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To investigate risk factors for nodal upstaging in patients with lung carcinoids and to understand which type of lymphadenectomy is most appropriate.Data regarding patients with lung carcinoids, who underwent surgical resection and lymphadenectomy in five institutions from January 1, 2005 to December 31, 2019, were collected and retrospectively analyzed. Clinical and pathological tumor characteristics were correlated to analyze lymph node upstaging.The analysis was conducted on 283 patients. Pathology showed 230 typical and 53 atypical carcinoids. Nodal and mediastinal upstaging occurred in 33 (11.6%) and 16 (5.6%) patients, respectively. At the univariable analysis, nodal upstaging was significantly correlated with central location (p = 0.003), atypical histology (p 0.001), pT dimension (p = 0.004), and advanced age (p = 0.043). The multivariable analysis confirmed atypical histology (odds ratio [OR]: 11.030; 95% confidence interval [CI]: 4.837-25.153, p 0.001) and central location (OR: 3.295; 95% CI: 1.440-7.540, p = 0.005) as independent prognostic factors for nodal upstaging. Atypical histology (p 0.001), pT dimension (p = 0.036), number of harvested lymph node stations (p = 0.047), and type of lymphadenectomy (p 0.001) correlated significantly with mediastinal upstaging. The multivariable analysis confirmed atypical histology (OR: 5.408; 95% CI: 1.391-21.020, p = 0.015) and pT (OR: 1.052; 95% CI: 1.021-1.084, p = 0.001) as independent prognostic factors.Atypical histology, dimension, and central location are associated with a high-risk for occult hilo-mediastinal metastases, and mediastinal radical dissection may predict nodal upstaging. Thus, we suggest radical mediastinal lymph node dissection in high-risk tumors, reserving sampling, or lobe-specific dissection in peripheral, small typical carcinoids.

Marco Cavaleri,1 Stefano Tigano,1,2 Roberta Nicoletti,1,2 Valeria La Rosa,1,2 Alberto Terminella,3 Giacomo Cusumano,3 Filippo Sanfilippo,1 Marinella Astuto1,2 1Department of General Surgery and Medical-Surgical Specialties, Section of Anaesthesia and Intensive Care, University Hospital “G. Rodolico”, University of Catania, Catania, 95123, Italy; 2School of Anaesthesia and Intensive Care, University Hospital “G. Rodolico”, University of Catania, Catania, 95123, Italy; 3Thoracic Surgery Unit, Department of General Surgery and Medical-Surgical Specialties, University Hospital “G. Rodolico” - San Marco Hospital, Catania, 95121, ItalyCorrespondence: Marco CavaleriDepartment of General Surgery and Medical-Surgical Specialties, Section of Anaesthesia and Intensive Care, University Hospital “G. Rodolico”, University of Catania, Via Santa Sofia 78, Catania, 95123, ItalyTel +393339369927Email markuscava@gmail.comIntroduction: The erector spinae plane block (ESPB) is a recently implemented analgesic technique initially reported for thoracic analgesia and subsequently adopted for both intra- and postoperative pain management. Thoracic surgery is among the most painful surgical procedures, even when conducted with minimally invasive approach. Robotic-assisted thoracic surgery (RATS) challenges the traditional analgesic regimens as one of its aims is to decrease the patient’s length of stay (LOS) whilst achieving optimal postoperative pain management. Furthermore, there is lots of growing evidence on the impact of poorly controlled postoperative pain (PP) on the development of chronic post-surgical pain (CPSP). In these case series, we aim to describe our preliminary experience of postoperative pain management with continuous ESPB in the field of RATS.Case Series Presentation: In eight consecutive patients undergoing elective RATS procedure, we performed the ESPB after surgery with an initial bolus of local anesthetic followed by catheter insertion for continuous infusion. The infusion of local anesthetic lasted for the first two postoperative days. The effectiveness of the ESPB was evaluated through serial pain assessment with numeric rate scale (NRS) score, both at rest and during movement every 6 hours. Any analgesic rescue drug prescription was reported. We noted that the ESPB strongly reduced the prescription of opioids and of rescue analgesic. In our series, only one patient needed opioids during the first two postoperative days, and no rescue analgesic administration was noted in the remaining cases.Conclusion: We report a small but promising experience regarding postoperative pain management with continuous ESPB performed after RATS. We implemented the ESPB before surgery. Larger studies on postoperative pain management with continuous regional blocks in thoracic surgery are warranted.Keywords: pain management, regional block, thoracic surgery, postoperative care

Idiopathic pulmonary fibrosis (IPF) is a fibrotic lung disease with uncertain origins and pathogenesis, it represents the most common interstitial lung disease (ILD), associated with a pathological pattern of usual interstitial pneumonitis (UIP). This disease has a poor prognosis, having the most lethal prognosis among ILDs. In fact, the progressive fibrosis related to IPF could lead to the development of complications, such as acute exacerbation, lung cancer, infections, pneumothorax and pulmonary hypertension. Pneumologists, radiologists and pathologists play a key role in the identification of IPF disease, and in the characterization of its complications&mdash, which unfortunately increase disease mortality and reduce overall survival. The early identification of these complications is very important, and requires an integrated approach among specialists, in order to plane the correct treatment. In some cases, the degree of severity of patients having IPF complications may require a personalized approach, based on palliative care services. Therefore, in this paper, we have focused on clinical and radiological features of the complications that occurred in our IPF patients, providing a comprehensive and accurate pictorial essay for clinicians, radiologists and surgeons involved in their management.

The AVM is a rare congenital disease that often affects the brain and only rarely we find in other organs. In this pathology there is an alteration of the vascular system, with the arteries discharging directly into the veins, bypassing the capillary system; this puts the patient at high risk of sudden hemorrhage. Today we present the case of a young woman suffering from unknown pulmonary avm. The breakdown of this avm caused a hemothorax in the immediate post-cesarean, necessitating emergency surgery and subsequent intensive care.

Histological subdivision into typical (TC) and atypical (AC) is crucial for treatment and prognosis of lung carcinoids but can be also very challenging, even for experts. In this study, we aimed to strengthen or reduce the prognostic value of several pathological, clinical, or per-operative factors some of which are still controversial. We retrospectively reviewed clinical records related to 195 patients affected by TC (159) or AC (36) surgically treated between 2000 and 2014, in three different centers. Survival and subtypes comparison analyses were performed to identify potential prognostic factors. TCs showed a lower rate of nodal involvement than ACs (N0 = 94.9%; N1 = 1.9%; N2 = 3.2% in typical and N0 = 63.8%; N1 = 16.6%; N2 = 19.4% in atypical carcinoids, respectively, p

OBJECTIVES A significant gap in our knowledge of how to manage pulmonary ground-glass opacities (GGOs) still exists. Accordingly, there is a lack of consensus among clinicians on this topic. The Italian Society of Thoracic Surgery (Società Italiana di Chirurgia Toracica, SICT) promoted a national expert meeting to provide insightful guidance for clinical practice. Our goal was to publish herein the final consensus document from this conference. METHODS The working panel of the PNR group (Pulmonary Nodules Recommendation Group, a branch of the SICT) together with 5 scientific supervisors (nominated by the SICT) identified a jury of expert thoracic surgeons who organized a multidisciplinary meeting to propose specific statements (n = 29); 73 participants discussed and voted on statements using a modified Delphi process (repeated iterations of anonymous voting over 2 rounds with electronic support) requiring 70% agreement to reach consensus on a statement. RESULTS Consensus was reached on several critical points in GGO management, in particular on the definition of GGO, radiological and radiometabolic evaluation, indications for a non-surgical biopsy, GGO management based on radiological characteristics, surgical strategies (extension of pulmonary resection and lymphadenectomy) and radiological surveillance. A list of 29 statements was finally approved. CONCLUSIONS The participants at this national expert meeting analysed this challenging topic and provided a list of suggestions for health institutions and physicians with practical indications for GGO management.

Background: To evaluate the efficacy of Endo-Bronchial Valves in the management of persistent air-leaks (PALs) and the procedural cost.Methods: It was a retrospective multicenter study including consecutive patients with PALs for alveolar pleural fistula (APF) undergoing valve treatment. We assessed the efficacy and the cost of the procedure.Results: Seventy-four patients with persistent air leaks due to various etiologies were included in the analysis. In all cases the air leaks were severe and refractory to standard treatments. Sixty-seven (91%) patients underwent valve treatment obtaining a complete resolution of air-leaks in 59 (88%) patients; a reduction of air-leaks in 6 (9%); and no benefits in 2 (3%). The comparison of data before and after valve treatment showed a significant reduction of air-leak duration (16.2 +/- 8.8 versus 5.0 +/- 1.7 days; P< 0.0001); chest tube removal (16.2 +/- 8.8 versus 7.3 +/- 2.7 days; P< 0.0001); and length of hospital stay (LOS) (16.2 +/- 8.8 versus 9.7 +/- 2.8 days; P=0.004). Seven patients not undergoing valve treatment underwent pneumo-peritoneum with pleurodesis (n=6) or only pleurodesis (n=1). In only 1 (14%) patient, the chest drainage was removed 23 days later while the remaining 6 (86%) were discharged with a domiciliary chest drainage removed after 157 +/- 41 days. No significant difference was found in health cost before and after endobronchial valve (EBV) implant (P=0.3).Conclusions: Valve treatment for persistent air leaks is an effective procedure. The reduction of hospitalization costs related to early resolution of air-leaks could overcome the procedural cost.

Bronchopleural fistula (BPF) is a serious and potentially fatal complication of lung resection surgery (1). It’s incidence ranges from 4.5% to 20% after pneumonectomy and is estimated at 0.5% after lobectomy; such complication has a remarkable impact on mortality in post-op setting with a mortality rate of 27% in the more recent series and up to 70% in the previous ones (2-4).

Simple Summary Thymomas are rare tumors developing in the anterior mediastinum. Despite their usually indolent behavior, recurrence might occur in 5–15% of cases. Considering their rarity, the optimal recurrence treatment is still unclear even if surgical treatment seems to ensure a remarkable long-term survival compared to chemo- or radiotherapy. However, the major part of studies report low patient numbers, and it is difficult to plan prospective studies due to tumor characteristics, long follow-up and rarity of cases. For these reasons, we planned a systematic review and meta-analysis comparing surgical treatment with other therapies, in order to identify the best treatment for these patients. Our meta-analysis included more than 700 patients showing that surgical treatment seems to be associated with a better survival compared to other treatments and should be considered where feasible. Abstract Background: Optimal recurrent thymoma management remains arguable because of limited patient numbers, and relatively late and variable recurrence patterns. Given the absence of high-quality evidence and relatively small study cohorts, we performed a quantitative meta-analysis to determine the outcome of surgical and non-surgical approaches assessing the five-year overall survival (5y overall survival (OS)) in patients with recurrent thymoma. Methods: We performed a comprehensive literature search and analysis according to PRISMA guidelines of studies published from 1 January 1980 until 18 June 2020 from PubMed/MEDLINE, EMBASE, and Scopus. We included studies with the cohorts’ superior to 30 patients describing recurrent thymoma treatment, comparing surgical and non-surgical approaches reporting survival data. Results: Literature search revealed 3017 articles. Nine studies met all inclusion criteria and were selected for the meta-analysis. The recurrences were local/regional in 73–98% of cases and multiple in 49–72%. After treatment, 5y OS ranged from 48–77% and 10y OS from 37–51%. The quantitative meta-analysis showed a better outcome comparing surgical vs other treatments. Two studies showed statistically significant risk differences in the 5y OS favoring complete resection. After pooling results of seven studies using the random model, the combined 5y OS risk difference was 0.39, with lower and upper limits of 0.16 and 0.62, respectively (p = 0.001), and a moderate heterogeneity among studies (p = 0.098, I2 = 43.9%). Definitive conclusions could not be drawn regarding the prognostic impact of myasthenia gravis, histology, and patterns of relapse reported in literature. Conclusions: Surgical treatment after thymoma recurrence is associated with a significant better 5y OS; therefore, surgical resection should be preferred in all technically feasible cases.

The main objective in surgery for non-small cell lung cancer (NSCLC) is to achieve good oncologic safety, which includes R0 resection of the tumor and radical lymphadenectomy. Patients with centrally-located NSCLC should undergo pneumonectomy (PN) but, considering the not negligible morbidity and mortality related to this technique, they could benefit from a lung tissue-preserving resection, especially when cardio-pulmonary reserve is limited. Since Thomas (1) firstly applied this procedure for therapeutic option, “sleeve” pulmonary resection was designed to conserve as much pulmonary tissue as possible.

Despite bronchoscopic lung volume reduction (BLVR) with valves is a minimally invasive treatment for emphysema, it can associate with some complications. We aimed at evaluating the rate and type of complications related to valve treatment and their impact on clinical outcomes. Background: Despite bronchoscopic lung volume reduction (BLVR) with valves is a minimally invasive treatment for emphysema, it can associate with some complications. We aimed at evaluating the rate and type of complications related to valve treatment and their impact on clinical outcomes. Methods: It is a retrospective multicenter study including all consecutive patients with severe heterogeneous emphysema undergoing BLVR with endobronchial valve treatment and developed any complications related to this procedure. The type of complication, the time of onset, the treatment required and the out-come were evaluated. Response to treatment was assessed according to the minimal clinically important difference (MCID) as follows: an improvement of ≥15% in forced expiratory volume in one second (FEV1); of −8% in residual volume (RV); of ≥26 m in 6-minnute walking distance (6MWD); and of ≥4 points on the St. George's Respiratory Questionnaire (SGRQ). Target lobe volume reduction (TLVR) ≥350 mL was considered significant. Results: One hundred and seven out of 423 (25.3%) treated patients had complications related to valve treatment including pneumothorax (17.3%); pneumonia (1.7%), chronic obstructive pulmonary disease (COPD) exacerbation (0.9%), respiratory failure (1.4%), valve migration (2.1%), and hemoptysis (1.9%). In all cases complications resolved with appropriate treatment including removal of valves in 21/107 cases (19.6%). Patients with TLVR ≥350 mL (n=64) vs. those

Background Several gray areas and controversies exist concerning the management of pulmonary ground-glass opacities (GGOs), and there is a lack of consensus among clinicians on this topic. One of the main aims of the Italian Society of Thoracic Surgery is to promote education and research, so we decided to perform a survey on this topic to estimate current trends in practice in a large sample of thoracic surgeons. Methods A total of 160 thoracic surgeons responded, namely, completed our questionnaire (response rate, 53%; 160 of 302). The survey was composed of 36 questions divided into six subsections: (1) demographic characteristics of the respondents; (2) terminology and taxonomy; (3) radiologic and radiometabolic evaluation; (4) diagnostic approach and indications for surgery; (5) surgical management; and (6) radiologic surveillance. Results We observed some divergence of opinion regarding the definition of mixed GGOs, the role of 18F fluorodeoxyglucose positron emission tomography and computed tomography scans, indications for nonsurgical biopsy, intraoperative techniques for localizing GGOs, indications for surgery, extension of lung resection and lymph node dissection according to the radiologic scenario, use of intraoperative frozen section analysis, and radiologic surveillance of pure GGOs. Conclusions This topic warrants more investigation in the future. An upcoming consensus conference of Italian Society of Thoracic Surgery experts (also open to experts in other specialties) could provide updated indications for GGO management based on the literature, expert opinions, and the results of the present survey.

Thymectomy plays an important role in patients with myasthenia gravis (MG). This study aimed to explore predictors of postoperative myasthenic crisis (POMC) after thymectomy and to define a predictive score of respiratory failure.The clinical data of 177 patients with MG undergoing thymectomy from January 1995 to December 2011 were retrospectively reviewed. The following factors were analysed in relation to the occurrence of myasthenic crisis: gender, age, body mass index (BMI), anti-acetylcholine receptor-antibody level, bulbar symptoms, comorbidities, duration of symptoms, Osserman-stage, Myasthenia Gravis Foundation of America (MGFA) stage, history of myasthenic crisis, use of immoglobulins or plasmapheresis, kind of therapy, spirometric and blood gas parameters, histology, kind of surgery, non-myasthenic complications and duration of intubation.Twenty-two patients experienced postoperative respiratory failure after thymectomy. Univariate analysis revealed a correlation with age60 years (odds ratio (OR) = 1.79, 95% confidence interval (CI) = 1.04-6.78; P = 0.040); Osserman-stage (IIB- OR = 5.16, 95% CI = 1.10-24.18; P = 0.037, III-IV- OR = 8.75, 95% CI = 1.53-50.05; P = 0.015); bulbar symptoms (OR = 7.42, 95% CI = 1.67-32.84; P = 0.008); BMI28 (OR = 3.99, 95% CI = 1.58-10.03; P = 0.003); preoperative plasmapheresis (OR = 2.97, 95% CI = 1.18-14.04; P = 0.021); duration of symptoms2 years (OR = 4.00, 95% CI = 1.09-14.762; P = 0.036); extended surgery (OR = 2.52, 95% CI = 1.02-6.22; P = 0.045); lung (OR = 4.05, 95% CI = 1.44-11.42; P = 0.008), pericardial (OR = 3.78, 95% CI = 1.45-9.82; P = 0.006) or pleural resection (OR = 3.23, 95% CI = 1.30-8.03; P = 0.012); Vital Capacity %80% (OR = 0.20, 95% CI = 0.05-0.82; P = 0.025) and PaCO240 mmHg (OR = 3.76, 95% CI = 1.12-12.68; P = 0.032). Multivariate logistic regression analysis showed that Osserman-stage (IIB- OR = 5.69, 95% CI = 1.09-29.69; P = 0.039 (III-IV- OR = 11.33, 95% CI = 1.67-76.72; P = 0.013), BMI28 (OR = 3.65, 95% CI = 1.10-12.15; P = 0.035), history of myasthenic crisis (OR = 24.10, 95% CI = 2.34-248.04; P = 0.007), duration of symptoms2 years (OR = 5.94, 95% CI = 1.12-31.48; P = 0.036) and lung resection (OR = 8.48, 95% CI = 2.18-32.97; P = 0.002) independently predict POMC. Excluding history of preoperative myasthenic crisis (statistically associated with Osserman-stage), we built a scoring system according to the OR of Osserman-stage (I-IIA, IIB, III-IV), BMI (28, ≥ 28), duration of symptoms (1, 1-2,2 years) and association with a pulmonary resection. This model helped in creating four classes with increasing risk of respiratory failure (Group I, 6%; Group II, 10%; Group III, 25%; Group IV, 50%).Our model facilitates the stratification of patient risk and prediction of the occurrence of POMC. Moreover, it could help to guide the anaesthesiologist's decision on the duration of intubation. Further studies based on larger series are needed to confirm these preliminary data.

Objective: Radical surgery is the cornerstone of treatment for thymic tumors, but a complete surgical resection in stage III is not always achievable; and recurrence of disease is not rare. We reviewed the results of four centers with large experience in multimodality treatment of stage III thymic tumors. Methods: Between 1980 and 2009, 249 patients (137 males: 112 females; median age 50 years) with stage III thymic tumors underwent surgery. Myasthenia gravis (MG) was present in 110 (44.2%) patients. A total of 94 (37.7%) patients received induction chemotherapy and 205 (82.7%) had adjuvant treatments. Results:Thirty-day mortality was 0.8%. A total of 203 (81.6%) had R0, 26 (10.4%) R1 and 20 (8%) R2 resection. World Health Organization (WHO) histotype was: A in 2.4%, AB in 15.3%, B1 in 16.5%, B2 in 31.3%, B3 in 22.1%, and thymic carcinoma in 12.4%. The R0 rate was lower in patients who received induction chemotherapy (p = 0.04), in B1—B2-thymic carcinoma histotypes (p = 0.05), and in patients without MG (p = 0.04). Overall 10-year survival rate was 64%; tumor-related and disease-free survival were 76% and 74%, respectively. At univariate analysis, R2 resection (p < 0.0001), recurrence of disease (p < 0.0001), absence of MG (p = 0.0009), thymic carcinoma (p = 0.002), age more than 50 years (p = 0.01), and vascular invasion (p < 0.0001) were predictors of poor survival. At multivariate analysis, type of resection (p < 0.0001), vascular involvement (p = 0.007), and recurrent disease (p < 0.0001) were independent predictors of prognosis. During follow-up, 43 (21.2%)patients developedrecurrence. Patients with recurrence, who underwent redo surgery (n = 24), showed a similar survival to patients without recurrence. Conclusions: Multimodality treatment of stage III thymic tumors achieved good survival. Radical surgery, even at recurrence, seems to be the most important prognostic factor. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

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

BACKGROUND Intraoperative pulmonary artery (PA) bleeding is common during thoracic surgery. We investigated the efficacy of the gelatin matrix-thrombin solution FloSeal (Baxter International, Deerfield, IL, USA) for control of major PA bleeding. METHODS Retrospective data were collected on all intraoperative PA injuries during open or minimally invasive lobectomy or pneumonectomy between January 2000 and January 2014. Patients received either 4/0 prolene sutures (Standard) or the gelatin matrix-thrombin solution, plus sutures as needed (Matrix), with at least 6-month follow-up. Endpoints included time to hemostasis, total blood loss, transfusion and complications. RESULTS Of 2809 procedures, 39 (1.4%) had intraoperative PA injury, of which 21 received standard care and 18 the gelatin matrix-thrombin solution. Hemostasis was achieved in all Standard group patients after 2 minutes, and after 5 minutes in Matrix patients. Additional sutures were required in 4 (19.0%) Standard group patients. Three (16.7%) Matrix patients had a second solution application, while 17 (77.8%) received precautionary sutures. Mean blood loss on postoperative day 1 was 836.1±186.1 mL and 957.1±163.0 mL in the Matrix and Standard groups, respectively (P=0.003). Four (22.2%) Matrix patients received postoperative transfusions versus eight (38.0%) Standard patients (P=0.02). Two Standard and no Matrix patients underwent surgical revision. There were no complications and no mortalities. CONCLUSIONS Our analysis suggests that the gelatin matrix-thrombin solution is safe and effective for the control of major bleeding following intraoperative PA injury, and may improve outcomes. Further prospective studies are required to confirm our findings.

Background: Perioperative atrial tachyarrhythmias (POAT) are the commonest arrhythmia after major lung resections. To date the relationship between POAT and CPET parameters were never tested after major thoracic surgery. Aim: To assess the association between CPET data and postoperative complications with particular focus on POAT. Methods: 48 consecutive patients undergoing major lung resection from Jan to Dec 2013 were assessed by pre-operative spirometry, arterial blood gas analysis, DLCO, CPET on cycle ergometer, ECG and echocardiogram. Cardiologic and respiratory complications were recorded and matched with functional parameters and to identify any potential risk factor. Results: Overall morbidity, POAT, atrial fibrillation (AF) and respiratory failure incidences were 18 (37.5%), 10 (20.8%), 5 (12.8%) and 9 (18%) respectively. The followed associations were found: older age (p=0.048), steeper Ve/VCO2 slope (p=0.002) and lower Maximum Heart Rate (MRH) (p=0.011) with POAT. Regression analysis indicated higher Ve/VCO2 (p=0.011; HR=1.39[CI95%:1.07-1.69],) and lower FC max (p=0.022; HR=1.06[CI95%:1.01-1.11],) as independent risk factors for POAT. AF was associated with age (p=0.037), lower VO2 max ml/Kg/min %pred (p=0.02), Ve/VCO2 slope (p=0.01), MHR (p=0.001); Pulmonary artery pressure (p=0.016); VO2 max ml/Kg/min %pred (p=0.011; HR=1.09[CI95%:1.02-1.16],) and lower MHR (p=0.048;HR=1.07[CI95%:1.00-1.15]) predict the risk of AF. Conclusions: VE/VCO2, MHR, VO2 max ml/Kg/min %pred are objective good predictor of POAT and AF and should be helpful to select patients for prophylactic therapy.

Bronchial fistula is one of the most serious complications after pulmonary resection. It presents a challenge in terms of treatment, with a high risk of perioperative mortality. We describe a patient who underwent a right upper lobectomy and systematic hilar-mediastinal lymphadenectomy for lung adenocarcinoma complicated by 2 bronchopleural fistulas. The lesions were sited at the upper lobar stump and the pars membranacea of the intermediate bronchus. The patient was successfully treated by placement of an endobronchial prosthesis (initially a self-expanding prosthesis and subsequently, a Dumon prosthesis) and a pleural chest drain, to avoid a potential right pneumonectomy.

The congenital thymic cysts are rare. They have a congenital origin and they are benign. The differential diagnosis of acquired cysts, cystic thymoma and thymic malignancies in cystic degeneration can be particularly difficult. Rarely, they assume clinical relevance for the appearance of symptoms of compression, more typical of malignant lesions, and the association with thymoma was reported in very few cases in literature. For all these features, treatment strategy remains controversial and in particular surgical approach. We report a case of a huge symptomatic congenital thymic cyst, surgically removed with histological finding of microscopic thymoma.

Objectives The treatment for recurrent thymoma remains a very controversial issue. This study aims to investigate the long-term outcomes in patients with relapse according to treatment strategies and clinicopathological features. Methods We retrospectively analyzed the database of three tertiary centers of thoracic surgery with the aim of reviewing the clinical records of 81 patients who experienced a recurrent thymoma after radical thymectomy, in the period between January 2001 and June 2013. The staging of both primitive and recurrent thymomas were based on the surgical and pathological criteria described by Masaoka. Experienced pathologists reassessed independently the histology of the initial thymoma and its relapse, according to the WHO classification. To the purposes of this study R+ resection or thymic carcinoma were considered as exclusion criteria. The overall outcome for long-term (5 years and 10 years) survival and disease-free survival after initial thymectomy and after treatment of recurrent thymoma were analyzed using standard statistics. Results The population was gender balanced (41 M, 40 F), mean age: 46.4 ± 12.3 years. Fifty-four patients (66.7%) were affected by myasthenia gravis, while the other 14 by other paraneoplastic conditions. Surgery was performed in 61 patients (75.3%,), and radiotherapy and/or chemotherapy in 14 patients (17.3%). The mean follow-up duration after recurrence onset was 66.3 ± 56.4 months. Adjuvant therapy had no effect on prolonging the disease-free survival: no differences were found when investigating the administration of adjuvant chemotherapy (no CHT=91.5 ± 76.4 months versus yes CHT=64.0 ± 41.3) and radiotherapy (no RT=86.2 ± 72.8 months versus yes RT=93.0 ± 62.3; p = 0.8). Relapses were mostly local (mediastinum: 15 cases, pleura: 44 cases); hematogenous distant recurrences were observed in 15 cases (lung: 12; liver: 1; bone: 2 cases). An upgrade in the WHO class (defined as the "migration" of WHO class at initial thymectomy to more aggressive WHO class assigned at thymic recurrence resection) was found in 25/61 cases (40.9%), but this phenomenon apparently did not influence patient's prognosis. Overall, the 5- and 10-year survival rates after the initial thymectomy were 94.8% and 71.7%, respectively, while the 5- and 10-year survival rates after the treatment of the recurrence at the thymic level were 73.6% and 48.3%, respectively (82.4% at 5 years and 65.4% at 10 years when a R0-re-resection was obtained). The analysis on the trends of disease-free survival indicated that the site of recurrence (hematogenous diffusion) seems to be associated to a higher risk of re-relapse ( p = 0.01). Conclusions Even following a thymectomy performed with radical intent, thymoma may recur several years later, usually as a locoregional relapse. A rewarding long-term survival may be expected after treatment, especially when a re-resection (radical) is performed (82.4% at 5 years). An histopathological "WHO upgrade" (from "low-risk" WHO classes at thymectomy to "high-risk classes" at relapse) may be observed in a remarkable percentage of patients (nearly 40% in this series), but this phenomenon seems to be not correlated with any worsening of the prognosis.

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

Introduction Post-operative pulmonary rehabilitation in patients who have undergone surgery for lung cancer is a subject of open debate. Clinical practice in this setting is based on the results of observational trials, such as the one described here. Prospective randomized controlled trials have been registered and recruitment is ongoing. Methods From 2005 to 2008, 110 patients with surgical non-small cell lung cancer were entered into a post-operative inpatient pulmonary rehabilitation programme for 3 weeks. All patients were evaluated for pulmonary function after surgery (time 0; T0) and at the end of pulmonary rehabilitation programme (time 1; T1). Statistical analysis focused on improvement in pulmonary function parameters and physical performance in the 6-min walking test (6MWT). Mixed models multiple linear regression was used to identify parameters related to the primary end-points of this research. Results Patients' mean age was 70.1 years (standard deviation (SD) 8.5 years); male/female ratio 73/37. A total of 94 patients underwent lobectomy, 8 underwent pneumonectomy, and the remaining 8 underwent bilobectomy. Among the analysed parameters a significant improvement could be detected only with regards to the 6MWT (257.4 (SD 112.2) at T0 and 382.8 (SD 11.09) at T1). Conclusion Post-operative pulmonary rehabilitation in patients with surgical non-small cell lung cancer is effective in terms of exercise tolerance.

Importance The role of multivisceral resection, in the setting of locally advanced gastric cancer, is still debated. Previous studies have reported a higher risk for perioperative morbidity and mortality, with limited objective benefit in terms of survival. Conversely, recent studies have shown the feasibility of enlarged resections and the potential advantage of extended resection for clinical stage T4b gastric adenocarcinoma with good long-term results. Objective To analyze the role of multivisceral resection for locally advanced gastric cancer with particular attention to the brief and long-term results and to the prognostic value of clinical and pathologic factors. Design Prospective multicenter study using data from between January 1, 1995, and December 31, 2008. Settings Seven Italian surgery centers. Patients A total of 2208 patients underwent curative resections for gastric carcinoma at the centers. Among them, 206 patients presented with a clinical T4b carcinoma. One hundred twelve underwent a combined resection of the adjacent organs with a gastrectomy owing to suspicion or direct invasion of these organs by the gastric cancer. Main Outcomes and Measures Clinical and pathologic variables were prospectively collected and the feasibility and efficacy of multivisceral resection for locally advanced clinical T4b gastric cancer were assessed. Results Postoperative mortality and complication rates of patients who underwent a gastrectomy with a combined resection of the involved organs were 3.6% and 33.9%, respectively. Pathologic factors revealed that the nodal involvement was present in about 89.3% of patients and the mean (SD) number of pathologic lymph nodes was 14.8 (16.6). The overall 5-year survival rate was 27.2%. The completeness of resection and lymph node invasion represent independent prognostic parameters at multivariate analysis. Conclusions and Relevance Our study indicates that patients undergoing extended resections experience acceptable postoperative morbidity and mortality rates, and an en bloc multivisceral resection should be performed in patients when a complete resection can be realistically obtained and when lymph node metastasis is not evident.

IntroductionAvailable data on the malignant solitary fibrous tumor of the pleura (mSFTP), a very rare neoplasm with unpredictable prognosis, are scarce. The aim of this study is to collectively analyze the aggregated data from the largest series in the English literature to date, a multicenter, 10-year study of 50-cases.MethodsWe retrospectively reviewed the clinical records of patients who underwent surgical resection for mSFTP in the period between January 2000 to July 2010. Long-term survival (LTS) and 5-year disease-free survival were analyzed in detail.ResultsThere were 24 men and 26 women (median age, 66 years; age range, 44–83 years). Thirty-two patients (64%) were symptomatic. A malignant pleural effusion was diagnosed in 12 cases. Surgical resection included isolated mass excision in 13 patients and extended resection in 35. In the remaining two cases only biopsies were undertaken. The resection was complete in 46 cases (92%). Adjuvant treatment was administered to 15 patients. Median follow-up was 116 months (range, 18–311 months). Overall LTS and disease-free survival were 81.1% and 72.1%, respectively. Fifteen patients (30%) experienced a relapse of the disease. Complete resection yielded much better LTS than partial resection (87.1% versus 0%; p < 0.001). At the Cox regression analysis, incomplete resection (hazards ratio [HR]: 39.02; 95% confidence interval [CI]:4.04–380.36; p = 0.002) and malignant pleural effusion (HR: 3.44; 95%CI: 0.98–12.05; p = 0.053) were demonstrated to be risk factors for earlier death. At multivariate analysis, chest-wall invasion and malignant pleural effusion increased the risk of recurrence (HR: 4.34; 95%CI: 1.5%–12.6%; p = 0.007 and HR: 3.48; 95%CI: 1.1%–11.0%; p = 0.038, respectively).ConclusionsSurgical resection remains the treatment of choice for mSFTP. Relapse is common (approximately 30%). Incomplete resection and malignant pleural effusion at diagnosis impact LTS negatively.

Small-bowel lymphoma is not a common disease, accounting for 15-20% of primary extranodal gastrointestinal lymphomas. Peritoneal lymphomatosis is considered a rare and aggressive presentation. We describe the case of a 55 years-old man affected by T-cell intestinal lymphoma, presenting with diffuse abdominal involvement, bowel dysfunction, severe ascites and pleural effusion, who underwent surgery. Clinical course led dramatically to death. Preoperative cytology and radiologic investigations did not yield diagnosis and were unable to differentiate between peritoneal carcinosis and lymphomatosis. It is suggested that, in such advanced cases, with rapidly deteriorating clinical conditions and huge systemic involvement, surgery is not indicated. On the contrary, maximum effort has to be spent to obtain a preoperative diagnosis.

The role of multivisceral resection in the setting of locally advanced gastric cancer is still unclear. Previous study studies have reported a higher risk of perioperative morbidity and mortality, with little objective benefit in survival. Accordingly, this approach has been recommended only for selected cases. By contrast, recent studies have shown the feasibility of enlarged resections and the potential advantage of extended resection for clinical T4bN0 gastric adenocarcinoma, with good long-term results. In this chapter, we analyze the state of the art of multivisceral resection for locally advanced gastric cancer, paying particular attention to the short- and long-term outcomes and to the prognostic value of many clinicopathological factors.

Cancer cachexia is a multifactorial paraneoplastic syndrome characterized by anorexia, decreased body weight, and loss of adipose tissue and skeletal muscle. It accounts for at least 20% of deaths in neoplastic patients. Cancer cachexia significantly impairs the quality of life and the response to anti-neoplastic therapies, thereby increasing morbidity and mortality of cancer patients. Muscle wasting is the most important phenotypic feature of cancer cachexia and the principal cause of function impairment, fatigue, and respiratory complications, mainly related to the hyperactivation of muscle proteolytic pathways. Most therapeutic strategies aimed at preventing cancer cachexia have proven to be only partially effective. The inhibition of catabolic processes in muscle has been attempted pharmacologically, with encouraging results in animal models. However, data in the clinical setting are scant and contradictory. Stimulation of muscle anabolism could represent a promising and valid therapeutic alternative for cancer-related muscle wasting.

The determinants and predictors of QOL in lung cancer survivors who have received surgery remain defined vaguely and still debated. We evaluate clinical, surgical, and pulmonary function characteristics as predictors of QOL in long-term lung cancer survivors who received surgery.Quality of life was evaluated 5 years after surgery in 67 lung cancer patients using the European Organization for Research and Treatment of Cancer (EORTC) QOL Core Questionnaire, its lung cancer-specific module QLQ LC-13, and the Hospital Anxiety and Depression Scale questionnaire. Preoperative clinical, surgical, and pathologic data were matched with the questionnaire scores.Sex was associated with role functioning and symptoms, with males more often reporting fatigue and pain, appetite loss, coughing, and hemoptysis (P.05). Lower education was associated with better cognitive functioning (P.05). Symptoms were worse for younger patients and for those with major comorbidity. Histology marginally influenced the global health status (P.10) and the cognitive functioning (P.05). Patients receiving complementary therapy more easily suffered from fatigue and insomnia (P.05), and to a lesser extent from nausea and vomiting, constipation, and stress related to financial difficulties (P.10). Higher values of forced expiratory volume at the first second (FEV(1)) and forced vital capacity (FVC) were significantly (P.05) associated with a lower frequency of nausea and vomiting and appetite loss, while low percentage levels of FEV(1) and FVC were associated with lower global function and a greater severity of specific and nonspecific symptoms (P.10 and P.05).Several preoperative features, particularly those reflecting pulmonary function, were moderately associated with QOL in long-term survivors and may be useful to address therapeutic strategies in lung cancer patients after surgery.

Gastrointestinal stromal tumor (GIST) account for 1% of all gastrointestinal neoplasms and are the most common mesenchymal tumor of gastrointestinal tract. There are considered to originate fom the intestinal cell of Cajal, an intestinal pacemaker cell, characterized usually express the KIT protein on immunohistochemistry. The stomach (40-60%) and small intestine (30-40%) are the most common locations. Diagnosis of these tumors is difficult to establish, because symptoms are vague and traditional diagnostic tests are not specific. GISTs shows a wide variety of clinical behaviours ranging fom benign to frankly malignant, making the outcome totally unpredictable. Surgery is the standard treatment of local GIST while Imatinib (tyrosine kinasi inhibitor) is considered as the standard treatment of metastatic disease. Resistence to Imatinib is also becoming a major clinical problem but new tirosyne kinase inibitor are being studied to improve the treatment and survival. The present paper is a review of the salient features of epidemiology, pathophysiology, diagnosis, therapy and prognostic factors of GIST

Background The use of small-bore wire-guided chest drains for pleural effusions and pneumothorax has become popular; however, limited data are available on its efficacy and morbidity. The aim of this retrospective study is to measure, via the analysis of the so far largest reported cohort, the efficacy, safety, and tolerability of this approach in different clinical conditions. Methods In the period from January 2002 to December 2008, 1092 patients have undergone the positioning of a small-bore wire-guided chest drain (12F) for the evidence of pneumothorax or pleural effusion and have been monitored over time for morbidity, pain at the time of insertion (measured via the visual analogue scale), and drain failure for misplacement or blockage. Patients with trauma were excluded from this study. Results Male/female ratio and mean age were respectively 418:674 and 55.85 ± 18.6. Three-hundred ninety-nine (36.5%) drains were inserted for pneumothorax, 324 (29.7%) for malignant effusion, 97 (8.9%) for empyema, and 272 (24.9%) for nonmalignant effusion. The pain experience was on average "very mild" (mean visual analogue scale = 4.6 mm). The overall drain failure rate was 12.9%. The percentage of successful cases was 93.8% in malignant effusion, 93% in pneumothorax, and 92.3% in nonmalignant effusion; in the cases of pathologically diagnosed empyema, drains were more likely to get blocked (74.2%). We recorded 1 serious complication within the malignant effusion group. Conclusions Wire-guided 12F Seldinger-type drains are a well-tolerated and effective method of treating pneumothorax and uncomplicated pleural effusions (malignant and nonmalignant) with acceptable morbidity. The use of 12F small-bore chest drain is not indicated for the treatment of empyema.

ObjectiveWe have analyzed short- and long-term variations of pulmonary function in locally advanced non–small cell lung cancer after induction chemoradiotherapy.MethodsTwenty-seven patients with stage IIIA (N2) non–small cell lung cancer underwent resection with radical intent after induction chemoradiotherapy in the period 2003 to 2006. Pulmonary function has been evaluated by spirometry, diffusing capacity of the lung for carbon monoxide, and blood gas analysis before induction chemoradiotherapy (T0), 4 weeks after induction chemoradiotherapy and before surgery (T1), and 1 (T2), 3 (T3), 6 (T4), and 12 months (T5) after surgery.ResultsA 22.80% decrease of diffusing capacity of the lung for carbon monoxide (P < .001) was observed at T1. At T2 significant decreases in the following were present: vital capacity, −20.50% (P < .001); forced vital capacity, −22.50% (P < .001); forced expiratory volume in 1 second, −23.00% (P < .001); peak expiratory flow, −29.0 (P

Objective We report our experience with 93 consecutive pulmonary artery reconstructions during pulmonary lobectomy with regard to morbidity, mortality, and long-term survival. Methods Clinical records of all patients who underwent lobectomy with partial or circumferential pulmonary artery resection in a single institution during an 8-year period were reviewed retrospectively. Results Lobectomy with partial (n = 90) or circumferential (n = 3) pulmonary artery resection was carried out in 93 patients. Indications for surgical intervention were non–small cell lung cancer in 87 patients and other malignancy in the remaining 6 patients. Bronchial sleeve resection was associated in 23 patients. Neoadjuvant chemotherapy had been administered in 34 cases because of cN2 disease. Operative mortality was 5.4%. Postoperative complications occurred in 27 (29.0%) patients. All the patients underwent contrast-enhanced computed tomographic scanning 6 to 8 weeks postoperatively, which always showed patency of the pulmonary arteries. In the whole population median and 5-year survivals were 40 months and 39.4%, respectively. Disease-free survival was 41.4% at 5 years. Among patients with non–small cell lung cancer, at univariate analysis, tumor size of less than 3 cm; presence of vascular peritumoral emboli, intratumoral emboli, or both; and dyspnea influenced 5-year survival. Multivariate analysis showed that the size of the primary tumor and the presence of vascular emboli were independent factors of worse outcome. Conclusions Lobectomy with arterial sleeve resection has acceptable mortality and no specific complications. Late results in terms of survival are satisfactory.

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

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

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