-five patients were included (M/F = 17/8). At least three needle passages on each target lymph node were performed. No complications during or after the procedures occurred. We found a 100% correspondence between ROSE on the sampled nodes and postoperative pathologic findings. An upstaging occurred in three cases (12%) because of the involvement of stations 5 and 6 (not accessible via EBUS), while the only case of downstaging (N2 → N0, 4%) was probably due to intercurrent neoadjuvant chemotherapy. In all cases, EBUS-TBNA has proved to achieve a diagnostic procedure on the target nodes., Conclusions: EBUS-TBNA is a safe and effective procedure that offers high sensitivity and specificity when performed together with ROSE, which improves the accuracy of sampling. Doubt on nodal stations 5 and 6 involvement should be settled by other techniques., (© 2024. Italian Society of Surgery (SIC).)

Objective: The aim of this study is to describe characteristics and survival outcome of patients who underwent surgical treatment for distant thymoma relapse according to the definition of the International Thymic Malignancy Interest Group., Methods: Data of patients affected by thymoma recurrence from four different institutions were collected and retrospectively reviewed. Patients with locoregional metastases who underwent nonsurgical therapies and with incomplete data on follow-up were excluded. According to the International Thymic Malignancy Interest Group distant recurrence definition, patients with recurrence due to hematogenic localization were included. Clinical and pathologic characteristics were described using descriptive statistics, whereas survival outcome was calculated using Kaplan-Meier curves and Cox regression analysis., Results: The analysis was conducted on 40 patients. A single localization was present in 13 patients, the relapse was intrathoracic in 28 cases (70%), and lung involvement was found in 26 cases. The liver was operated in seven cases, whereas other kinds of abdominal involvement were detected in eight cases. Adjuvant treatment was administered in 22 cases (55%).Five- and 10-year overall survival (OS) were 67% and 30%, respectively. Univariable analysis identified as significant favorable factor a low-grade histology (A, B1, B2): five-year OS at 92.3% versus 53.3% in high-grade (B3-C) (p = 0.035). Site of recurrence and number of localization did not influence the prognosis, but in patients with adjuvant therapy administration, there was a survival advantage also if not statistically significant: five-year OS 84.8% versus 54.5% in patients without adjuvant therapy (p = 0.101).Multivariable analysis confirmed as independent prognostic factor low-grade histology: hazard ratio = 0.176, 95% confidence interval 0.042-0.744, p = 0.018., Conclusions: Our study revealed a good survival outcome in patients who underwent surgery for distant thymoma recurrence, independently from the number and site of the relapse localization. Patients with A, B1, or B2 histology presented a significantly better survival than patients with B3-C., Competing Interests: Disclosure All authors declare no conflict of interest., (Copyright © 2024 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

Background/Objectives : The surgical resection of pulmonary metastases is considered a therapeutic option in selected cases. In light of this, we present the results from a national multicenter prospective registry of lung metastasectomy. Methods : This retrospective analysis involves data collected prospectively and consecutively in a national multicentric Italian database, including patients who underwent lung metastasectomy. The primary endpoints were the analysis of morbidity and overall survival (OS), with secondary endpoints focusing on the analysis of potential risk factors affecting both morbidity and OS. Results : A total 470 lung procedures were performed (4 pneumonectomies, 46 lobectomies/bilobectomies, 13 segmentectomies and 407 wedge resections) on 461 patients (258 men and 203 women, mean age of 63.1 years). The majority of patients had metastases from colorectal cancer (45.8%). In most cases (63.6%), patients had only one lung metastasis. A minimally invasive approach was chosen in 143 cases (30.4%). The mean operative time was 118 min, with no reported deaths. Morbidity most frequently consisted of prolonged air leaking and bleeding, but no re-intervention was required. Statistical analysis revealed that morbidity was significantly affected by operative time and pulmonary comorbidities, while OS was significantly affected by disease-free interval (DFI) > 24 months ( p = 0.005), epithelial histology ( p = 0.001) and colorectal histology ( p = 0.004) during univariate analysis. No significant correlation was found between OS and age, gender, surgical approach, surgical extent, surgical device, the number of resected metastases, lesion diameter, the site of lesions and nodal involvement. Multivariate analysis of OS confirmed that only epithelial histology and DFI were risk-factors, with p -values of 0.041 and 0.031, respectively. Conclusions : Lung metastasectomy appears to be a safe procedure, with acceptable morbidity, even with a minimally invasive approach. However, it remains a local treatment of a systemic disease. Therefore, careful attention should be paid to selecting patients who could truly benefit from surgical intervention.

Early-stage (ES) non-small cell lung cancer (NSCLC) is diagnosed in about 30% of cases. The preferred treatment is surgery, but a significant proportion of patients experience recurrence. Neoadjuvant and adjuvant chemotherapy has a limited clinical benefit. EGFR tyrosine kinase inhibitors and immunotherapy have recently opened new therapeutic scenarios. However, only a few data are available about the ES-NSCLC molecular landscape and the impact of oncogene addiction on therapy definition. Here, we determined the prevalence of the main lung cancer driver alterations in a monocentric consecutive cohort. Molecular analysis was performed on 1122 cases, including 368 ES and 754 advanced NSCLC. The prevalence of actionable alterations was similar between early and advanced stages. ES-NSCLC was significantly enriched for MET exon-14 skipping alterations and presented a lower prevalence of BRAF p.(V600E) mutation. PD-L1 expression levels, evaluated according to actionable alterations, were higher in advanced than early tumors harboring EGFR , KRAS , MET alterations and gene fusions. Taken together, these results confirm the value of biomarker testing in ES-NSCLC. Although approved targeted therapies for ES-NSCLC are still limited, the identification of actionable alterations could improve patients' selection for immunotherapy, favoring the enrollment in clinical trials and allowing a faster treatment start at disease recurrence.

Objectives: To assess the current practice of pulmonary metastasectomy at 15 European Centres. Short- and long-term outcomes were analysed., Methods: Retrospective analysis on patients ≥18 years who underwent curative-intent pulmonary metastasectomy (January 2010 to December 2018). Data were collected on a purpose-built database (REDCap). Exclusion criteria were: previous lung/extrapulmonary metastasectomy, pneumonectomy, non-curative intent and evidence of extrapulmonary recurrence at the time of lung surgery., Results: A total of 1647 patients [mean age 59.5 (standard deviation; SD = 13.1) years; 56.8% males] were included. The most common primary tumour was colorectal adenocarcinoma. The mean disease-free interval was 3.4 (SD = 3.9) years. Relevant comorbidities were observed in 53.8% patients, with a higher prevalence of metabolic disorders (32.3%). Video-assisted thoracic surgery was the chosen approach in 54.9% cases. Wedge resections were the most common operation (67.1%). Lymph node dissection was carried out in 41.4% cases. The median number of resected lesions was 1 (interquartile range 25-75% = 1-2), ranging from 1 to 57. The mean size of the metastases was 18.2 (SD = 14.1) mm, with a mean negative resection margin of 8.9 (SD = 9.4) mm. A R0 resection of all lung metastases was achieved in 95.7% cases. Thirty-day postoperative morbidity was 14.5%, with the most frequent complication being respiratory failure (5.6%). Thirty-day mortality was 0.4%. Five-year overall survival and recurrence-free survival were 62.0% and 29.6%, respectively., Conclusions: Pulmonary metastasectomy is a low-risk procedure that provides satisfactory oncological outcomes and patient survival. Further research should aim at clarifying the many controversial aspects of its daily clinical practice., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Thymomas are rare tumors of the anterior mediastinum with peculiar clinical and pathological features. They have been deeply analyzed by pioneer authors, who strictly linked their name to the main pathological and staging classifications. Before the latest edition of the WHO classification of thymic epithelial tumors, the history of thymoma pathological classification inherited the name of the pathologists who systematically addressed the issue, from Levine-Rosai to Muller-Hermelink. Similarly, the thymoma staging system is intimately related to the name of two surgeons, Masaoka and Koga, who historically dealt with this disease. More recently, the traditional tumor-nodes-metastasis (TNM) system has been developed for the staging of this condition, in a rational attempt to put thymomas in conformity with the other solid tumors. The efforts of the International Thymic Malignancies Interest Group (ITMIG) and the Thymic Domain of the Staging and Prognostic Factors Committee (TD-SPFC) of the International Association for the Study of Lung Cancer (IASLC) resulted in the TNM classification of thymic tumors, which have been included in the eighth edition of the American Joint Committee on Cancer's (AJCC) Cancer Staging Manual. Herein, we report a narrative review of the evolution of the thymic epithelial tumors (TET) staging system and present a critical appraisal of the actual TNM classification compared with the historical Masaoka-Koga classification, with special focus on the proposal for the ninth edition of the TNM, expected in 2024.

SARS-CoV2 outbreak led to several healthcare system challenges, especially concerning respiratory support to Covid-19 patients. In the first 2 years of pandemic (2020-2021), we assisted to a marked increase of post-invasive mechanical ventilation (IMV) tracheal stenosis incidence, many of them requiring surgical treatment, namely resection and primary end-to-end anastomosis. Our aim is to describe our experience during the abovementioned biennium, focusing on postoperative outcomes of patients who have had Covid-19 ("post-Covid"). We retrospectively collected pre-, intra- and postoperative data on all patients who underwent tracheal surgery for benign stenosis in our Unit from May 2020 to October 2021, including previous Covid-19. Comparison between "post-Covid-19" and "non-Covid-19" groups' outcomes was then performed. Patients were 9 males and 6 females, and mean age was 57.4 ± 13.21 years. Nine patients had previous Covid-19 (60%). All patients underwent multidisciplinary preoperative evaluation. Almost every operation was conducted by cervicotomy, and the mean length of the resected specimen was 23.9 ± 6.5 mm. Postoperative complications were: dysphonia (3 cases), wound infection (1), bleeding (1), ab-ingestis pneumonia (1), anastomosis dehiscence (2), and stenosis recurrence (1). Thirty-day mortality rate was 6.7% (1 patient). No significant differences between "post-Covid-19" and "non-Covid-19" groups were identified. Pathology revealed, in 5 "post-Covid-19" patients, signs of vasculitis or perivascular inflammatory infiltrate. Tracheal stenosis' surgical treatment has always been known as a challenging procedure because of high perioperative morbidity and mortality rates. Our experience shows that previous Covid-19 and ongoing pandemic did not significantly affect perioperative outcomes of patients who underwent tracheal resection and primary end-to-end anastomosis in a high-volume Center and after multidisciplinary workup., (© 2023. The Author(s).)

Background: Thymic epithelial tumors are rare malignant neoplasms that are frequently associated with paraneoplastic syndromes, especially myasthenia gravis. GTF2I is an oncogene mutated in a subgroup of thymomas that is reputed to drive their growth. However, for GTF2I wild-type tumors, the relevant mutations remain to be identified., Methods: We performed a meta-analysis and identified 4,208 mutations in 339 patients. We defined a panel of 63 genes frequently mutated in thymic epithelial tumors, which we used to design a custom assay for next-generation sequencing. We sequenced tumor DNA from 67 thymomas of patients with myasthenia gravis who underwent resection in our institution., Results: Among the 67 thymomas, there were 238 mutations, 83 of which were in coding sequences. There were 14 GTF2I mutations in 6 A, 5 AB, 2 B2 thymomas, and one in a thymoma with unspecified histology. No other oncogenes showed recurrent mutations, while sixteen tumor suppressor genes were predicted to be inactivated. Even with a dedicated assay for the identification of specific somatic mutations in thymic epithelial tumors, only GTF2I mutations were found to be significantly recurrent., Conclusion: Our evaluation provides insights into the mutational landscape of thymic epithelial tumors, identifies recurrent mutations in different histotypes, and describes the design and implementation of a custom panel for targeted resequencing. These findings contribute to a better understanding of the genetic basis of thymic epithelial tumors and may have implications for future research and treatment strategies., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Pardini, Cucchiara, Palumbo, Tarrini, Di Vita, Coppedè, Nicolì, Guida, Maestri, Ricciardi, Aprile, Ambrogi, Barachini, Lucchi and Petrini.)

Objectives: Nearly-one-third of thymomas are locally-advanced at diagnosis. The traditional dogma that surgery is justified in case a complete resection can be achieved has remained unmovable until today. This study aimed to investigate feasibility and oncologic efficacy of incomplete resection for locally-advanced thymomas in a contest of multimodality therapy., Materials and Methods: A retrospective analysis was conducted using data of prospectively maintained thymomas database in a single high-volume centre. Data on 285 consecutive patients undergoing surgery for stage III and IVa thymomas between 1995 and 2019 were reviewed. Patients who underwent incomplete resection with curative-intent (removal of at least 90% of tumour burden) were included. Long-term outcomes and predictors of cancer-specific survival (CSS) and progression-free survival (PFS) were analyzed. Secondary endpoint was to assess adjuvant therapy efficacy., Results: The study included 79 patients, 60 with microscopic residual tumour (76%, R1) and 19 with macroscopic residual disease (24%, R2). Masaoka-Koga stage was: III in 41 patients (52%) and IVa in 38 (48%). Histology was B2-thymomas (n = 31, 39.2%) followed by B3 (n = 27, 34.2%). Five- and 10-years CSS was 88% and 80%. Seventy patients (90%) underwent adjuvant treatment; they showed CSS comparable to radical resected patients (5-years: 89.1% vs 98.9%, respectively; 10-years: 81.8% vs 92.7%, respectively, p = 0.43). The site of residual disease, Masaoka-Koga stage and WHO histology did not affect prognosis. Stepwise multivariable analysis confirmed adjuvant therapy as a favourable CSS prognostic factor (HR, 0.51; 95% CI, 0.33-0.79, p = 0.003). Stratifying by subgroups, R2-patients who received postoperative chemo(radio)therapy (pCRT) showed a significantly better prognosis than R2-patients treated by consolidation radiotherapy alone (10-years CSS: 60%, p < 0.001)., Conclusion: In locally-advanced thymomas, whenever a radical surgery cannot be achieved, incomplete resection has proved to be effective in a contest of multimodality strategy, independently of WHO histology, Masaoka-Koga stage and site of residual disease., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Prolonged air leak (PAL) due to an alveolar-pleural fistula (APF) is the most common complication after lung surgery. PAL is associated with an increased risk of morbidity and mortality, a longer chest tube duration, hence a prolonged hospitalization. Management of PAL may be challenging, and the thoracic surgeon should be aware of the possible therapeutic strategies., Methods: A systematic literature review was performed in PubMed, Cochrane Library, EMBASE, Ovid and Google Scholar. Title, abstract and full-text screening was performed, followed by structured data extraction, methodological quality assessment and Cochrane risk of bias assessment. Inclusion criteria were: case-control studies/randomized controlled trials (RCTs) comparing the new tested method with the standard of care to manage PAL after lung surgery; PAL due to APF; at least 10 patients; English-written papers., Results: A total of 942 initial papers from literature search, resulted in 43 papers after the selection. This systematic review found that the use of intraoperative measures as surgical sealants or pleural tenting, as well as a proper management of the chest drain and the use of blood patch or sclerosant agents seem to reduce postoperative air leaks incidence and/or duration and length of chest drain stay and hospitalization., Conclusions: Different measures have been described in literature to manage or prevent postoperative PAL. Most of them seem to be safe and efficient if compared to the "wait and see" strategy, even if large comparative studies that standardize the intra- and post-operative management of APF after lung resection are lacking and, actually, hard to conceptualize. However, there is a large consensus on the value of a preoperative PAL-risk stratification and on the necessity of tailoring PAL management or prevention's strategy and its timing on each patient's features., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-736/coif). The special series “Prolonged Air Leak after Lung Surgery: Prediction, Prevention and Management” was sponsored by Bard Limited. Bard Limited has no interference on the contents of the special series. The authors have no other conflicts of interest to declare., (2023 Journal of Thoracic Disease. All rights reserved.)

Objectives: Primary spontaneous pneumothorax is a common disease, whose surgical treatment is still enigmatic in terms of timing and technique. Herein, we reported our experience with the parenchymal-sparing technique via cold coagulation (CC), in comparison to stapler apicectomy (SA)., Methods: We retrospectively collected data of all patients with apical blebs or <2 cm bullae treated with minimally invasive surgery for recurrent or persistent spontaneous pneumothorax, from 2010 to 2020. Two different surgical techniques were used: SA and the parenchymal-sparing CC of the apex. Perioperative and long-term results were analysed and compared., Results: Out of 177 patients enrolled, 77 patients (CC group) underwent cold-coagulation of the apex while 100 patients (SA group) were treated with SA. Two groups were comparable in terms of age, surgical indication, intraoperative findings and affected side. CC group had a mean operative time of 43.2 min (standard deviation ± 19.5), shorter than SA group with 49.3 min (standard deviation ± 20.1, P-value: 0.050). Complication rate was significantly different between 2 groups, 5 (7%) and 16 (16%), for the CC and SA groups, respectively (P: 0.048), even if not in terms of prolonged postoperative air leak (P: 0.16). During the follow-up, 13 homolateral recurrences were reported: 2 (3%) in group CC and 11 (11%) in group SA; with a significant difference (P: 0.044). All reinterventions (postoperative prolonged air leak and recurrences) required an SA., Conclusions: Parenchymal-sparing technique through CC of apical blebs and bullae is an effective treatment for primary spontaneous pneumothorax and guarantees a good immediate lung sealing, despite stapling still represents the choice treatment in complex cases., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

The 2021 WHO Classification of Tumors of the Pleura has introduced significant changes in mesothelioma codification beyond the three current histological subtypes-epithelioid, sarcomatoid and biphasic. Major advances since the 2015 WHO classification include nuclear grading and the introduction of architectural patterns, cytological and stromal features for epithelioid diffuse mesothelioma. Mesothelioma in situ has been recognized as a diagnostic category. Demonstration of loss of BAP1 or MTAP by immunohistochemistry, or CDKN2A homozygous deletion by FISH, is valuable in establishing the diagnosis of epithelioid mesothelioma. Recent emerging data proved that grading and histological subtypes have prognostic implications and may be helpful to patient risk stratification and clinical management. Nevertheless, the latest mesothelioma classification increases the already non-negligible diagnostic pitfalls, especially concerning differential diagnosis of pre-invasive tumors. In this review, recent changes in histologic classification of mesothelioma and advances in molecular markers are presented and their relation to diagnostic challenges and prognostic implications is discussed.

Background: Thymoma and myasthenia gravis share several pathogenetic aspects including the role of surgery as a therapeutic option. Extended thymectomy is associated with excellent survival and good local control, especially in early stages, and its role for the neurologic disease has been recently validated. The aim of this study is evaluating oncologic and neurologic outcomes of myasthenic patients with thymoma who underwent extended thymectomy., Methods: We retrospectively collected surgical, oncologic, and neurologic data of all myasthenic patients with thymoma who underwent extended thymectomy at our department from January 1994 to December 2016. Clinical and pathologic data, neurologic remission rate, and overall survival and disease-free interval were analyzed., Results: In all, 219 patients underwent extended thymectomy. The B2 histotype was the most represented thymoma (24.2%), and the most prevalent pathologic Masaoka stage was IIB (37.9%). The overall survival and disease-free survival were statistically different between early stage and advanced stage. During the surveillance, 33 patients (15.1%) had recurrences, treated in 21 cases with iterative surgery. Regarding neurologic outcomes, 75 patients (34.2%) reached a complete stable remission, 84 (38.4%) a pharmacologic remission, 51 (23.3%) had an improvement of their symptoms, and in 9 patients (4.1%) myasthenia was unchanged or worsened., Conclusions: Surgery is a cornerstone in the treatment of patients with both thymoma and myasthenia gravis. Extended thymectomy, as proposed by Masaoka, offers considerable oncologic outcomes with an excellent survival and low recurrence rate of thymoma; moreover, surgery leads to remarkable neurologic results., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: The International Thymic Malignancy Interest Group (ITMIG) classifies thymoma recurrences on the basis of the topographic location, but its effectiveness in prognosis prediction has not been well investigated yet. Aims of this study are to analyze survival outcome of patients surgically treated for thymoma recurrence according to the ITMIG recurrence classification and to investigate possible alternatives., Methods: From January 1, 1990, to January 7, 2017, data on 135 surgically treated patients for thymoma recurrence from three high-volume centers were collected and retrospectively analyzed. Patients were classified according to the ITMIG classification as local, regional, and distant. The ITMIG classification and alternative classifications were correlated to overall survival (OS)., Results: According to the ITMIG classification, recurrence was local in 17 (12.5%), regional in 97 (71.8%), and distant in 21 (15.7%) patients, with single localization in 38 (28.2%) and multiple localizations in 97 (71.8%). The 5- and 10-year OS were 79.9% and 49.7% in local, 68.3% and 52.6% in regional, and 66.3% and 35.4% in distant recurrences, respectively, but differences were not statistically significant (p = 0.625). A significant difference in survival was present considering single versus multiple localizations: 5- and 10-year OS of 86.2% and 81.2% versus 61.3% and 31.5% (p = 0.005, hazard ratio = 7.22, 95% confidence interval: 0.147-0.740), respectively. Combining the localization number with the recurrence site, ITMIG locoregional single recurrence had a statistically significant better survival compared with patients with ITMIG locoregional multiple recurrence or ITMIG distant recurrence (p = 0.028). Similarly, a significant difference was present considering intrathoracic single versus intrathoracic multiple versus distant recurrence (p = 0.024)., Conclusions: The ITMIG classification for thymoma recurrence did not have significant survival differences comparing local, regional, and distant recurrences. Integrating this classification with the number of the localizations may improve its effectiveness in prognosis prediction., (Copyright © 2021. Published by Elsevier Inc.)

Introduction: Malignant Pleural Mesothelioma (MPM) is characterized by an aggressive behavior and an inevitably fatal prognosis, whose treatment is still far from being standardized. The role of surgery is questionable since a radical resection is unattainable in most cases. Hyperthermic IntraTHOracic Chemotherapy (HITHOC) combines the advantages of antitumoral effects together with those of high temperature on the exposed tissues with the aim to improve surgical radicality., Material and Methods: this is a narrative review on the role of HITHOC in the management of MPM patients. To provide data on the beginnings and the historical evolution of this technique, we searched the available literature by selecting the more exhaustive papers on this topic., Results: from 1994 to date different authors experimented HITHOC following a cytoreductive surgery in MPM, obtaining in most cases a good local control and a better overall survival associated to very low complication rate., Conclusions: HITHOC may be considered as a safe, feasible and effective procedure although there is a high heterogeneity between different protocols adopted worldwide. More structured studies are needed to reach a unanimous consensus on this technique.

Objective: With this narrative review, we retraced the history of hypertermic intrathoracic chemotherapy (HITHOC) since the beginning, analyzing literature on operative technique, feasibility and efficacy of this treatment. Moreover, we report the fifteen-year experience of our center in this relatively new technique, for what concerns both early postoperative results and long-term oncological outcomes., Background: Thymomas are frequently misdiagnosed and recognized in advanced stage, often with pleural dissemination, especially when not associated to Myasthenia Gravis that allows an early diagnosis during the initial assessment. Moreover, the natural history of locally advanced thymoma is characterized by a high rate of pleural or pericardial relapses. Surgery has always been considered a milestone in thymoma's treatment, even in case of serous dissemination or relapses, although his role as exclusive therapy does not guarantee an acceptable local disease control. In case of disseminated disease, different multidisciplinary protocols have been experimented, from chemotherapy to radiation therapy, alone or associated to surgery, in order to increase overall and disease-free survival, but the breakthrough happened in the early 90s with the introduction of HITHOC following surgery. Combination of surgery and HITHOC resulted in less toxic than systemic chemotherapy and providing a good local disease control in patients with stage IVa thymomas or thymoma's pleural recurrences., Methods: We searched PubMed for relevant literature, up to January 2020, on hypertermic intrapleural chemotherapy for thymomas (TPR or DNT), selecting only those reporting information about HITHOC protocol used, postoperative course and oncological outcomes., Conclusions: HITHOC is a safe and feasible procedure, with a very low complication rate and negligible systemic effects of chemotherapeutic agents, effective in controlling both TPR and DNT, in particular as regards local disease-free survival., Keywords: Hypertermic intrathoracic chemotherapy (HITHOC); thymoma; intracavitary chemotherapy; hyperthermia; redo-surgery., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-20-6704). The series “Hyperthermic Intraoperative Chemotherapy (HITHOC) in thoracic surgical oncology” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare., (2021 Annals of Translational Medicine. All rights reserved.)

Objectives: To prospectively assess reproducibility, safety, and efficacy of microwave ablation (MWA) in the treatment of unresectable primary and secondary pulmonary tumors., Methods: Patients with unresectable primary and metastatic lung tumors up to 4 cm were enrolled in a multicenter prospective clinical trial and underwent CT-guided MWA. Treatments were delivered using pre-defined MW power and duration settings, based on target tumor size and histology classifications. Patients were followed for up to 24 months. Treatment safety, efficacy, and reproducibility were assessed. Ablation volumes were measured at CT scan and compared with ablation volumes obtained on ex vivo bovine liver using equal treatment settings., Results: From September 2015 to September 2017, 69 MWAs were performed in 54 patients, achieving technical success in all cases and treatment completion without deviations from the standardized protocol in 61 procedures (88.4%). Immediate post-MWA CT scans showed ablation dimensions smaller by about 25% than in the ex vivo model; however, a remarkable volumetric increase (40%) of the treated area was observed at 1 month post-ablation. No treatment-related deaths nor complications were recorded. Treatments of equal power and duration yielded fairly reproducible ablation dimensions at 48-h post-MWA scans. In comparison with the ex vivo liver model, in vivo ablation sizes were systematically smaller, by about 25%. Overall LPR was 24.7%, with an average TLP of 8.1 months. OS rates at 12 and 24 months were 98.0% and 71.3%, respectively., Conclusions: Percutaneous CT-guided MWA is a reproducible, safe, and effective treatment for malignant lung tumors up to 4 cm in size., Key Points: • Percutaneous MWA treatment of primary and secondary lung tumors is a repeatable, safe, and effective therapeutic option. • It provides a fairly reproducible performance on both the long and short axis of the ablation zone. • When using pre-defined treatment duration and power settings according to tumor histology and size, LPR does not increase with increasing tumor size (up to 4 cm) for both primary and metastatic tumors.

Objectives: Recurrence of thymoma is described in 10-30% of cases after surgical resection. Iterative surgery for thymoma pleural relapses (TPRs) is often part of a multimodal treatment. Hyperthermic intrathoracic chemotherapy (HITHOC) following macroscopic radical surgery is an option that combines the effects of mild hyperthermia with those of chemotherapeutic agents. We evaluated the effectiveness of surgery + HITHOC, compared with surgery alone, in the treatment of TPR., Methods: We retrospectively collected data of all patients who underwent surgery for TPR in our centre from 2005 to 2017. Relapses were treated by partial pleurectomy with radical intent, followed by HITHOC when not contraindicated. Patients were divided into 2 groups: surgery + HITHOC and surgery alone. We collected demographic and clinical data and analysed postoperative results together with oncological outcomes., Results: Forty patients (27: surgery + HITHOC, 13: surgery alone), mean age 49.8 (±13.7) years, were included in this study. There were no perioperative deaths. We experienced 33.3% perioperative morbidity in the surgery + HITHOC group compared with 23.1% in the surgery alone group (P = 0.71). The overall survival rate was comparable between the 2 groups (P = 0.139), whereas the local disease-free interval was 88.0 ± 15 months in the surgery + HITHOC group and 57 ± 19.5 months in the surgery alone group (P = 0.046). The analysis of factors affecting the outcomes revealed that radical surgery is related with a better survival rate whereas the local disease-free interval was significantly influenced by HITHOC., Conclusions: The safety and feasibility of HITHOC in the treatment of TPR are already known, even if it should be reserved for selected patients. Surgery + HITHOC seems to be associated with a longer local disease-free time compared to surgery alone., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Primitive malignant sternal tumours are extremely rare and represent less than 1% of all chest wall tumours. A combination of radical surgery and accurate reconstruction is mandatory to ensure adequate stability and to reduce paradoxical movement. To date, this is one of the few reports on a successful sternal reconstruction using a rigid titanium mesh to restore the skeletal integrity, which was then covered by bilateral muscular flaps., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The demonstration of tissue invasion by histology is an essential criterion for the differential diagnosis of benign and malignant mesothelial proliferations. When tissue invasion cannot be identified, the use of ancillary tests is sometimes necessary. Among investigated markers, the loss of BRCA1 associated protein 1 (BAP1) protein expression and the homozygous deletion of p16 have shown 100% specificity in separating benign and malignant mesothelial lesions. However, beyond the excellent specificity of these two markers, their low sensitivity limits their clinical utility. In this context, a previous study developed and tested a novel tool for use in the differential diagnosis of malignant pleural mesothelioma (MPM) using the NanoString System and a classification algorithm. In the current study, the performance of gene classifiers were compared using BAP1 and p16 testing. p16 FISH and BAP1 immunohistochemistry were performed on the same series of 34 epithelioid MPM and 20 benign pleural lesions, which were previously analyzed by the system. The diagnostic performance of p16 , BAP1 and our classification models were compared using ROC analysis. It was observed that BAP1 loss and p16 deletion were highly specific for MPM, since they were not detected in benign lesions. However, their AUC values were not completely satisfying (BAP1: 0.8235; p16 : 0.7647) particularly due to their low sensitivities. As expected, combining BAP1 and p16 tests increased the diagnostic sensitivity, thus improving the AUC (0.8824). In the same series of cases, our MPM tool outperformed BAP1 and p16 tests using the 22 and 40-gene classification models (AUC 22-gene model: 0.9996; AUC 40-gene model: 0.9990). In conclusion, the present gene-expression-based classification exhibited great potential and further validation is required to support these findings in a prospective fashion, in order to provide a solid alternative for pleural proliferation diagnosis., (Copyright © 2020, Spandidos Publications.)

Objectives: Thymomas are rare neoplasms with a low recurrence rate, which are preferably surgically treated. Iterative thymoma surgery has not been well investigated yet. Study aim is to analyse prognostic factors after iterative recurrence treatment., Methods: Clinical, pathological and surgical findings of 155 patients, treated for thymoma recurrence in three high-volume centres from 01/01/1990 to 1/07/2017, were retrospectively reviewed. Recurrence patterns/treatment types (surgery or chemotherapy, radiotherapy or combined) were correlated to overall (OS) and disease free survival (DFS)., Results: Myasthenia Gravis was present in 135 (87%) patients. Surgery was performed in 135/155 (87%) patients with 109 (80.7%) complete resections. Sixty (55%)patients experienced a second recurrence surgically treated in 31/60 (52%) cases with 18 (58%) complete resections. Eleven (61%) patients experienced a third recurrence and nine underwent complete resection. Myastenia Gravis (HR: 0.45; 95% CI: 0.20-0.98, p = 0.046), DFS after the initial thymectomy >36 months (HR: 0.9; 95% CI: 0.96-0.99, p = 0.006) and complete second recurrence resection (HR: 1.45; 95% CI 2.07-10.01, p = 0.010) resulted as independent favorable prognostic survival factor. Despite patient selection bias, rewarding long-term survivals was predictable after iterative thymoma surgery (5 and 10 years survival of 79.6% and 64.6%) while a poor prognosis was observed after CT/RT (5 and 10 years OS of 56.7% and 21.5%), Masaoka stage and DFS > 36 months were risk factor for iterative recurrences., Conclusions: Myasthenia Gravis and long DFS after thymectomy are favorable survival factors for multiple thymoma recurrences. Iterative surgical treatment is a viable therapeutic option associated to long-term survival if technically and clinically feasible., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Phrenic nerve infiltration has been described in as many as 33% of advanced thymomas; en bloc resection causes diaphragmatic loss of function, with detrimental effects on pulmonary function. We report the outcomes of selected patients operated on for invasive thymoma with a nerve-sparing technique., Methods: From 1990 to 2015 we used nerve-sparing surgery with the intention to treat all patients with advanced stage thymomas without preoperative evidence of hemidiaphragmatic palsy, but with macroscopic evidence of phrenic nerve involvement. All patients underwent adjuvant radiotherapy (45 to 60 Gy) with or without chemotherapy. Long-term outcomes and the pattern of recurrence were retrospectively analyzed., Results: Among 140 patients with stage III and IVa operated on during the study period, 19 women and 18 men with a median age of 52 years received a nerve-sparing resection. Myasthenia gravis was associated in 25 cases. In 12 patients, phrenic palsy was observed postoperatively, and eventually 4 of them recovered. Recurrence was found in 10 patients (7 stage IVa, 3 stage III) requiring additional therapies. Three patients died of cancer-related causes, with an overall survival of 265.4 months and a disease-free survival of 233.2 months., Conclusions: Phrenic nerve preservation in cases of invasive thymomas is feasible and may warrant an acceptable local control of disease, if associated with radiotherapy. According to these results, this technique could be proposed to all patients with invasive thymoma, especially in those affected by severe comorbidities or with a poor performance status., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The best surgical treatment for malignant pleural mesothelioma is still under a debate, but recent evidence points toward a less-invasive approach to reduce morbidity and mortality. We reported our 10-year experience of a limited surgical approach associated with hyperthermic intrathoracic chemotherapy (HITHOC)., Material and Methods: Between 2005 and 2014, patients with epithelioid or biphasic malignant pleural mesothelioma were treated with lung-diaphragm-pericardium-sparing pleurectomy associated with double-drug HITHOC; at least 3 cycles of adjuvant chemotherapy were then administered. The primary outcome examined was the feasibility of the procedure, whereas secondary outcomes were overall survival and disease-free interval., Results: Among 49 patients, 41 were male. Median age was 68 years (35-76 years). Histology was epithelioid in 43 cases. Pathologic stage I, II, III, and IV occurred in 12, 14, 20, and 3 cases, respectively. No intraoperative complications or postoperative mortality occurred, whereas morbidity rate was 46.9%. Median hospital stay was 8 days (5-45 days). Actuarial median overall survival was 22 months and a 1-, 2-, and 5-year survival accounted for 79.6%, 45.7%, and 9.9%, respectively. Disease-free survival after surgery was 62%, 37.5%, and 18.5% at 1, 2, and 5 years, respectively. Risk factors analysis for overall survival confirmed a significant role for early stages, epithelioid histology, and fibrinogen serum levels., Conclusions: Cytoreductive surgery associated with HITHOC and adjuvant chemotherapy appears feasible and safe, with no mortality and low morbidity. Preserving lung and diaphragmatic function might warrant an acceptable long-term outcome., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Lobectomy is the gold standard treatment for resectable Non-Small Cell Lung Cancer (NSCLC). We compared oncological outcomes of patients undergoing a "multi-segmentectomy" (trisegmentectomy or lingulectomy) and left upper lobectomy for early stage (T1-2, N0) NSCLC of the left upper lobe., Methods: We retrospectively analyzed all patients with pathological early stage (T1-T2 N0) NSCLC located in left upper lobe who underwent a lobectomy, a trisegmentectomy, or a lingulectomy between 2006 and 2013, focusing on surgical and oncological outcomes., Results: Among 159 patients, 105 patients underwent a lobectomy and 54 patients a multi-segmentectomy (33 lingulectomy and 21 trisegmentectomy). Actuarial mean Overall Survival was 87 months (95%CI 79-95) and 89 months (95%CI 76-101) for lobectomies and multi-segmentectomies, respectively (P-value: 0.895), while actuarial mean Disease Free Interval was 91 months (95%CI 82-100) and 96 months (95%CI 84-108) respectively (P-value: 0.565). We did not observe any difference in terms of local recurrence rate between the two groups (P = 0.337)., Conclusions: Lingulectomy and trisegmentectomy lead to similar oncological outcomes compared to left upper lobectomy for T1 and T2 N0 NSCLC, and they could be used as an alternative to lobectomy even in patients with a good pulmonary function., (© 2017 Wiley Periodicals, Inc.)

Surgery is one of the steps of multimodality approach for the treatment of MPM. Due to anatomical features, microscopically radical (R0) resection is never possible and a Macroscopic Complete Resection (R1) is considered the target for mesothelioma surgeons. Recently, intracavitary therapies have been described with the aim of extending the loco-regional effect of surgery. Different agents might be administered intrapleurally: chemotherapy drugs are the most widely used, but also photodynamic therapy (PDT) showed to lead to satisfactory long-term outcomes; furthermore, immunotherapies and gene therapies have been also reported. Despite promising results, no high-quality evidences are currently available and controlled randomized trials are required to establish the exact role of intracavitary therapies and to standardize the technique., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Objectives: No clear evidence of which surgical procedure should be performed for early stage mesothelioma is available to date. We analyzed our 10-year experience in the treatment of early stage mesothelioma with surgery and Hyperthermic IntraTHOracic Chemotherapy., Methods: We retrospectively analyzed all cases of histologically proven epithelioid or biphasic IMIG stage I and II mesothelioma that we operated between 2005 and 2014. We performed an open pleurectomy and partial decortication of any visible lesion on the visceral pleura in all cases and both diaphragm and pericardium were always spared; Hyperthermic IntraTHOracic Chemotherapy was ran using Cisplatin 80 mg/m 2 and Doxorubicin 25 mg/m 2 at a target temperature of 42.5 °C for 60 min., Results: We operated on 26 patients (23 male and 3 female); epithelioid tumor was diagnosed in 23 cases. Twelve patients were in IMIG stage I and 14 in IMIG stage II; median overall survival for all patients, stage I and II were 35.6, 46 and 23 months respectively and disease free survival was 18, 18 and 16 months respectively. Our results for stage I were better than those reported in literature and were similar for stage II. We observe no 30- and 90- mortality and the rate of severe complication (all CTCAE stage 3) were 30%; the median postoperative stay was 7.5 days., Conclusions: Our lung sparing approach for the treatment of pleural mesothelioma in early stages allows promising long term outcomes with a complete sparing of pulmonary and diaphragmatic function. Larger studies are needed to confirm our good results., (Copyright © 2017 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Objectives: Surgical resection of pulmonary metastases is considered as a therapeutic procedure in selected cases. However, many patients are unable to tolerate surgical intervention due to comorbidities and/or poor pulmonary reserve, also related to repeated parenchymal resections. Considering this scenario, we decided to investigate the role of radiofrequency ablation (RFA)., Methods: The outcomes of all patients that underwent RFA for lung metastases, during the period 2003-2013, were analysed. The primary end-points were overall survival (OS) and local progression-free survival (LPFS). Secondary end-point was the analysis of possible risk factors affecting OS and LPFS., Results: Ninety-nine RFAs were performed on 61 patients (38 men, 23 women, median age of 74 years). Fourteen patients were treated for two or more lesions, for a total of 86 lesions. Twelve lesions were treated up to three times. The median lesion diameter was 2 cm. The majority of patients were affected by lung metastases from colorectal cancer (47.5%). All procedures were successfully completed. One death occurred, whereas the morbidity rate was 11% (8% pneumothorax requiring chest drainage). At a median follow-up of 28 months, the 1-, 3-, 5-year OS (LPFS) rates were 94.8% (86.3%), 49.0% (70.3%) and 44.5% (68.3%), respectively. No significant correlation was found, using univariate and multivariate analysis, between OS and age, gender, histology of primary cancer (colon versus others), type of approach (computed tomography versus ultrasonography guidance), number of treated lesions (1 vs >1), disease-free interval (from primary tumour to first lung metastases) (1-35 vs >35 months), previous lung resections (yes versus no), whereas a tendency towards better OS was observed, by applying univariate analysis, for a lesion of <3 cm (P = 0.051) and for the presence of local disease 1 month after treatment (P = 0.056), however, without a statistically significant difference. With regard to LPFS, lesion dimensions (P = 0.005) and the presence of local disease 1 month after treatment (P < 0.001) were found to be significant risk factors, in both univariate and multivariate analyses., Conclusions: RFA appears as a feasible and safe procedure, with an acceptable morbidity, offering the possibility to safely repeat the treatment on the same lesion. RFA can be considered a valid option for the local control of lung metastases, in patients not eligible for surgery, especially those with lesions smaller than 3 cm., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

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., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The main aim of this study was to compare radiofrequency ablation (RFA) and wedge resection in terms of disease recurrence and survival, as intent-to-treat therapy for stage I nonsmall cell lung cancer (NSCLC) in marginal or non-surgical candidates. 121 high-risk patients, treated for stage I NSCLC with wedge resection (n=59) or RFA (n=62) in a 7-year period, were analysed. Age, sex, comorbidity score, performance status, forced expiratory volume in 1 s and forced vital capacity values, body mass index, T-stage and histology were evaluated as possible risk factors affecting disease recurrence and survival. At a median follow-up of 36 and 42 months for wedge resection and for RFA (p=0.232), local recurrence rate was 2 and 23%, respectively (p=0.002). The 1-, 2- and 5-year overall survival (disease-free interval) rates were 100% (96%), 96% (90%) and 52% (76%) for wedge resection, and 93% (87%), 72% (63%), and 35% (55%) for RFA (p=0.044 and p=0.01, respectively). None of the analysed parameters was found to be risk factor for disease recurrence and survival, except stage T2, which significantly affected disease-recurrence, overall and cancer-related survival and disease-free interval in the RFA group. Whenever possible, surgical resection, even if limited, should be preferred due to its higher disease control and survival rates. RFA can be considered a valid option for inoperable patients, especially for those with stage T1N0., (Copyright ©ERS 2015.)

Objectives: The already low invasiveness of the thoracoscopic treatment of spontaneous pneumothorax may be further reduced by the transcollation® technique. Herein, we report our further experience with a new device, to coagulate blebs and bullae, compared with contrast to endostapler resection., Methods: Data of patients with recurrent or persistent spontaneous pneumothorax, who underwent thoracoscopic treatment, were prospectively collected and reviewed. Those with blebs or bullae (Stages III and IV in accordance with Vanderschueren's classification) were treated with a new device, based on coupling saline solution perfusion with radiofrequency energy. The combination of fluid with radiofrequency allows the sealing of tissue, avoiding charring or burning. Most operations were performed through two 1-cm incisions only., Results: From 2005 to 2010, 73 patients were treated. These were 59 males (80.8%) and 14 females (19.2%), with a mean age of 27.9 years [standard deviation (SD): 11.7]. Forty-three patients underwent general anaesthesia with selective intubation, 9 awake epidural anaesthesia and 21 spontaneous breathing anaesthesia with laryngeal mask. The mean operation time was 31 min (SD: 10.2). The median postoperative drainage period and hospital stay were 2 days (range of 1-11) and 3 days (range of 2-11), respectively. Prolonged air leak occurred in 1 patient (1.4%). Over a mean follow-up period of 60 months (SD: 22.5), two recurrences (2.7%) were reported., Conclusions: The transcollation® technique by cold coagulation of blebs and bullae seems to be effective in the treatment of primary spontaneous pneumothorax. Owing to its potential advantages, it appears to be particularly suitable to be associated with awake epidural and LMA anaesthesia., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

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., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: During the past 20 years, the use of video-assisted thoracoscopic surgery has increased as an important minimally invasive tool. To further reduce its invasiveness, after a preliminary experience, we decided to use a nonintubated spontaneous breathing general anesthesia, for video-assisted thoracoscopic surgery resection of lung nodule, using a laryngeal mask (LMA). This study aimed to verify the safety and the feasibility of this technique., Methods: Twenty consecutive patients who underwent thoracoscopic wedge of lung nodule under spontaneous breathing general anesthesia with LMA are the subjects of this study. Clinical data, American Society of Anesthesiologists status, Adult Comorbidity Evaluation-27 score, and Revised Cardiac Risk Index score were recorded for each patient. General inhalatory anesthesia (sevoflurane) was given in all cases through an LMA, without muscle relaxants, thus allowing spontaneous breathing. All procedures were performed in the lateral decubitus position. The maximum and minimum values of end-tidal carbon dioxide tension and oxygen saturation were recorded during the procedure. The level of technical feasibility was stratified by the operating surgeon according to four levels: excellent, good, satisfactory, and unsatisfactory., Results: There were 13 men and 7 women (mean age, 57 years). The mean induction anesthesia time was 6 minutes, whereas the mean operative time was 38 minutes. The values of oxygen saturation as well as minimum and maximum end-tidal carbon dioxide tension were 99.1%, 33.6 mm Hg, and 39.1 mm Hg, respectively. No mask displacement occurred. The mean operative time was 38 minutes (range, 25-90 minutes). The level of technical feasibility was defined as excellent in 19 cases and good in 1 case. No mortality occurred. Morbidity consisted of pleural effusion (one case), which was medically resolved. The mean postoperative stay was 3.5 days. Histopathologic results were one squamous cell lung cancer (lung primary), one adenocarcinoma (lung primary), five metastasis from colon cancer, four metastasis from breast cancer, three metastasis from renal cancer, three sarcoidosis, two amartocondroma, and one tuberculosis., Conclusions: Our experience suggests that thoracoscopic wedge resection of lung nodule is safe and feasible under spontaneous breathing anesthesia with LMA. This technique permits a confident manipulation of lung parenchyma and a safe stapler positioning, without cough, pain, or panic attack described for awake epidural anesthesia, avoiding the risks related to tracheal intubation and mechanical ventilation.

During the last decade the role of minimally invasive surgery has been increased, especially with the introduction of the robotic system in the surgical field. The most important advantages of robotic system are represented by the wristed instrumentation and the depth perception, which can overcome the limitation of traditional thoracoscopy. However, some data still exist in literature with regard to robotic lobectomy. The majority of papers are focused on its safety and feasibility, but further studies with long follow-ups are necessary in order to assess the oncologic outcomes. We reviewed the literature on robotic lobectomy, with the main aim to better define the role of robotic system in the clinical practice.

Objectives: To analyse clinical and biomolecular prognostic factors associated with the surgical approach and the outcome of 247 patients affected by primary atypical carcinoids (ACs) of the lung in a multi-institutional experience., Methods: We retrospectively evaluated clinical data and pathological tissue samples collected from 247 patients of 10 Thoracic Surgery Units from different geographical areas of our country. All patients were divided into four groups according to surgical procedure: sub-lobar resections (SURG1), lobar resections (SURG2), tracheobronchoplastic procedures (SURG3) and pneumonectomies (SURG4). Overall survival analysis was performed using the Kaplan-Meier method and log-rank test. Survival was calculated from the date of surgery to the last date of follow-up or death. The parameters evaluated included age, gender, smoking habits, laterality, type of surgery, 7th edition of TNM staging, mitosis Ki-67 (MIB1), multifocal forms, tumourlets, type of lymphadenectomy and neo/adjuvant therapy. For multivariate analysis, a Cox regression model was used with a forward stepwise selection of covariates., Results: Two hundred and forty-seven patients (124 females and 123 males; range 10-84, median 60 years) underwent surgical resection for AC in the last 30 years as follows: n = 38 patients in SURG1, 181 in SURG2, 15 in SURG3 and 14 in SURG4. A smoking history was present in 136 of 247 (55%) patients. The median follow-up period was 98.7 (range 11.2-369.9) months. The overall survival probability analysis of the AC was 86.7% at 5 years, 72.4% at 10 years, 64.4% at 15 years and 58.1% at 20 years. Neuroendocrine multicentric forms were detected in 12 of 247 patients (4.8%; 1 of 12 pts) during the follow-up (range 11.2-200.4, median 98.7 months) and 33.4% had recurrence of disease. There were no significant differences between gender, tumour location and type of surgery at the multivariate analysis. Age [P < 0.001, hazard ratio (HR) 0.60; confidence interval (CI) 0.32-1.12], smoking habits (P = 0.002; HR 0.43, 95% CI 0.23-0.80) and lymph nodal metastatic involvement (P = 0.008; HR 0.46, 95% CI 0.26-0.82) were all significant at multivariate analysis., Conclusions: ACs of the lung are malignant neuroendocrine tumours with a worst outcome in patients over 70 years and in smokers. With the exception of pneumonectomy, the extent of resection does not seem to affect survival and should be accompanied preferably by lymphadenectomy. Pathological staging, along with a mitotic index more than Ki-67 (MIB1), appears to be the most significant prognostic factor at the univariate analysis.

Background: The demand for adequate tissue sampling to determine individual tumor behavior is increasing the number of lung nodule resections, even when the diagnosis is already recognized. Video-assisted thoracic surgery (VATS) is the procedure of choice for diagnosis and treatment of small pulmonary nodules. Difficulties in localizing smaller and deeper nodules have been approached with different techniques. Herein we report our 13-years' experience with radio-guided thoracoscopic resection., Methods: Patients with pulmonary nodules smaller than 1 cm and/or deeper than 1 cm, below the visceral pleura, underwent computed tomography (CT)-guided injection of a solution, composed of 0.2 ml (99)Tc-labeled human serum albumin microspheres and 0.1 ml nonionic contrast, into the nodule. During the VATS procedure, an 11-mm-diameter collimated probe connected to a gamma ray detector was introduced to scan the lung surface. The area of major radioactivity, which matched with the area of the nodule, was resected., Results: From 1997 to 2009, 573 patients underwent thoracoscopic resection of small pulmonary nodules, 211 with the radio-guided technique. There were 159 men and 52 women, with an average age of 60.6 years (range = 12-83). The mean duration of the surgical procedure was 41 min (range = 20-100). The procedure was successful in 208/211 cases. Three patients (0.5%) required conversion to a minithoracotomy. The mean length of pleural drainage and hospital stay was 2.3 and 3.7 days, respectively. Histological examination showed 98 benign lesions and 113 malignant lesions (61 metastases and 52 primary lung cancers)., Conclusion: This study confirms that radio-guided localization of small pulmonary nodules is a feasible, safe, and quick procedure, with a high rate of success. The spread of the sentinel lymph node technique has increased the availability of technology required for RGTS.

Objective: The aim of this study was to report a single referral centre experience in the exeresis of mediastinal lesions with robotic surgical system. The outcomes of all patients were retrospectively investigated with special regard to myasthenic and thymomatous patients., Methods: From February 2001 to December 2010, 69 patients (30 males, 39 females), with a mean age of 55.4 years (range 20-81), underwent robotic surgery for treatment of mediastinal lesions. There were 39 thymectomies, 13 paravertebral neurogenic tumour removals, 9 pleuropericardial cyst removals, 3 teratoma excisions, 4 lymphonodal removals and 1 enterogenous cyst excision. Operative time, conversion rate, morbidity and mortality were analysed., Results: There were no intra-operative complications, and no mortality. The mean operative time was 124.3 min (range 45-240). Conversion to open surgery occurred in three cases (4.3%). All post-operative complications (7.2%) were conservatively treated. The mean post-operative stay was 4.3 days (range 3-10). For the myasthenic patients (mean follow-up of 18 months), the Myasthenia Gravis Foundation of America change in status resulted improved in 18 (90%) patients and unchanged in 2 (10%) patients. In cases of thymoma, the pathological analysis revealed Masaoka stage I (seven cases), IIA (three cases), IIB (two cases) and III (one case). No disease recurrence occurred at a mean follow-up of 16 months., Conclusions: Our experience suggests that the surgical system was safe in performing mediastinal mass resection, with low morbidity and conversion rate. The robotic system proved useful, especially in a tiny space such as the mediastinum, and appeared to be an effective treatment for myasthenia gravis and for early-stage thymoma.

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.

As the European population ages, surgeons are regularly faced with octogenarians with resectable early stage non-small cell lung cancer (NSCLC). We compared our experience with those reported in the literature to comprehend the feasibility, outcomes and lessons learned regarding surgical treatment. We reviewed octogenarians who underwent lung resection for NSCLC in the past nine years in our Department. The purpose of this paper is to retrospectively analyse postoperative surgical and oncological outcomes of our series, trying to find possible correlations between mortality, morbidity, survival and preoperative oncological and functional assessment, surgical approach and extent of resection. Eighty-two patients (M/F = 63/19), with a mean age 81.0 years (range 80-87 years) underwent lung resection for NSCLC: 63 lobectomies, one inferior bilobectomy, three segmentectomies, and 15 wedge resections. There were two perioperative deaths (2.4%). The overall complication rate was 30.0%, with a major complication rate of 2.5%. Actuarial cancer-related survival rates at one, three and five years were 90%, 44% and 36%, respectively, with a statistically-significant correlation with pathological stage. Octogenarians may benefit from surgical treatment of NSCLC with an acceptable morbidity and mortality rate, if an accurate preoperative selection is pursued.