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Background The reconstructive tracheal options for extensive lesions still remain limited and although a valid substitute is required unfortunately, the biomechanical tracheal characteristics do not allow an easy replacement. In this study we reviewed the described options and investigated, in human cadaver model, whether thigh fascia can be used, as an alternative to forearm fascia, as recipient site for trachea graft heterotopical allotransplantation. Anatomical study In three fresh cadavers, 3 tracheal graft, 6 radial forearm (RF) fascial flaps and 6 antero-lateral thigh (ALT) fascial flaps were harvested. For each flap we simulated the heteretopical transplantation of the trachea in each fascial flap, and the harvesting of the composite graft as a free flap. The composite graft was finally decomposed at bench and the pedicle was injected to confirm fascial vascularization. The main measured outcomes were: flap fascia vascularization after pedicle injection, average time of flap harvesting, number of perforators included in ALT fascial flap and diameter of the vessels for anastomosis. Difficulties were noted, in order to compare RF flap and ALT flap. Results Fascia vascularization was confirmed in all cases by pedicle injection. The main difficulty with radial flap was to harvest the fascial layer due to its thinness and its strong adherence to palmaris longus tendon, while the main difficulty with ALT flap was to prevent any traction on the perforators. The average time of flap harvesting and graft inset (by a junior plastic surgeon) was 1 h and 30 min for radial forearm flap and 2 h and 10 min for ALT flap. Conclusion Despite many different techniques proposed in the literature, tracheal heterotopical allotransplantation still seemed the most promising, and ALT flap promised be a feasible alternative for heterotopical transplantation of trachea.

Catamenial pneumothorax (CP) is defined as a recurrent, spontaneous pneumothorax occurring within a day before or 72 h after the onset of menstruation. Most first episodes go undiagnosed and treated as primary spontaneous pneumothorax, and only after recurrence is the clinical suspicion of CP raised. No gold-standard management approach exists, especially in terms of managing diaphragmatic involvement.This study is a single-centre cohort retrospective study of 24 female patients who underwent surgery for pneumothorax due to diaphragmatic endometriosis between January 2008 and December 2016. Two groups were compared: a group that underwent pleurodesis alone (8 patients) and a group that underwent diaphragmatic surgery and pleurodesis (16 patients).There were differences in BMI and smoking habits between the two groups. The right diaphragm was involved more often (6vs15, p = 0.190). VATS was the preferred surgical approach and only one conversion occurred in the diaphragmatic surgery group (p = 0.470). Diaphragmatic abnormalities were present in all the patients, brown/violet spots (100%) in the pleurodesis group and perforations (100%) in the diaphragmatic surgery group (p 0.001). There were no differences in days of chest tube removal and length of stay. The recurrence rate was 100% in the pleurodesis alone group while it was only 12.5% in the diaphragmatic surgery group ( 0.001).In our experience, diaphragmatic surgery and pleurodesis followed by hormonal therapy was an effective approach in preventing recurrence in patients with catamenial pneumothorax and diaphragmatic involvement.

Purpose Lung cancer relapse may be associated with the presence of a small population of cancer stem cells (CSCs) with unlimited proliferative potential. Our study assessed the relationship between CSCs and the relapse rate in patients harboring adenocarcinoma (ADL) and squamous cell carcinoma of the lung (SCCL). Experimental design This is an observational prospective cohort study (NCT04634630) assessing the influence of CSC frequency on relapse rate after major lung resection in 35 patients harboring early (I-II) (n = 21) and locally advanced (IIIA) (n = 14) ADL and SCCL. There was a 2-year enrollment period followed by a 1-year follow-up period. Surgical tumor specimens were processed, and CSCs were quantified by cytofluorimetric analysis. Results Cancer stem cells were expressed in all patients with a median of 3.1% of the primary cell culture. Primary analysis showed no influence of CSC frequency on the risk of relapse (hazard ratio [HR] = 1.05, 95% confidence interval [CI] = 0.85-1.30). At secondary analysis, patients with locally advanced disease with higher CSC frequency had an increased risk of relapse (HR = 1.26, 95% CI = 1.14-1.39), whereas this was not observed in early-stage patients (HR = 0.90, 95% CI = 0.65-1.25). Conclusion No association was found between CSC and relapse rates after major lung resection in patients harboring ACL and SCCL. However, in locally advanced-stage patients, a positive correlation was observed between CSC frequency and risk of relapse. These results indicate a need for further molecular investigations into the prognostic role of CSCs at different lung cancer stages. Clinical Trial Registration NCT04634630.

Introduction Achalasia with megaesophagus is a pathology characterized by widespread and irregular dilation of the esophageal lumen. In most cases, this dilation is caused by contraction and subsequent failed relaxation of the lower esophageal sphincter (LES). It may be associated with a partial or complete slowing of the esophageal peristalsis. Case overview We present the case of a 58-year-old woman who developed dysphagia, regurgitation, and substantial weight loss (11 kg) over a span of 1 year. Symptomatic achalasia with megaesophagus was diagnosed following chest and abdominal computed tomography (CT) with contrast and transit RX with gastrografin and esophageal manometry. The patient refuse all minimally endoscopic treatments and opted straightly for the treatment with esophagectomy sec. Ivor–Lewis. At the 6-month follow-up, the patient appeared in excellent general clinical condition and oral gastrografin radiography (OGR) showed good channeling. Discussion Patients require medical attention when presenting with achalasia that has eroded the esophageal wall enough to form a megaesophagus. Early and minimally invasive treatments (i.e., medical therapy, endoscopic dilation, and myotomy) are insufficient at this stage, and thus esophageal surgery is required. Among the most common surgical approaches, we must mention esophagectomy sec. McKeown and esophagectomy with interposition of a colic loop sec. Wilkins; however, based on our experience, esophagectomy sec. Ivor–Lewis with intrathoracic anastomosis leads to excellent results and can therefore be considered a valid alternative for treating complex cases. Conclusions Subtotal esophagectomy sec. Ivor–Lewis with intrathoracic anastomosis is effective in treating achalasia with megaesophagus.

The importance of defining new molecules to fight cancer is of significant interest to the scientific community. In particular, it has been shown that cancer stem cells (CSCs) are a small subpopulation of cells within tumors with capabilities of self-renewal, differentiation, and tumorigenicity; on the other side, circulating tumor cells (CTCs) seem to split away from the primary tumor and appear in the circulatory system as singular units or clusters. It is becoming more and more important to discover new biomarkers related to these populations of cells in combination to define the network among them and the tumor microenvironment. In particular, cancer-associated fibroblasts (CAFs) are a key component of the tumor microenvironment with different functions, including matrix deposition and remodeling, extensive reciprocal signaling interactions with cancer cells and crosstalk with immunity. The settings of new markers and the definition of the molecular connections may present new avenues, not only for fighting cancer but also for the definition of more tailored therapies.

Purpose Cancer stem cells (CSCs) are described as resistant to chemotherapy and radiotherapy. It has been shown that CSCs influence disease-free survival in patients undergoing surgery for lung cancer (NCT04634630). We recently described an overexpression of CSCs recurrence-related genes (RG) in lung cancer. This study aims to investigate CSC frequency and RG expression as predictors of disease-free survival in lung cancer. Experimental Design This secondary analysis of a prospective cohort study involved 22 surgical tumor specimens from 22 patients harboring early (I-II) and locally advanced (IIIA) stages ACL and SCCL. Cell population frequency analysis of ALDHhigh (CSCs) and ALDHlow (cancer cells) was performed on each tumor specimen. In addition, RG expression was assessed for 31 target genes separately in ALDHhigh and ALDHlow populations. CSCs frequency and RG expression were assessed as predictors of disease-free survival by Cox analysis. Results CSCs frequency and RG expression were independent predictors of disease-free survival. CSC frequency was not related to disease-free survival in early-stage patients (HR = 0.84, 95%CI = 0.53-1.33, P = .454), whereas it was a risk factor for locally advanced-stage patients (HR = 1.22, 95%CI = 1.09-1.35, P = .000). RG expression—if measured in CSCs—was related to a higher risk of recurrence (HR = 1.19, 95%CI = 1.03-1.39, P = .021). The effect of RG expression measured in cancer cells on disease-free survival was lower and was not statistically significant (HR = 1.12, 95%CI = 0.94-1.33, P = .196). Conclusions CSCs frequency and RG expression are independent predictors of relapse in lung cancer. Considering these results, CSCs and RG may be considered for both target therapy and prognosis.

Background: Left ventricular penetrating injuries are rare but often lethal. Transport times greater than 30 min have been shown to increase the injury severity; thus early recognition of cardiac tamponade, prompt pericardial decompression, and control of cardiac hemorrhage are mandatory. Methods: We retrospectively reviewed our record to include patients with penetrating trauma of the heart. Results: Four hemodynamically unstable young male patients with left ventricular penetrating injury of the heart were referred to our unit between January 2007 and December 2015. Median time from trauma to surgery was 16 min (range 14-21). A cardiorrhaphy through sternotomy with no extracorporeal support was performed. We had no in-hospital mortality. Conclusion: According to our experience, in patients with hemodynamic shock and penetrating cardiac injury, a timely recognition of injuries and referral to the closest thoracic surgery unit may increase patient survival if it is located closer than a level I trauma center.

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.

Background: Pleural empyema is associated with relevant morbidity and mortality, and it may be classified, according to evolution and ultrasound, into three stages: stage I (free-flowing effusion), stage II (viscous effusion with the tendency to loculate), and stage III (organizing phase). According to guidelines, antibiotic therapy and pleural drainage are recommended, with surgery being performed when patients fail and/or in case of organized empyema. Objectives: The aim of the study was to report the efficacy and safety of medical thoracoscopy in patients with pleural empyema stratified by chest ultrasound. Method: Observational retrospective cohort study analyzing patients with pleural empyema treated with medical thoracoscopy. Procedure success and mortality were evaluated at 30 days and 90 days after the procedure; complications were also reported. Results: 131 patients were included. Intrapleural fibrinolytic therapy was performed thereafter in the majority of cases. Medical thoracoscopy was considered successful without subsequent intervention in 99 patients (76%); 19 patients (15%) underwent a second procedure (drainage, thoracoscopy, video-assisted thoracic surgery, or thoracotomy); and 6 patients (5%) died of the evolution of empyema. Patients treated in stages I and II showed significantly better post-procedure results compared with patients treated in stage III (100%, 83.3%, and 58.1%, respectively). Thoracoscopy complications were observed in 18 patients and were reversible in all cases. Conclusions: Patients with pleural empyema treated in earlier stages (free-flowing or multiloculated effusion) with medical thoracoscopy show significantly better results than patients treated in later stages (organized empyema). This approach is safe, minimally invasive, and efficient in these patients with disease having relevant mortality; however, patient selection remains essential.

Aging results in a progressive decline in skeletal muscle mass, strength and function, a condition known as sarcopenia. This pathological condition is due to multifactorial processes including physical inactivity, inflammation, oxidative stress, hormonal changes, and nutritional intake. Physical therapy remains the standard approach to treat sarcopenia, although some interventions based on dietary supplementation are in clinical development. In this context, thanks to its known anti-inflammatory and antioxidative properties, there is great interest in using extra virgin olive oil (EVOO) supplementation to promote muscle mass and health in sarcopenic patients. To date, the molecular mechanisms responsible for the pathological changes associated with sarcopenia remain undefined; however, a complete understanding of the signaling pathways that regulate skeletal muscle protein synthesis and their behavior during sarcopenia appears vital for defining how EVOO might attenuate muscle wasting during aging. This review highlights the main molecular players that control skeletal muscle mass, with particular regard to sarcopenia, and discusses, based on the more recent findings, the potential of EVOO in delaying/preventing loss of muscle mass and function, with the aim of stimulating further research to assess dietary supplementation with EVOO as an approach to prevent or delay sarcopenia in aging individuals.

The aim of this study was to assess the impact of BMI on perioperative outcomes in patients undergoing VATS lobectomy or segmentectomy. Data from 5088 patients undergoing VATS lobectomy or segmentectomy, included in the VATS Group Italian Registry, were collected. BMI (kg/m

Background Stage III non-small cell lung cancer (NSCLC) encompasses a variety of local invasion and nodal involvement and its management is still under debate. Immune checkpoint inhibitors (ICIs) have been shown to improve the survival in metastatic NSCLC, but are far from being accepted as an induction therapy. Methods We retrospectively collected data of all patients who received induction ICIs (nivolumab or pembrolizumab) and chemotherapy (carboplatin with paclitaxel) for stage IIIA-B NSCLC followed by surgery in our unit between January 2019 and March 2020. Results Of the 12 patients (9 men, 3 women) 6 had a squamous cell carcinoma, 4 had adenocarcinoma, 1 had an undifferentiated adenocarcinoma, and 1 had adeno-squamous carcinoma. Seven patients had stage IIIA disease and 5 had stage IIIB. After induction therapy, 6 patients had stable disease and 6 had a partial response. The median tumor reduction was 3.05 cm (range, 2.30-8.70 cm). All patients, but 1 due to the COVID-19 outbreak, had no delay in surgery. Two patients experienced myelosuppression after induction therapy, 2 had minor adverse effects. Three patients had postoperative complications not related to the induction therapy. All patients had a pathologic response: 5 complete, 4 major, and 3 partial. Eleven patients are alive (mean follow-up, 18.17 ± 4.97 months) and free of disease. Conclusions Induction ICI chemotherapy may be a valid treatment in patients with locally advanced NSCLC, providing important tumor downstaging and rendering patients operable. In our experience patients had few side effects and a good pathologic response.

Minimally invasive surgery is considered the gold standard approach for early stage lung cancer. Techniques range from a standard three-port approach to uniportal lobectomies, with no technique emerging as superior thus far. We retrospectively compared the pain outcomes of a standard approach using a utility incision with a totally thoracoscopic technique.Between January 2015 and December 2019, 168 patients received a VATS lobectomy in our centers. Two groups were created, Group A (82 patients, totally thoracoscopic approach) and Group B (86 patients, standard approach with utility incision). Perioperative outcomes, such as operative time, complications, length of stay, perioperative and chronic pain using visual analog scale (VAS), and rescue doses of painkillers were examined. A one-way analysis of covariance (ANCOVA) was conducted to investigate the impact of surgical time and days of drainage on VAS score.Pain was less on postoperative day (POD) 1 and 2 (p = 0.025 and p = 0.020, respectively) in Group A. No differences were found in the baseline and perioperative characteristics of the two groups, in the mean VAS score at 1 month (p = 0.429), 1 year (p = 0.561), doses of NSAIDs (p = 0.609), and chronic pain (3vs7 patients, p = 0.220). The ANCOVA test showed no significant effect of surgical time and days of drainage on VAS score (p 0.05).In our experience, a totally thoracoscopic approach may improve acute postoperative pain without compromising the oncological results of the procedure and the safety of the patients.

Extensive chest wall resection and reconstruction is a challenging procedure that requires a multidisciplinary approach, including input from thoracic surgeons, plastic surgeons and oncologists. Neoplastic chest wall pathologies are associated with a high surgical morbidity and can result in full thickness defects which are complicated to reconstruct. The goals of a successful chest wall reconstruction is to restore the chest wall rigidity, preserve ventilatory mechanics and protect the intrathoracic organs. Large full thickness defects require reconstruction with synthetic, biologic or composite meshes with or without titanium plate to restore thoracic cage rigidity. After skeletal stability is established full tissue coverage can be achieved using direct sutures, skin grafts or local advancement flaps, pedicled myocutaneous flaps or free flaps. The aim of this chapter is to illustrate the indications and the various materials and techniques for chest wall reconstruction with the goal of obtaining the best chest wall rigidity and soft tissue coverage.

Hemothorax, whether spontaneous or related to thoracic trauma lesions, is treated using basic principles that are well-accepted by trauma and cardiothoracic surgeons. Only a small percentage of patients require a tube thoracostomy; for the rest, a nonoperative technique is appropriate and safe. Only a small percentage of patients require surgical intervention due to retained hemothorax, persistent bleeding or incoming complications (i.e. pleural empyema or entrapped lung). Early in the 1990s, significant technological advancements led to an increase in diagnostic and therapeutic indications for Multi-port Video-assisted thoracoscopic surgery (VATS) as the gold standard therapy for retained and persistent hemothorax, allowing for earlier diagnosis, total clot removal, and better tube placement, with less morbidity, reduced post-operative pain, and a shorter hospital stay. Even if there is no agreement in the Literature about the timing for draining hemothorax, best results are obtained when the drainage is performed within the first five days after the onset. An important evolution of traditional multi-port approach is represented by uniportal approach, with the same results of open surgical technique and the real advantage of a non-rib-spreading single small incision. Currently, in experienced hands, this technique is used for diagnostic and therapeutic interventions as hemothorax evacuation as like as the more complex procedures such as lobectomies or bronchial sleeve and vascular reconstructions. Many authors have confirmed the advantages of single-port technique compared with multi-port in term of better post-operative pian control, easier surgical approach and better cosmetic results, but longer and harder learning curve.

Malignant pleural mesothelioma (MPM) is an aggressive asbestos-related tumour with poor prognosis. To date, a multimodality treatment, including chemotherapy and surgery, with or without radiotherapy, is the gold standard therapy for selected patients with epithelioid and early-stage MPM. In this setting, the goal of surgery is to achieve the macroscopic complete resection, obtained by either extrapleural pneumonectomy or pleurectomy/decortication. Failure, in local and/or distant sites, is one of the major concerns; in fact, there has been no established treatment for the recurrence of MPM after the multimodal approach, and the role of surgery in this context is still controversial. By using electronic databases, studies that included recurrent MPM patients who underwent a second surgery were identified. The endpoints included were: a pattern of recurrence, post-recurrence survival (PRS), and the type of second surgery. When available, factors predicting better PRS and perioperative mortality and morbidity were collected. This systematic review offers an overview of the results that are currently obtained in patients undergoing a second surgery for relapsed MPM, with the aim to provide a comprehensive view on this subject that explores if a second surgery leads to an improvement in survival.

Malignant mesothelioma (MM) has a wide range of clinical, radiologic, and pathologic presentations, mimicking lung cancer or interstitial lung diseases when predominantly involving the lung parenchyma. The case herein refers to a 79-year-old man, active smoker without asbestos exposure, incidentally discovered to have a pulmonary nodule in the right upper lobe (1.5 cm). The lesion was misinterpreted as primary lung adenocarcinoma at the frozen section in light of the predominant lepidic growth pattern. Definitive examination confirmed neoplastic proliferation along alveolar structures. However, the unusual globous shape of tumor cells along the alveoli abruptly merging with normal pneumocytes prompted us to perform some immunostains that surprisingly revealed a mesothelial differentiation (positive staining with calretinin, cytokeratins (CK5/6), D2-40, and negativity with BRCA-associated protein 1 (BAP1), Thyroid Transcription Factor 1 [TTF-1], claudin-4, carcinoembryonic antigen [CEA], and napsin). MM represents the pathologic counterpart of so-called pseudomesotheliomatous carcinoma, since it appears as a localized pulmonary neoplastic nodule displaying a predominant lepidic growth pattern (pseudocarcinomatous mesothelioma). The challenging diagnostic features of this unique case and a review of similar cases in the literature are discussed.

Left-side secondary carina resection and reconstruction is a rare, complex procedure, performed just in a few specialized centers in a restricted group of patients. Few studies describe this technique and report its short and long-term results. We reviewed our experience to evaluate the perioperative and short-term outcomes of a very demanding surgery. We retrospectively collected the information of all the patients who underwent secondary carina resection and reconstruction for low-grade malignant bronchial tumors at our center. Between January 2012 and September 2018, 23 patients received surgery for low-grade malignant bronchial tumors. In all patients, a secondary carina resection and reconstruction with total lung parenchymal preservation was performed. The mean age was 44.5 ± 12.2 years. Pathologies included adenoid cystic carcinoma in ten patients, carcinoid in 7 (6 typical and 1 atypical), mucoepidermoid carcinoma in 4, myoepithelioma in 1 and inflammatory myofibroblastic tumor in 1. The median length of the resected bronchus was 25 mm (range 15-50 mm). Three patients (13%) had, at least, one postoperative complication with no deaths. Two patients had lymph node metastases and eight had positive margins. Nine patients received adjuvant therapy. Follow-up ranged from 13 to 96 months, all patients are currently alive and free of recurrence. Resection and reconstruction of the left secondary carina with preservation of the lung parenchyma can be performed safely in anatomically and oncologically appropriate patients, providing good short-term results when combined with adjuvant therapies.

Foreign bodies in the pulmonary circulation have been documented in the literature, with almost all cases being iatrogenic, involving venous catheters, or due to penetrating foreign body emboli. Foreign body pulmonary emboli are often difficult to diagnose due to their varied clinical presentation, the nature of the embolizing material and dubious radiological features. We describe the case of a patient who experienced episodes of massive hemoptysis with inconclusive radiological findings, who underwent a thoracotomy with the discovery of a wooden object of 7 cm in length in the right lower lobe artery, with no apparent mechanism of injury. Supplementary Information The online version contains supplementary material available at 10.1007/s11748-020-01570-5.

Objectives A rare and complex procedure, total lung sparing left secondary carinal resection and reconstruction is only performed in a few specialized centers in a restricted group of patients. We reviewed our experience to evaluate its safety. Methods Patients who underwent left secondary carinal resection and reconstruction with complete lung parenchymal preservation for low-grade bronchial malignancies at the Shanghai Chest Hospital and the Padua University Hospital were retrospectively reviewed. Clinicopathologic factors and perioperative outcomes were analyzed. Results Thirty patients underwent the procedure between July 2012 and July 2019 (mean age, 42.9 years). No operative mortality occurred and postoperative complications developed in 4 patients (13.3%), including pneumonia (n = 3 [10.0%]), subcutaneous emphysema (n = 2 [6.7%]), and prolonged air leak (n = 2 [6.7%]). Pathologies included adenoid cystic carcinoma (n = 11), mucoepidermoid carcinoma (n = 6), carcinoid tumors (n = 9 [8 typical and 1 atypical subtypes]), inflammatory myofibroblastic tumor (n = 3), and myoepithelioma (n = 1). The margins were positive in 8 patients (26.7%), whereas 2 patients (6.7%) had positive lymph nodes. Adjuvant therapies were performed postoperatively, including chemoradiotherapy for positive lymph nodes and radiotherapy for positive margins. Conclusions Total lung sparing left secondary carinal resection and reconstruction can be performed safely in well-selected and oncologically appropriate patients with low-grade bronchial malignancies.

Background: Bronchoplastic procedures have become the reference standard in the lung parenchyma-sparing treatment of centrally located bronchopulmonary tumors. Two schools of thought exist regarding performing a bronchial sleeve resection: those who wrap the anastomosis with a pedicled flap and those who leave the anastomosis unprotected. We performed a study comparing these 2 methods. Methods: This study was a retrospective multicenter observational analysis of 90 consecutive patients undergoing bronchial sleeve resections for neoplastic disease between June 2009 and July 2019. Group A (60 patients) underwent bronchial wrapping and group B (30 patients) did not undergo wrapping. Results: The only difference between group A, which had 5 patients (8.3%), and group B, which had 10 patients (33.3%), regarding general characteristics was the presence of diabetes (P = .003). There were no differences in surgical, postoperative, and follow-up characteristics. There was no statistically significant difference between groups (group A, 9 patients [15%]; and group B, 6 patients [20%]) in terms of anastomotic complications at 1 year (P = .425). Diabetes was an independent predictive factor for anastomotic complications at 1 year (P = .035). The number of postoperative complications (P < .001) was an independent risk factor for length of hospital stay. Conclusions: We found no differences between groups in terms of postoperative complications and length of hospital stay, which confirmed previous reports that sleeve resections may be performed safely without bronchial wrapping.

Introduction: despite the accumulating data on clinical and imaging features of COVID-19, its pathogenesis is still poorly understood. The majority of data regarding morphology and molecular changes regards post-mortem analysis; however, the value of performing lung biopsy on live patients more than autopsies on deceased patients is significantly high, as they may provide an insight into the complexity of the disease pathophysiology. Objectives: we examine the morphologic and molecular features of patients affected by COVID-19 who underwent lung biopsy at different times in the course of the disease: either at an earlier or at a later stage. Methods: comparative, multicenter, prospective, observational study. 24 patients were recruited. Lung samples were obtained by either cryobiopsy or TBB or SLB. Results: in most “early” phases of pneumonia the morphological changes did not match with typical DAD pattern; the exudative phase with jaline membranes and alveolar collapse were absent. Alveolar damage was patchy, varying from focal AECII hyperplasia to extensive nodular proliferation. The involvement of linear AECI was only partial; in advanced cases consistent remnants of normally looking AECI were present. A wide panel of immunohistochemical markers were just applied in samples (cytokeratin-7, cytokeratin 5/6, TTF1, CD34, Tubulin beta-3, alfa-SMA, CD163, CD14, CD20, CD138, CD3, CD4, CD8, T-bet, FoxP3, Gata-3, PD1, TCF1). Molecules involved in cell signaling, cell proliferation and activation were also investigated (beta-Catenin, phospho-STAT3, PDL-1, IDO, HLA-DR, CD25, gamma-fibrinogen).

BackgroundPathogenesis of Coronavirus disease 2019 (Covid-19) is poorly understood. Most histologic studies come from post-mortem analysis, with existing data indicating that histologic features of acute respiratory distress syndrome are typically present in fatal cases. However, this observation may be misleading, due to confounding factors in pre-terminal disease, including injury resulting from prolonged mechanical ventilation. Ante-mortem lung biopsy may provide major pathogenetic insights, potentially providing a basis for novel treatment approaches.AimThis comparative, multicenter, prospective, observational study was planned to identify ante-mortem histological profile and immunohistochemical features of lung tissue in patients with Covid-19 in early and late phases of the disease, including markers of inflammatory cells and major pathways involved in the cytokine storm triggering.MethodsEnrolled patients underwent lung biopsy, according to the study protocol approved by local Ethical Committee, either within 15 days of the first symptoms appearing (early phase) or after >15 days (more advanced disease). Key exclusion criteria were excessive or uncorrectable bleeding risk and cardiovascular disease with heart failure. Lung samples were obtained by conventional transbronchial biopsy, trans-bronchial lung cryobiopsy or surgical lung biopsy.Results23 patients were enrolled: 12 patients underwent lung biopsy within 15 days and 11 patients more than 15 days after the onset of symptoms. Early biopsies were characterized by spots of patchy acute lung injury (ALI) with alveolar type II cells hyperplasia and significant vascular abnormalities (disordered angiogenesis with alveolar capillary hyperplasia, luminal enlargement and thickened walls of pulmonary venules, perivascular CD4-T-cell infiltration), with no hyaline membranes. In the later stages, the alveolar architecture appeared disrupted, with areas of organizing ALI, venular congestion and capillary thromboembolic microangiopathy. Striking phenotypic features were demonstrated in hyperplastic pneumocytes and endothelial cells, including the expression of phospho-STAT3 and molecules involved in immunoinhibitory signals (PD-L1 and IDO-1). Alveolar macrophages exhibited macrophage-related markers (CD68, CD11c, CD14) together with unusual markers, such as DC-Lamp/CD208, CD206, CD123/IL3AR.ConclusionA morphologically distinct “Covid pattern” was identified in the earlier stages of the disease, with prominent epithelial and endothelial cell abnormalities, that may be potentially reversible, differing strikingly from findings in classical diffuse alveolar damage. These observations may have major therapeutic implications, justifying studies of early interventions aimed at mitigating inflammatory organ injury.

We discuss the hypothesis that common Chest Drain Systems collected to a COVID-19 patient, could be a possible source of contamination for health care staff in a Thoracic Surgery ward and we propose an alternative way to minimize this further risk of transmission.

A video-assisted right pneumonectomy is a challenging but feasible procedure in expert hands. This video tutorial presents in detail the indications for and the individual surgical steps needed to safely perform a biportal video-assisted right pneumonectomy. In selected patients, this technique guarantees the same oncological results in terms of the perioperative outcome as those achieved by minimally invasive surgery.

Posterior mediastinal tumors are not infrequent, and among them neurogenic masses and schwannomas are the most common histologic varieties. These benign, initially asymptomatic tumors later become symptomatic as a result of mass effect. Surgical excision is the preferred therapy, and the approach can be determined according to the dimensions of the lesion. This report describes the case of a giant schwannoma originating from the left vagus nerve in a middle-aged woman whose symptoms were exertion-induced dyspnea and atrial fibrillation.

Background Sternal resection and reconstruction with cryopreserved allografts provides a safe alternative to traditional methods of anterior chest wall reconstruction. Despite favorable results, successful integration of the graft sternum has never been demonstrated owing to the invasiveness of bone biopsy. We describe our experience of using 18F-sodium fluoride positron emission tomography/computed tomography scans as a noninvasive method of evaluating graft integration. Methods Seven patients underwent surgery and radiologic follow-up. Surgical indications were sternal metastases (n = 5) and sternal dehiscence (n = 2). Sternal reconstruction was performed using a cryopreserved cadaveric sternal allograft fixed in place with titanium plates and screws. Follow-up with 18F-sodium fluoride positron emission tomography/computed tomography scans was performed at 1 and 2 years after surgery. Results Three patients underwent total sternectomy. Two underwent partial upper sternectomy involving the manubrium, clavicle (1 patient only), and upper sternal body; and 2 had partial sternectomy of the sternal body and xiphoid process. Focal tracer accumulation occurred at the junctions between native bone and graft bone. The median maximum standardized uptake value at 1 year was 16.8 (range, 11.2 to 37.9; interquartile range, 13.6 to 19.4), and at 2 years it was 10.8 (range, 6.1 to 30.2; interquartile range, 8.9 to 15.1). In 6 cases accumulation was lower at the second scan, whereas in 1 patient the accumulation was higher at the second scan. Conclusions Sternal reconstruction with cryopreserved allograft is safe and well tolerated. The 18F-sodium fluoride positron emission tomography/computed tomography scans are a useful and promising noninvasive method of demonstrating the metabolic activity of the graft and its incorporation into the host skeleton during follow-up.

Trauma is the leading cause of death in the first four decades of life and the fourth leading cause of death overall, trailing only cancer and coronary artery disease. Thoracic traumas are common following both, penetrating and blunt trauma and remain an issue for health services. It has been estimated that severe chest injuries are responsible for 20–25% of all trauma deaths. Moreover, mild trauma is also associated with significant morbidity, in fact, chest injuries are also common in multiple injured patients and are a major contributing factor in the development of subsequent organ failure. This chapter discusses general aspects of trauma, focusing on thoracic traumas from primary survey to the institution of definitive care.

Sialadenoma papilliferum is a benign salivary tumour which rarely occurs in the bronchial tree. Up to now, only four cases of pulmonary papillary sialadenoma have been reported in the literature. We discuss the case of a male patient with an accidental finding of a middle lobe nodule. The patient underwent a minimally invasive anatomical resection of the lobe to remove the lesion; the postoperative course was regular, and he was healthy at the last follow-up.

Trauma is the most common cause of death in the population under forty years old. Blunt traumas, together with penetrating ones, remain an issue for health services. They can affect any one of the components of the chest with all its organs. This chapter focuses on surgical techniques of blunt trauma, discussing therapy for each organ system separately.

Introduction Smooth muscle tumours of uncertain malignant potential (STUMP) are mesenchymal uterine tumours with a malignant potential found somewhere between that of benign leiomyomas and leiomyosarcomas. Only three cases of STUMP pulmonary metastasis exist in the literature. Case presentation We report the case of a 63 year-old female patient presenting with dysphonia secondary to recurrent laryngeal nerve paralysis due to an enormous mediastinal STUMP metastasis, 14 years after having undergone a total hysterectomy with bilateral salpingo-oophorectomy. A successful left pneumonectomy was performed and the mass weighing 1570 g was histologically confirmed as a STUMP metastasis. Discussion Only three cases of pulmonary metastasis from STUMP have been reported in the recent literature and no robust information exists about the metastatic nature of STUMP. No cases exist in the literature of a successful pneumonectomy performed for a STUMP metastasis of such large dimensions presenting after many years from the diagnosis of the primary uterine lesion. Physicians should keep in mind that the finding of a smooth muscle tumour in the lung of a woman should promptly raise the suspicion of a metastatic uterine malignancy, even several years after diagnosis of the primary lesion. Conclusion Despite the size, invasiveness and late presentation of the STUMP metastasis, the surgery was successful and the patient no longer requires oxygen therapy., Highlights • Smooth muscle tumours of uncertain malignant potential (STUMP) are mesenchymal uterine tumours with malignant potential. • Pulmonary metastasis from STUMP is very rare, with only 3 cases found in the recent literature. • These tumours have a malignant potential somewhere between that of benign leiomyomas and leiomyosarcomas. • Smooth muscle tumours may metastasize several years after removal of the primary uterine lesion.

Introduction Eso-SPONGE® has proved to be an excellent method for the treatment of persistent dehiscence of the intrathoracic esophagogastric anastomosis during the operation of subtotal esophagectomy sec. Ivor Lewis. Clinical case presentation The case presented is of a 72-year-old patient with esophageal adenocarcinoma (ADK) who underwent sub-total esophagectomy and esophagoplasty sec. Ivor Lewis complicated by an esophageal leak. The Eso-SPONGE® therapy has been successful halving the index of inflammation after the first two sessions and generation of a neowall after seven sessions. Discussion Eso-SPONGE® therapy has proven to be a valuable resource as a treatment for esophageal anastomotic dehiscences because it is easily repeatable in suburban centers, provided that they have a digestive endoscopy specialized in the positioning process. Conclusions Eso-SPONGE® is a minimally invasive method that delivers excellent results in the treatment of fragile patients, such as those who have post-esophageal anastomotic dehiscence., Highlights • Anastomotic dehiscence is an adverse event in esophageal surgery. • Eso-SPONGE® is an excellent method to treat the esophageal post-surgery dehiscence. • Eso-SPONGE® has provided better results than previous methods. • Eso-SPONGE® is easily repeatable even in not-expert centers.

Incidental pulmonary nodules are commonly encountered in computed tomography (CT) imaging [...]

Background Surgical excision with wide margins, prevention of respiratory impairment, and protection of surrounding organs are primary goals in resection and reconstruction of the chest wall. We describe our experience of the use of cadaveric cryopreserved sternal allograft. Methods Eighteen patients underwent surgery. Indications for sternectomy were sternal metastases (n= 9), primary chondrosarcoma (n= 4), sternal dehiscence (n= 2), soft tissue sarcoma (n= 1), malignant solitary fibrous tumor (n= 1), and direct involvement of thymic carcinoma (n= 1). The defect was reconstructed using a cadaveric sternal allograft harvested aseptically, treated with antibiotic solution, and cryopreserved (−80°C). The graft was tailored to fit the defect and fixed in place with titanium plates and screws. Results Four patients underwent a total sternectomy, 8 a partial lower sternectomy, and 6 a partial upper sternectomy. In 14 patients, muscle flaps were positioned to cover the graft. During the postoperative course, 1 patient died of pulmonary embolism, 1 had systemic Candida infection, and 1 had surgical revision for bleeding at the site of muscle flap. One patient required removal of a screw on the clavicle 4 months after operation because of partial dislocation. At a median follow-up of 36 months, neither infection nor rejection of the graft occurred; 13 patients are alive without disease, and 4 patients had died. None had local tumor relapse. Conclusions Sternal replacement with cadaveric allograft is safe and effective, providing optimal stability of the chest wall and protection of the surrounding organs, even after extensive chest wall resections. The allograft was biologically well tolerated, allowing a perfect integration into the host.

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Case report of a 78-year-old male who came to our observation for a growing pulmonary mass of the left upper lobe without a pre-operative diagnosis. Post-operative histopathology revealed an intrapulmonary Solitary Fibrous Tumour (SFT) of the lung.The pulmonary lesion was an ovoid mass centrally located in the left upper lobe; it had been known and stable in size for two years; the last Chest Computed Tomography (CT) Scan highlighted a marked increase in maximum diameter (35 versus 22 mm) with contrast enhancement. In view of the growth of the lesion, the patient was referred for surgery after multidisciplinary team evaluation, although a pre-operative diagnosis had not been reached. The patient underwent Video-Assisted Thoracic Surgery (VATS) left upper lobectomy by a biportal approach. The pulmonary nodule consisted of a proliferation of bland-looking spindle cells intermingled with fibrotic stroma and alternating sclerotic and cellular areas. At immunohistochemistry, the spindle cells expressed CD34, bcl2 and CD99. A final diagnosis of intrapulmonary SFT was reached. The 36-month follow-up was negative for relapses.Primary intrapulmonary SFTs are extremely rare neoplasms, generally with benign biological behaviour; surgical resection is safe and essential in order to be curative and can be achieved by a minimally invasive approach. Pre-operative diagnosis is challenging, due to aspecific clinical and radiological features.Lung, Solitary Fibrous Tumour, Video-Assisted Thoracic Surgery Lobectomy.Riportiamo il caso singolare di un tumore solitario fibroso intrapolmonare; i tumori solitari fibrosi generalmente originano dalla pleura, raramente da siti extrapleurici quali il polmone o altri organi solidi. Il paziente, un uomo di 78 anni ci era stato inviato dopo discussione multidisciplinare per una lesione polmonare del lobo superiore sinistro in accrescimento volumetrico; come spesso accade per i tumori solitari fibrosi del polmone, la diagnostica per immagini non è stata dirimente. Il nodulo si presentava a margini lisci e ovoidali; la captazione PET non era significativa. Il nostro sospetto spaziava dal carcinoide polmonare all’amartoma condroide, pur non potendo escludere lesioni neoplastiche maligne. Il paziente è stato sottoposto ad una lobectomia superiore sinistra in VATS con approccio biportale: in sede intra-operatoria non fu possibile eseguire una resezione atipica per un esame estemporaneo in quanto la lesione era centrale e voluminosa. La diagnosi anatomo-patologica post-operatoria si è avvalsa di tecniche immunoistochimiche ed ha rivelato una proliferazione cellulare mesenchimale compatibile con un tumore solitario fibroso polmonare. Il decorso post-operatorio è stato caratterizzato dalla comparsa tardiva di enfisema sottocutaneo dei tessuti molli dell’emitorace sinistro, che non ha comunque richiesto il posizionamento di un nuovo drenaggio pleruico. Il followup è attualmente negativo per recidive a tre anni dall’intervento chirurgico. Concludendo, i tumori solitari fibrosi del polmone sono rare neoplasie mesenchimali dal comportamento biologico incerto. Una bassa percentuale presenta caratteristiche di malignità: per questo l’atto chirurgico deve essere sempre finalizzato a rispettare i canoni di radicalità oncologica ed il follow-up a medio-lungo termine è necessario.