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OBJECTIVES History of anatomical lung resection complicates lung transplantation (LTx). Our aim was to identify indications, intraoperative approach and outcome in these challenging cases in a retrospective multicentre cohort analysis. METHODS Members of the ESTS Lung Transplantation Working Group were invited to submit data on patients undergoing LTx after a previous anatomical native lung resection between January 2005 and July 2020. The primary end point was overall survival (Kaplan–Meier estimation). RESULTS Out of 2690 patients at 7 European centres, 26 (1%) patients (14 males; median age 33 years) underwent LTx after a previous anatomical lung resection. The median time from previous lung resection to LTx was 12 years. The most common indications for lung resection were infections (n = 17), emphysema (n = 5), lung tumour (n = 2) and others (n = 2). Bronchiectasis (cystic fibrosis or non-cystic fibrosis related) was the main indication for LTx (n = 21), followed by COPD (n = 5). Two patients with a previous pneumonectomy underwent contralateral single LTx and 1 patient with a previous lobectomy had ipsilateral single LTx. The remaining 23 patients underwent bilateral LTx. Clamshell incision was performed in 12 (46%) patients. Moreover, LTx was possible without extracorporeal life support in 13 (50%) patients. 90-Day mortality was 8% (n = 2) and the median survival was 8.7 years. CONCLUSIONS The history of anatomical lung resection is rare in LTx candidates. The majority of patients are young and diagnosed with bronchiectasis. Although the numbers were limited, survival after LTx in patients with previous anatomical lung resection, including pneumonectomy, is comparable to reported conventional LTx for bronchiectasis.

The use of extracorporeal membrane oxygenation (ECMO) in the field of lung transplantation has rapidly expanded over the past 30 years. It has become an important tool in an increasing number of specialized centers as a bridge to transplantation and in the intra-operative and/or post-operative setting. ECMO is an extremely versatile tool in the field of lung transplantation as it can be used and adapted in different configurations with several potential cannulation sites according to the specific need of the recipient. For example, patients who need to be bridged to lung transplantation often have hypercapnic respiratory failure that may preferably benefit from veno-venous (VV) ECMO or peripheral veno-arterial (VA) ECMO in the case of hemodynamic instability. Moreover, in an intra-operative setting, VV ECMO can be maintained or switched to a VA ECMO. The routine use of intra-operative ECMO and its eventual prolongation in the post-operative period has been widely investigated in recent years by several important lung transplantation centers in order to assess the graft function and its potential protective role on primary graft dysfunction and on ischemia-reperfusion injury. This review will assess the current evidence on the role of ECMO in the different phases of lung transplantation, while analyzing different studies on pre, intra- and post-operative utilization of this extracorporeal support.

Background Air leak is the most common complication after lung resection and leads to increased length of hospital (LOH) stay or patient discharge with a chest tube. Management by autologous blood patch pleurodesis (ABPP) is controversial because few studies exist, and the technique has yet to be standardized. Methods We retrospectively reviewed patients undergoing ABPP for prolonged air leak (PAL) following lobectomy in three centers, between January 2014 and December 2019. They were divided into two groups: Group A, 120 mL of blood infused; Group B, 60 mL. Propensity score-matched (PSM) analysis was performed, and 23 patients were included in each group. Numbers and success rates of blood patch, time to cessation of air leak, time to chest tube removal, reoperation, LOH, and complications were examined. Univariate and multivariate analysis of variables associated with an increased risk of air leak was performed. Results After the PSM, 120 mL of blood is statistically significant in reducing the number of days before chest tube removal after ABPP (2.78 vs. 4.35), LOH after ABPP (3.78 vs. 10.00), and LOH (8.78 vs. 15.17). Complications (0 vs. 4) and hours until air leak cessation (6.83 vs. 3.91, range 1–13) after ABPP were also statistically different (p Conclusion In our experience, 120 mL is the optimal amount of blood and the procedure can be repeated every 24 hours with the chest tube clamped.

Pediatric lung transplantation is performed in highly experienced centers due to the peculiar population characteristics. The literature is limited and not representative of individual countries' differences. The purpose of this study was to analyze the Italian experience.A multicentric retrospective analysis was performed on 110 pediatric patients (18 years old) who underwent lung transplantation from 1992 to 2019 at 9 Italian centers. Heart-lung transplantations and lung retransplantations were excluded.The population was composed of 44 male and 66 female patients, with a median age of 15 years. The most frequent indication was cystic fibrosis (83%). One quarter of patients were transplanted in an emergency setting. Median donors' Oto score and age were 1 and 15 years, respectively, with 43% of adult donors. In 17% of patients a graft reduction was performed. Postoperatively, the median duration of mechanical ventilation, intensive care unit, and in-hospital stay were 48 hours, 11 and 35 days, respectively. Thirty-day mortality was 6%, and 1-, 5-, and 10-year survival was 72%, 52%, and 33%, respectively. Risk factors for mortality were Oto score and recipients' body mass index.The outcomes of pediatric lung transplantation in Italy are comparable with current literature. Particular attention should be paid to the Oto score and recipient body mass index. Conversely, adult donors and graft reductions can be safely used to expand the donor pool.

Coronavirus disease 2019 (COVID-19) has been declared pandemic since March 2020. In Europe, Italy was the first nation affected by this infection. We report anamnestic data, clinical features, and therapeutic management of 2 lung transplant recipients with confirmed COVID-19 pneumonia. Both patients were in good clinical condition before the infection and were receiving immunosuppression with calcineurin inhibitors (CNI), mycophenolate mofetil, and corticosteroids. Whereas mycophenolate mofetil was withdrawn in both cases, CNI were suspended only in the second patient. The first patient always maintained excellent oxygen saturation throughout hospitalization with no need for additional oxygen therapy. He was discharged with a satisfactory pulmonary function and a complete resolution of radiological and clinical findings. However, at discharge SARS-CoV-2 RNA could still be detected in the nasopharyngeal swab and in the stools. The second patient required mechanical ventilation, had a progressive deterioration of his clinical conditions, and had a fatal outcome. Further insight into SARS-CoV-2 infection is eagerly awaited to improve the outcome of transplant recipients affected by COVID-19 pneumonia.

Background This group previously reported on the repair of a wide tracheoesophageal fistula with a bioabsorbable patch. The current study describes a consecutive series of patients operated on using the same technique. Methods Data of patients undergoing surgical closure of tracheoesophageal fistula at a single center from 2011 to 2018 were extracted and analyzed. Results An absorbable patch was used in 8 of 23 patients (34.8%) operated on for tracheoesophageal fistula during the study period. Causes of the fistulae included postintubation injury (n = 6), mediastinal radiotherapy (n = 1), and a complication of lung resection (n = 1). The median fistula size was 27.5 mm (range, 15 to 45 mm). In 3 patients, the surgical approach was through cervicotomy and in 5 it was through right thoracotomy. Prosthetic materials consisted of Gore Bio-A (W.L. Gore & Associates, Inc, Newark, DE) tissue reinforcement in 6 patients and polyglactin 910 knitted mesh in 2 patients. In every case, the prosthesis was covered with a pedicled muscle flap. The esophageal defect was treated by primary closure in 7 patients and by esophageal exclusion in 1. Fistula recurrence and postoperative death occurred in 1 patient (12.5%), whereas 7 patients experienced postoperative complications (87.5%). Five patients resumed oral intake, and 3 breathed without a tracheal appliance. Compared with the other patients, in those who underwent repair of their fistula using a prosthesis, the median size of the airway defect was larger, morbidity was greater, and the rate of resumption of oral intake was lower. Conclusions Repair of tracheoesophageal fistulae with synthetic prostheses is feasible and may be effective in complex cases. Further research is needed to identify the ideal prosthetic material.

Non-small cell lung cancer (NSCLC) is still one of the leading causes of death worldwide. This is mostly because the majority of lung cancers are discovered in advanced stages. In the era of conventional chemotherapy, the prognosis of advanced NSCLC was grim. Important results have been reported in thoracic oncology since the discovery of new molecular alterations and of the role of the immune system. The advent of new therapies has radically changed the approach to lung cancer for a subset of patients with advanced NSCLC, and the concept of incurable disease is still changing. In this setting, surgery seems to have developed a role of rescue therapy for some patients. In precision surgery, the decision to perform surgical procedures is tailored to the individual patient; taking into consideration not only clinical stage, but also clinical and molecular features. Multimodality treatments incorporating surgery, immune checkpoint inhibitors, or targeted agents are feasible in high volume centers with good results in terms of pathologic response and patient morbidity. Thanks to a better understanding of tumor biology, precision thoracic surgery will facilitate optimal and individualized patient selection and treatment, with the goal of improving the outcomes of patients affected by NSCLC.

A lung transplant is an effective therapeutic option for selected patients with end-stage lung diseases. The shortage of donors is a major limitation for this life-saving therapy, especially in patients with small body sizes or with reduced thoracic cavities, who usually wait longer for grafts with adequate dimensions. Nonanatomic or sublobar graft resections can be sufficient in cases of a small size discrepancy between the donor and the recipient; however, in cases of a greater size mismatch, lobar reduction is mandatory but, because of the associated technical difficulties, only a few centers have adopted this procedure as part of their routine clinical practice. We describe a left upper lobectomy performed at the back table and the subsequent implantation of the left lower lobe in the recipient’s chest cavity.

Surgery for malignant pleural mesothelioma (MPM) should be reserved only for patients who have a good performance status. Sarcopenia, a well-known predictor of poor outcomes after surgery, is still underinvestigated in MPM. The aim of this study is to evaluate the role of sarcopenia as a predictor of short-and long-term outcomes in patients surgically treated for MPM. In our analysis, we included patients treated with a cytoreductive intent in a multimodality setting, with both pre- and post-operative CT scans without contrast available. We excluded those in whom a complete macroscopic resection was not achieved. Overall, 86 patients were enrolled. Sarcopenia was assessed by measuring the mean muscular density of the bilateral paravertebral muscles (T12 level) on pre-and post-operative CTs; a threshold value of 30 Hounsfield Units (HU) was identified. Sarcopenia was found pre-operatively in 57 (66%) patients and post-operatively in 61 (74%). Post-operative sarcopenic patients had a lower 3-year overall survival (OS) than those who were non-sarcopenic (34.9% vs. 57.6% p = 0.03). Pre-operative sarcopenia was significantly associated with a higher frequency of post-operative complications (65% vs. 41%, p = 0.04). The evaluation of sarcopenia, through a non-invasive method, would help to better select patients submitted to surgery for MPM in a multimodality setting.

Objective For small-sized recipients of lung transplantation, the time span for organ reception from standard donors is generally longer than for normal-sized patients. Despite its underuse, lobar reduction may be a concrete option for these patients. This study aims to assess early and long-term outcomes associated with lobar reduction in lung transplantation. Methods A retrospective study was performed on 608 consecutive lung transplantations at 2 centers between January 2005 and August 2019 (559 standard lung transplantations [standard transplantation] and 49 with lobar reduction [lung transplantation group]). A propensity-score weighting approach was used to account for potential confounding related to patients' nonrandom allocation to the 2 intervention groups. The effects of the intervention on postoperative outcomes were assessed with a weighted regression approach. Results The propensity score was estimated on 571 patients (522 in standard transplantation group and 49 in lung transplantation group). In terms of early outcomes, the lung transplantation group showed a higher percentage of severe primary graft dysfunction at 0 hours and reported longer intensive care unit stay than the standard transplantation group. No other differences in terms of morbidity, mortality, mechanical ventilation time, hospital stay, and anastomotic complications were observed. Although the lung transplantation group showed worse long-term pulmonary function, the 2 populations had comparable survival outcomes. Conclusions The use of lobar reduction showed early and long-term results comparable to those after standard lung transplantation. Although a higher rate of early severe primary graft dysfunction and slightly reduced respiratory function were detected in the lobar group, these did not affect patients' morbidity and survival.

Simple Summary The involvement of mediastinal great vessels is common in advanced stage thymic tumors, which makes their surgical resection challenging. Moreover, the impact of vascular involvement on the oncological prognosis is still unclear. The aim of our retrospective, single-center study is to investigate surgical and oncological in a population of patients operated for advanced stage thymic tumors, dividing them in two groups according to the presence or absence of vascular involvement. We demonstrated that resection of thymic tumors with vascular involvement can be performed with optimal surgical results in a high-volume center and that the involvement of the great vessels seems to be associated with a higher recurrence rate, without affecting long-termsurvival. Abstract Background: The involvement of mediastinal great vessels is common in advanced stage thymic tumors, which makes their surgical resection challenging. Moreover, the impact of vascular involvement on the oncological prognosis is still unclear. The aim of this study is to investigate the surgical and oncological outcomes and the impact of vascular involvement in a population of patients operated for advanced stage thymic tumors. Methods: A retrospective analysis on four hundred and sixty-five patients undergoing resection for advanced stage (Masaoka III–IV) thymic tumors in a single high-volume center was performed. One hundred forty-four patients met the inclusion criteria and were eligible for the study. Patients were divided in two groups according to the presence or absence of vascular involvement. Results: the two groups did not differ for the baseline characteristics and showed comparable surgical outcomes. Vascular involvement was not associated with worse overall survival but with an increased recurrence rate (p = 0.03). Multivariable analysis demonstrated a higher risk of recurrence in patients without R0 resection (HR 0.11, 0.02–0.54, p = 0.006) and with thymic carcinoma (HR 2.27, 1.22–4.24, p = 0.01). Conclusions: resection of thymic tumors with vascular involvement can be performed with optimal surgical results in a high volume center. From the oncological point of view, the involvement of the great vessels seems to be associated with a higher recurrence rate without affecting long-term survival.

A recent history of malignancy is an absolute contraindication for lung transplantation according to the International Society of Heart and Lung Transplantation; however, a 5-year disease-free interval should be demonstrated in most cases of malignancies to consider the patient a suitable recipient. Currently, no specific guidelines are reported for addressing previous lung cancer in the selection of recipients. We report a case of a patient who underwent right upper lobectomy for small cell lung cancer in 2013 followed by adjuvant chemotherapy and prophylactic encephalic radiotherapy. In 2019 she underwent lung transplantation for emphysema. Currently she is alive with no recurrence of neoplastic disease.

Purpose Bronchial stenoses are challenging complications after lung transplantation and are associated with high rates of morbidity and mortality. We report a series of patients who underwent bronchoplasty or sleeve resection for bronchial stenoses that did not resolve with endoscopic treatment after lung transplantation. Methods Between 1995 and 2020, 497 patients underwent lung transplantation at our Institution. 35 patients (7.0%) experienced bronchial stenoses with a median time from transplantation of 3 months. Endoscopic management was effective in 28 cases (5.6%) while 1 patient required re-transplantation. Six patients (1.2%) underwent bronchoplasty or sleeve resection. Results The procedures of the six patients who underwent bronchoplasty or sleeve resection were as follows: lower sleeve bilobectomy (n = 3), wedge bronchoplasty of the bronchus intermedius (n = 1), isolated sleeve resection of the bronchus intermedius (n = 1), and isolated sleeve resection of the bronchus intermedius (n = 1), associated with a middle lobectomy. All patients were discharged after a median time of 11 days. At a median of 12 months from surgery, two patients remain alive with a preserved pulmonary function. Four patients died after a median time of 56 months from bronchoplasty of causes that were not related to surgery. Conclusions Bronchial reconstructions are challenging procedures that can be performed in highly specialized centers. Despite this, they can be considered a good strategy to obtain a definitive resolution of stenosis after lung transplantation.

Recensione di La traduzione: teorie e metodi di Raffaella Bertazzoli, Iperstoria, 2007: Blog Series

The effective incidence of cutaneous squamous cell carcinoma of the skin (cSCC) is unknown, in general cSCC is the second most common skin cancer, accounting for 20% of all cutaneous malignancies, with a continuous increase in its frequency (1). The skin of the thorax is a very rare localization for this kind of tumor (1-4). Despite cSCC is a malignant proliferation of keratinizing cells of the epidermis, generally, when the diagnosis is made, early surgical resection with adequate surgical margins is curative in more than 95% of the cases (5). Here we present a very rare case of local recurrence of a huge cSCC involving the anterior chest wall that underwent extensive chest wall resection associated to complex reconstruction by using a combination of synthetic materials and autologous flaps.

Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal lung disease characterized by irreversible scarring of the distal lung. IPF is best described by its histopathological pattern of usual interstitial pneumonia (UIP), characterized by spatial heterogeneity with alternating interstitial fibrosis and areas of normal lung, and temporal heterogeneity of fibrosis characterized by scattered fibroblastic foci (FF), dense acellular collagen and honeycomb changes. FF, comprising aggregated fibroblasts/myofibroblasts surrounded by metaplastic epithelial cells (EC), are the cardinal pathological lesion and their presence strongly correlates with disease progression and mortality. We hypothesized that the EC/FF sandwich from patients with UIP/IPF has a distinct molecular signature which could offer new insights into the crosstalk of these two crucial actors in the disease. Laser capture microdissection with RNAseq was used to investigate the transcriptome of the EC/FF sandwich from IPF patients versus controls (primary spontaneous pneumothorax). Differentially expressed gene analysis identified 23 up-regulated genes mainly related to epithelial dysfunction. Gene ontology analysis highlighted the activation of different pathways, mainly related to EC, immune response and programmed cell death. This study provides novel insights into the IPF pathogenetic pathways and suggests that targeting some of these up-regulated pathways (particularly those related to secreto-protein/mucin dysfunction) may be beneficial in IPF. Further studies in a larger number of lung samples, ideally from patients with early and advanced disease, are needed to validate these findings.

Purpose Lung transplantation (LT) usually requires an optimal donor/recipient size matching to guarantee satisfactory results. In patients of small dimensions or with reduced thoracic cage the waiting time to receive a standard organ may be greater than their life expectancy. Lobar reduction is an important surgical option for these subjects but it is so far underutilized. In addition, lobar transplantation is suspected of high perioperative complications being technically demanding. This bicentric cohort study analyzed the impact of lobar lung transplantation on 1-year survival. Secondary end-point were common early and long-terms outcomes. Methods A retrospective study was performed on 619 consecutive LT between January 2006 and December 2018 (559 standard LT, group I and 60 lobar reduction, group II). A propensity score weighting approach was employed to account for potential confounding factors. The effect of the intervention on the post-operative outcomes of interest was assessed using a weighted regression approach. Results The propensity score was estimated on 571 patients (522 in group I and 49 in group II). Group I presented a higher percentage of single LT (29% vs 4%, p Considering early outcomes, group II presented a higher percentage of severe PGD (2-3) at 72 hours (52 vs 35%, p=0.022) and longer ICU stay (9 vs 6 days, p=0.014) compared to group I. No other differences in terms of morbidity, mortality, mechanical ventilation and hospital stay were observed. At long-terms, the two groups presented comparable 5-year survival (51 vs 57%) and pulmonary function (best post-operative percentage FEV1, 84 vs 78%). At the regression analysis, lobar lung transplantation was associated with severe PGD at 72 hours (p=0.01) and worse long-term pulmonary function (p=0.04). Conclusion In our cohort, lobar transplantation did not affect 1-year survival. Although a higher rate of severe PGD at 72 hours and a slightly reduced respiratory function were observed in the lobar transplantation group, these factors did not affect the morbidity and long-term survival. Lobar transplantation could be positively considered to increase the donors’ pool especially for recipients with small chest cavity.

Despite the availability of antifibrotic therapies, many patients with idiopathic pulmonary fibrosis (IPF) will progress to advanced disease and require lung transplantation. International guidelines for transplant referral and listing of patients with interstitial lung disease are not specific to those with IPF and were published before the widespread use of antifibrotic therapy. In this review, we discussed difficulties in decision-making when dealing with patients with IPF due to the wide variability in clinical course and life expectancy, as well as the acute deterioration associated with exacerbations. Indeed, the ideal timing for referral and listing for lung transplant remains challenging, and the acute deterioration might be influenced after transplant outcomes. Of note, patients with IPF are frequently affected by multimorbidity, thus a screening program for occurring conditions, such as coronary artery disease and pulmonary hypertension, before lung transplant listing is crucial to candidate selection, risk stratification, and optimal outcomes. Among several comorbidities, it is of extreme importance to highlight that the prevalence of lung cancer is increased amongst patients affected by IPF; therefore, candidates’ surveillance is critical to avoid organ allocation to unsuitable patients. For all these reasons, early referral and close longitudinal follow-up for potential lung transplant candidates are widely encouraged.

Improved knowledge has highlighted the importance of additional histological and clinico/radiological features for the diagnosis of Usual Interstitial Pneumonia(UIP)-non Idiopathic Pulmonary Fibrosis(IPF) patients. We present preliminary findings of bicentric revised UIP/IPF cases after a multidisciplinary discussion (MDD) according to the 2018 ATS/ERS/JRS/ALAT Guidelines. All 2002-2017 cases with diagnosis of IPF were retrieved. Histological review was performed considering features suggestive of other diagnoses, i.e.connective tissue diseases (CTD) (germinal centers, >4 lymphoid follicles/cm2, lymphocyte/plasma-cell ratio ≥1, lymphocytic pleuritis, vessel remodelling) and chronic hypersensitivity pneumonitis (CHP) (bridging fibrosis, peribronchial metaplasia, centrolobular fibroblastic foci, granulomas/giant-cells). Clinico/radiological data were reviewed and all cases were re-categorized after MDD. 62 cases were reviewed:in 47% the final diagnosis was IPF, in 11% IPF(likely), in 13% indeterminate IPF and in 29% non-IPF. Among the “indeterminate IPF”, the most prevalent diagnosis was CHP, while in the “non-IPF”, CHP and CTD were almost equally detected (see Figure). In conclusion, the rate of IPF diagnoses appears to have been overestimated. The current knowledge and good practice of MDD have significantly improved the diagnostic accuracy.

Introduction: Malignant pleural mesothelioma (MPM) is a fatal malignancy for which there is no definitive cure. The most effective multimodality treatment in prolonging survival is still matter of debate. Surgery remains one of the cornerstones in the multimodality therapy for MPM. Extra-pleural pneumonectomy and pleurectomy/decortication are the two main curative-intent procedures; however, the superiority of one technique over the other is still debated. This review aims to assess short- and long-term results of extrapleural pneumonectomy for MPM.Areas covered: This article focuses on the role of extrapleural pneumonectomy in MPM. A systematic review was performed by using electronic databases to identify studies that included patients treated by this procedure for MPM. Endpoints included overall survival, disease-free survival, recurrence rate, perioperative mortality, and morbidity.Expert commentary: This paper offers an overview of the results that are currently obtained in patients undergoing extrapleural pneumonectomy for MPM. The benefit of surgical treatments in MPM is still debated and its primary goal should be the achievement of a macroscopic complete resection. Several alternative multimodality protocols exist, with specific advantages and drawbacks; therefore, individualization of care for each patient is fundamental. The complexity of the surgical treatment mandates that patients be referred to specialized centers.

Malignant pleural mesothelioma (MPM) is an aggressive neoplasia with a poor prognosis. The optimal treatment of MPM is still a matter of debate and yet today there is no effective therapy for this tumor. Multimodality treatments, including the association of induction and/or adjuvant therapeutic regimens with surgery, have been reported to give encouraging results.

Background: Sternal resection is indicated for different pathological conditions. Sternectomy leaves a large anterior chest-wall defect, and so a correct reconstruction is mandatory to guarantee an optimal respiratory dynamic and to protect the mediastinal organs. This study is aimed to evaluate the results of anterior chest-wall reconstruction using a sternal allograft and to summarize the use of this technique in clinical experience worldwide. Methods: In the last ten years at our institution, 14 patients have undergone sternectomy followed by anterior chest wall reconstruction using cadaveric cryopreserved sternal allograft mainly for neoplastic disease except one patient whose surgery was performed for complex sternal dehiscence after cardiac operation. Results: One patient died in the perioperative period. No patients experienced postoperative respiratory failure, surgical site infections, or mechanical failure of the reconstruction. After a median follow-up time of 54 months, there no was occurrence of infection or graft rejection. No respiratory impairment or flail chest occurred in any patients. Eight patients are still alive at the present follow-up time. Conclusions: Thus far, complications related to graft necrosis or rejection have not been reported on in the literature. In our clinical experience, sternal allograft transplantation has been a safe and reproducible technique providing excellent results. At our institution, allografts have been well-tolerated biologically, even after long term follow-up. We hope that the good results obtained in our experience and in other published series may contribute to the further diffusion of this technique as the first choice in cases of anterior chest wall reconstruction. Further studies are necessary to consolidate the early and long term results.

Background: The use of smoking donors (SD) is one strategy to increase the organ pool for lung transplantation (LT), but the benefit-to-risk ratio has not been demonstrated. This study aimed to evaluate the impact of SD history on recipient outcomes and graft alterations. Methods: LTs in 293 patients were retrospectively reviewed and divided into non-SD (n = 225, group I), SD &lt, 20 pack-years (n = 45, group II), and SD ≥ 20 pack-years (n = 23, group III) groups. Moreover, several lung donor biopsies before implantation (equally divided between groups) were evaluated, focusing on smoking-related lesions. Correlations were analyzed between all pathological data and smoking exposure, along with other clinical parameters. Results: Among the three groups, donor and recipient characteristics were comparable, except for higher Oto scores and age in group III. Group III showed a longer intensive care unit (ICU) and hospital stay compared with the other two groups. This finding was confirmed when SD history was considered as a continuous variable. However, survival and other mid- and long-term major outcomes were not affected by smoking history. Finally, morphological lesions did not differ between the three groups. Conclusions: In our study, SDs were associated with a longer post-operative course, without affecting graft aspects or mid- and long-term outcomes. A definition of pack-years cut-off for organ refusal should be balanced with the other extended criteria donor factors.

The histological diagnosis of pleural epithelioid mesothelioma can be difficult in the case of rare variants or in the definition of neoplasm origin in patients with previous or concomitant tumours. Currently, several immunohistochemical reactions are available in the surgical pathologist’s armamentarium that allow us to obtain a more sensitive and specific diagnosis of malignant pleural mesothelioma. However, in some cases, the final interpretation remains inconclusive. Historically, ultrastructural examination has represented a useful tool for the definition of the mesothelial nature of neoplastic cells due to their peculiar morphological characteristics. The recent international guidelines for pathological diagnosis of pleural mesothelioma suggest the use of electron microscopy when the immunohistochemical reactions are equivocal or when further support of a diagnosis of mesothelioma is needed. This paper presents three cases of pleural epithelioid mesothelioma whose diagnoses were finally supported by ultrastructural examination.

Introduction Myocarditis is an inflammatory process that is caused by several factors including infection, systemic disease and/or exposure to drugs and toxins. Its clinical course is extremely variable, ranging from lack of symptoms to sudden cardiac death. Here we report a case of viral myocarditis in a cystic fibrosis (CF) patient subjected to retransplantation for chronic lung allograft dysfunction (CLAD). Case Report The patient was a 42-year-old male who had undergone his first lung transplant 18 years earlier for cystic fibrosis. He was referred for retransplantation for CLAD. The cardiac tests performed at the time of re-listing, as well as those repeated during waiting list time were unremarkable. Intraoperatively, during the first pneumonectomy, the patient developed an episode of ventricular fibrillation (VF), without recurrence after a single intrathoracic defibrillation. Due to the risk of hemodynamic instability, he was put on veno-arterial extracorporeal membrane oxygenation (ECMO). The remainder of the procedure was uneventful, and, after careful monitoring, ECMO cannulae were removed. Soon after skin closure, however, the patient first experienced multiple episodes of VF that required cardioversion, after which he quickly became asystolic. After one hour of advanced cardiac arrest treatments - including norepinephrine, cardiac massage, reopening of the chest and epicardial pacing - the patient was pronounced dead. At autopsy, coronary artery disease was excluded; the only pathological finding was the presence of multifocal acute myocarditis with fibrosis. Tissue molecular analysis detected high viral copies of Epstein Barr virus and Parvovirus B19. Summary In the present case, most probably, a surgery-induced systemic inflammatory response syndrome, with massive cytokine release, was responsible for precipitating an unsuspected preexisting condition of myocarditis. Recipients who undergo retransplantation for CLAD are severely immunocompromised and at risk of getting different forms of infections. Based on this experience, we suggest that cardiac magnetic resonance imaging be added to the preoperative workup of patient candidates for retransplantation for CLAD, so as to be able to detect potentially life-threatening pathologies of the myocardium with higher sensitivity.

Purpose The routine utilization of intraoperative extracorporeal membrane oxygenation (ECMO) in lung transplantation is recently extensively investigated for its protective role, especially on reperfusion injury. The purpose of this study is to compare pathological features on pre and post-reperfusion biopsies and on 30 and 90-days surveillance trans-bronchial biopsies in lung transplantations performed with or without ECMO support to assess its protective role on the graft Methods 51 patients (13 with ECMO support, 38 without ECMO support) underwent bilateral lung transplantation at our Institution between 2012 and 2019. Only patients on ECMO at time of anesthetic induction or before the first clamping of the pulmonary artery were included. Patients submitted to graft volume reduction before lung reperfusion were excluded from the analysis.Intra-operative pre and post-reperfusion biopsies were collected to analyze edema, leucocyte margination and congestion/extravasation (score 0-3). The presence of acute rejection (grade A0-3, grade B0-2) diffuse alveolar damage (DAD), organizing pneumonia (OP) on 30 and 90-days trans-bronchial surveillance biopsies was also compared in the two groups. Results No significant differences were found between the two groups in terms of edema, leucocyte margination and congestion in pre reperfusion biopsies. On post reperfusion biopsies, leucocyte margination was significantly less frequent in ECMO group (46% vs 76%; p=0.043). A lower frequency of acute rejection (grade A0-3) was also found in the ECMO group on 30-days biopsies (25% vs 58%, p=0.047). Conclusion In conclusion, this analysis does not show significant differences between the two groups except for a lower frequency of leucocyte margination at post-reperfusion biopsies and acute rejection at 30-days biopsies in the ECMO group. Other studies, with a larger population, are needed in order to evaluate whether the positive clinical impact of using ECMO as a prevention of reperfusion edema after lung transplantation can also be explained by a defined pathological picture

Purpose The extracorporeal membrane oxygenation (ECMO) is a technical option to support cardiorespiratory function during double lung transplantation (DLT). To date, intraoperative ECMO support during DLT seems to give excellent results when planned and used prophylactically, on the other hand the need to use an emergency unplanned ECMO support seems to increase significantly the postoperative morbidity and mortality. The primary endpoint of our study was to search for any factors that could significantly influence the risk of unplanned intraoperative ECMO support. The perioperative and one-year outcome analysis of patients who underwent unplanned ECMO were the secondary endpoints. Methods Records of 95 patients who underwent DLT at our institution between January 2016 and December 2019 were retrospectively reviewed. Patients who underwent lung transplantation with elective intraoperative cardio-circulatory support were excluded from the study. Patients who underwent DLT with unplanned intraoperative ECMO (50 patients, Group A) were compared with no ECMO patients (45 patients, Group B). Results Group A patients showed more preoperative pulmonary artery hypertension (PAH), NYHA class>3, low cardiac-index, higher lactate and dose of inotropes during anesthesia induction. Group A more frequently received donors with higher PCO2 and with cerebral ischemic or hemorrhagic cause of death. After regression analyses PAH (OR7.42), PaCO2 of donors (OR6.29) were the major risk factors for unplanned ECMO. The postoperative period was more complicated for patients requiring intraoperative ECMO. The failure to wean from ECMO at the end of surgery further increase the risk of post-operative morbidity (OR8.43) and mortality (OR4.21). Group A showed a higher in-hospital mortality (24%vs7%, p Conclusion The PAH and a higher PaCO2 of the donor were risk factors for unplanned ECMO. These results support the hypothesis that resolving critical intraoperative events by an unplanned ECMO does allow the intervention to be completed but then is reflected in a worse outcome, in particular after weaning failure at the end of surgery. Identifying a preoperative risk profile could be useful to use prophylactic ECMO and thus avoid the establishment of critical intraoperative events.