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BACKGROUND: In the last years immunotherapy has revolutionized the treatment of non-small cell lung cancer (NSCLC) not supported by a driver mutation. Immunotherapy related adverse events (irAEs) have a unique toxicity profiles distinct from the toxicities of classical chemotherapy treatment relating to their mechanism of action. We analyzed some serious and uncommon life-threatening irAEs, needing a change in the therapeutic strategy. METHOD: Between October 2018 and October 2020, 63 NSCLC patients underwent immunotherapy. Thirty-eight patients underwent first-line Pembrolizumab, 200 mg every 21 days (Group A). Twenty patients were treated in second line with Pembrolizumab 200 mg every 21 days or Nivolumab 240 mg every 14 days or Atezolizumab 800 mg every 14 days (Group B). Five stage III patients treated after radio chemotherapy with Durvalumab 1500 mg every 14 days (Group C). RESULTS: We experienced: a) 2 bowel perforations (3.2%), necessitating Hartmann’s resection. Only one of the two patients restored immunotherapy; b) 1 chronic renal insufficiency (1.6%, creatinine up to 8 mg/dL) and 2 severe hypertransaminasemias (3.2%, up to 65 U/L), requiring the immediate and definitive interruption of ICIs; c) 2 pericardial effusions (3.2%), of which one needed subxiphoid pericardiocentesis for cardiac tamponade. Patient restored immunotherapy after resolution of the acute event. CONCLUSIONS: Immunotherapy include monoclonal antibodies reducing the suppression of effector T cells and improving the tumor-specific immune responses. Most common irAEs are evident in mild and reversible form, but sometimes life-threatening irEAs show up. Therefore, further clinical trials needed to increase knowledge of drugs and prevent unexpected irAEs.

Sternal resection and anterior chest wall reconstruction techniques for malignant processes are not always standardized. We report an innovative method of sternal osteosynthesis in two patients, 65-year-old and 41-year-old women, with Ewing's sarcoma, and infiltrating thymoma, respectively. The first case manifested itself as a voluminous palpable mass while the second case was characterized for a paramediastinal mass widely extended to the anterior chest wall. Reconstruction with titanium mesh allowed the quick restoration of parietal stability, facilitating respiratory dynamic and recovery of patients.

Thoracoscopic lobectomy (VATS-L) for non-small-cell lung cancer (NSCLC) is a well-established option for early stage NSCLC, but the evidences are limited for octogenarians.The objectives of this multi-institutional study were to evaluate the post-operative outcomes of VATS-L in octogenarians and to estimate the post-operative quality of life (QoL) using a validated questionnaire (EuroQoL5D).Data from patients underwent VATS-L between 2014 and 2019 were analysed and divided into two groups: Group A (younger patients) and Group B (octogenarians). To define predictors for complications, univariate and multivariable logistic regression analysis were performed.7023 patients underwent VATS-L and 329 (4.6%) were octogenarians. 30-day and 90-day post-operative mortality were similar (0.95% vs 0.91%, p = 0.84 and 1.3% vs 1.2%, p = 0.58), whereas the percentage of patients who suffered from any complication (25.5% vs 31.9%, p = 0.012) and the complication rate (31.6% vs 45.2%, p=0.01) were higher for octogenarians. At discharge, the values of EuroQoL5D were worse in group B, but after one month these levels became similar. Age80 years had a significant influence on morbidity on both univariate and multivariable analyses (p = 0.025).VATS-L for NSCLC can be performed in selected octogenarians without increased risk of post-operative death, acceptable not-life-threatening complications and a moderate impact on QoL.

Surgery in COVID‐19 disease complicated by APF represents the last life‐saving treatment option. The choice of the therapeutic period to indicate this approach is fundamental. In fact, the clinical stability of patient is necessary in order to allow single‐lung ventilation and to minimize postoperative sequelae.

Surgery is the gold standard treatment of lung cancer. The minimally invasive technique does not only concern access to the chest but also the limits of parenchymal resection. The study debates on the safety and oncological adequacy of sublobar resections in bronchogenic carcinoma patients. A systematic analysis of the data in the literature was carried out, comparing the outcomes of patients with resectable non-small lung cancer (NSCLC) who underwent lobectomy or sublobar resection. These last interventions include both segmentectomies and wedge resections taking into consideration the following parameters: complications, relapse rate and overall survival. The complication rate is higher in patients underwent lobectomy compared to sublobar resection, especially in presence of high comorbidity index or octogenarian patients (overall values respectively between 0 and 48% and 0 and 46.6%). Contrarily, the relapse rate (6.2% to 32% vs. 3.6% to 53.4%) and overall survival (50.2% to 93.8% vs. 38.6% to 100%) are more favorable in patients undergoing lobectomy. Sublobar resections are particularly indicated in elderly patients and in patients with high comorbidity index or reduced respiratory functional reserve. However, pulmonary lobectomy still remains the safest and oncologically correct method in patients with good performance status or higher risk of recurrence.

Notwithstanding advances in medical and surgical management of flail chest, its morbidity and mortality rates are still high. Aim of this study is to compare three approaches for parietal thoracic stabilization by analyzing both early and long-term patient outcomes.A retrospective study from January 2006 to January 2018 involving sixty-five surgical flail chest (25 plates,11 struts and 29 wires fixations) was conducted. A mean Abbreviated Injury Scale (AIS) was 2.38±0.82 and a mean Injury Severity Score (ISS) was 32.02±8.21.Struts and plates stabilizations compared with wires fixation showed an immediate restoring of the partial pressure of oxygen (90.56 mmHg vs 91.90 mmHg vs 89.23 mmHg, p = 0.021), the carbon-dioxide levels (36.00 mmHg vs 35.03 mmHg vs 38.98 mmHg, p = 0.000) and the oxygen-blood saturation (97.71% vs 98.21% vs 92.12%, p = 0.000) in the early postoperative period. Furthermore, struts and plates ensured a better recovery of daily activities up to the 3rdmonth (QoL=1.0: p0.001 in lateral flail chest and p0.02 in anterior and antero-lateral flail chest). At the 12thmonth no difference in QoL was found between the different approaches.Plate and strut fixation revealed a lower rate of postoperative morbidity and mortality. Wires stabilization was characterized for a reduction of operative time.

Background: In the setting of solitary pulmonary nodules (SPNs), fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography ( 18 F-FDG-PET/CT) is considered a useful noninvasive diagnostic tool though false positive (FP) and false negative (FN) results affects accuracy due to different conditions, such as inflammatory diseases or low-uptake neoplasms. Aim of this study is to evaluate overall diagnostic performance of 18 F-FDG-PET/CT for malignant pulmonary nodules. Methods: A computerized research, including published articles from 2012 and 2017, was carried out. 18 F-FDG-PET/CT overall sensitivity (Se), specificity (Spe), positive likelihood ratio (PLR), negative likelihood ratio (NLR), positive predictive value (PPV), negative predictive value (NPV), diagnostic index and odds ratio were pooled. No selection-bias were found according to asymmetry test. Results: A total of twelve studies were included in the meta-analysis. The pooled Se, Spe, PLR, NLR, PPV, NPV and accuracy index (AI) with relative 95% confidence intervals (CI) were 0.819 (95% CI: 0.794– 0.843), 0.624 (95% CI: 0.582–0.665), 2.190 (95% CI: 1.950–2.440), 0.290 (95% CI: 0.250–0.330), 0.802 (95% CI: 0.783–0.819), 0.652 (95% CI: 0.618–0.684) and 0.649 (95% CI: 0.625–0.673), respectively. The diagnostic odds ratio (DOR) was 7.049 with a relative 95% CI between 5.550 and 8.944. Conclusions: The results suggest 18 F-FDG-PET/CT has good diagnostic accuracy in SPNs evaluation; but, it should not be considered as a discriminatory test rather than a method to be included in a clinical and diagnostic pathway.

Background Intraoperative alveolar air leak (IOAAL) is one of most common complications after video-assisted thoracoscopic surgery (VATS) lobectomy. The study aimed to evaluate if, in moderate IOAAL, intraoperative polymeric biodegradable sealant (ProgelTM) reduced postoperative air leak (PAL) and consequently was cost-effective. Methods Patients with moderate IOAAL were randomised in a multicentre trial to intraoperative use of a sealant (Sealant group) or standard management of air leaks (Control group). Primary endpoint was the postoperative duration of air leakage. Secondary outcomes included: time to drainage removal, length of hospital stay, postoperative complications within 2 months, and cost analysis. Results Between January 2015 and January 2017, 255 VATS lobectomies were performed in four centres. Fifty-five met inclusion criteria and were randomly assigned to Sealant group [28] and Control group [27]. The mean air leakage duration was statistically different between groups (Sealant group =1.60 days, Control group =5.04 days; P

Background: To investigate current role of three-dimensional video-assisted thoracoscopic surgery (VATS) and its differences from conventional flat video-assisted procedures for lymph node dissections in both pulmonary and esophageal cancers. Methods: A PubMed Embase, Google Scholar, OpenDOAR research was carried out according to a prepended Boolean function in order to speculate some difference in mean harvested lymph nodes, blood loss and postoperative chylothorax according to the techniques. Results: Electing six articles, for a total of 1,262 patients (609 3D-VATS and 653 2D-VATS patients), significant differences favouring a 3D approach were found in mean node count [mean difference: 1.56; standard error (SE): 0.23; 95% confidence interval (95% CI): 1.11–2.01, difference freedom (DF) =1,260; t=6.85; P 2 =0.009; 95% CI: −1.61–1.69, DF=1; P=0.926). Conclusions: The management of the hilar and mediastinal lymphatic areas seems to be ameliorated by the adoption of three-dimensional video-assisted strategies potentially significantly influencing patients’ outcome.

I would like to thank Konge et al . (1) for the interest and comment about my article. I take this opportunity to voice our point of view on the need of the specific video-assisted thoracoscopic surgery (VATS) lobectomies training program, whose methods focused on the different opinions of surgeons. While in the past VATS approach represented only the smallest part of total lobectomies, today this is around 90% of total interventions in high-volume centers. The new generations of surgeons are faced with the necessity to quickly acquire the mastery of this technique, with the best planning which still arouses debate and controversy among experienced colleagues.

Solitary pulmonary nodules are common radiologic findings and their detection has increased due to the introduction and improvement of diagnostics. Since a nodule can be an expression of early lung cancers, a proper classification and management are required because its treatment might lead to decreased morbidity and mortality. In this regard, prominent guidelines are available although they are characterized sometimes by discordant and misleading evidences. Furthermore, the same results of studies in the literature appear conflicting. Aim of this work is to evaluate the role of imaging through an extensive literature review but focusing on 18-fluorine fluorodeoxyglucose positron emission tomography combined with computed tomography (18F-FDG-PET/CT) in order to assess the limits and future perspectives of solitary pulmonary nodule characterization in early detection of lung cancer. Key messages Detection of solitary pulmonary nodules has increased. Management of solitary pulmonary nodules is still debated. Future perspectives of early solitary pulmonary nodule characterization.

Background: Primary hyperhidrosis is characterized by excessive sweating in distinct parts of the body. Surgery appears to be the best strategy considering the limited invasiveness of modern techniques. In this work, we compared the excision of main sympathetic trunk with ganglia (sympathectomy) or the interruption of sympathetic chain (sympathicotomy) with the positioning of metal clips. Methods: A research via PubMed, including published articles between 2009 and 2019, was carried out. Meta-analysis was performed by combining the reported recurrence/failure and compensatory sweating outcomes of the individual studies using a random effect model. Results: Of the one hundred and twenty-five articles identified, only 9 are considered valid for meta-analysis with overall information on 2,206 patients treated for primary hyperhidrosis. For the compensatory hyperhidrosis, despite a considerable data heterogeneity, we found a stronger correlation with the endoscopic sympathectomy/sympathetic procedure compared to clipping (odds ratio of 0.62). For the recurrence/failure of treatment, although the same heterogeneity of the data, we highlighted a strong correlation with the clipping procedure compared to endoscopic sympathectomy/sympathicotomy (odds ratio of 2.35). Conclusions: Sympathectomy or sympathicotomy have instead proved to be a safe and effective technique, with a low rate of recurrences. Clipping showed a reduced percentage of compensatory sweating but the removal of device is never easy, exposing patients to higher risks of open approach.

Background: Malignant pleural mesothelioma (MPM) is a rare neoplasm with indolent course and worse prognosis. Notwithstanding improvements in histologic and cytologic characterization, a generalized lack of consensus about diagnostic criteria still claims debate, though several new immunohistochemical markers have been introduced. Aim of this study is to evaluate current role and accuracy of glucose transporter-1 (GLUT-1) assay in the evaluation of malignant mesothelial proliferations. Methods: A PubMed Embase, Google Scholar research was carried out by identifying eight eligible articles fulfilling inclusion criteria. Quality assessment was conducted according to QUADAS-2 test. Data were extracted to evaluate true positive (TP), false positive (FP), true negative (TN) and false negative (FN) rates. Results: Enrolling 728 patients (297 MPM vs. 431 reactive pleural diseases), TP, FP, TN and FN cases were 215, 33, 398 and 82, respectively. A proportion of 74.25% of MPM patients showed immunoreactivity for GLUT-1. The pooled sensitivity (Se), specificity (Spe), positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy (DA) and disease prevalence (DP) were 0.74 [95% confidence interval (CI): 0.57–0.85], 0.91 (95% CI: 0.79–0.96), 0.87 (95% CI: 0.82–0.90), 0.83 (95% CI: 0.80–0.85), 0.84 (95% CI: 0.81–0.97) and 0.41 (95% CI: 0.37–0.44). Conclusions: In conclusions, GLUT-1 immunohistochemistry for MPM is characterized both by high Se and Spe rates. However, according to DP rates, its properties should be considered in the setting of a panel of markers rather than alone.

The challenge of surgeons in our era is a less-invasive procedure. Over the last 20 years, video assisted thoracic surgery (VATS) become the treatment of choice in multiple chest related illnesses. Usually, VATS requires general anaesthesia with the selective intubation. However, in severe patients, with a high comorbidity index or elevated risk for anaesthesia, general anaesthesia may not be possible. An alternative is to perform the VATS in patients under local anaesthesia, awake, and non-intubated. We conducted an attempt of systematic literature review and meta-analysis of non-intubated VATS (AVATS) focusing attention on mortality rate, the complications and the hospital length of stay. AVATS is a feasible and safe technique that is increasingly aware of the possibility of applying for surgery even patients with high indexes of comorbidity, reduced cardiovascular function and general conditions contraindicating general anaesthesia. Nevertheless, further investigations are required to confirm these findings.

The national registers arise from the need to collect data in order to improve the known techniques and to direct towards new treatment strategies. In this study we tried to emphasize the importance of the sampling of information taking into account two aspects: (I) analysis of learning curves; (II) the choice of surgical strategies, by which to set a standardization of techniques designed to establish future treatment guidelines. Data collection and medical practice will influence each other. In fact, we find in literature several studies conducted on very large series which provide valuable support to the therapeutic choices. The goal is to reach new standards of treatment, through the consent of the national and international scientific community.

Summary: Skin necrosis is a rare complication after thoracomyoplasty and usually needs conservative treatment. We described positive findings with surgical approach. A 54-year-old man showed bronchopleural fistula after undergoing right pneumonectomy for lung cancer, treated with thoracomyoplasty. On the 20th postoperative day, a skin wound lesion was noted, whose deterioration required a skin flap transposition. Patient was discharged from hospital on the 7th postoperative day and did not show relapse at the 7th year follow-up. Surgery can be the most viable alternative to medical treatments in the management of a chest wall cutaneous complication even in high-risk patients.

The scientific world is enriched daily with new knowledge, due to new technologies and continuous discoveries. The mathematical functions explain the statistical concepts particularly those of mean, median and mode along with those of frequency and frequency distribution associated to histograms and graphical representations, determining elaborative processes on the basis of the spreadsheet operations. The aim of the study is to highlight the mathematical basis of statistical models that regulate the operation of spreadsheets in Microsoft Excel.

Background: The VATS Group and the National Register for VATS Lobectomy were set up in 2013. Both quality and quantity of collected data within the database are two fundamental tools for scientific and statistical purposes, similar to other important databases, such as the European Society of Thoracic Surgeons (ESTS) Database, the Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) and the Danish Lung Cancer Registry (DLCR). Methods: Four thousand seven hundred and four VATS lobectomy patients have recruited to date. Several parameters were recorded, such as preoperative clinical condition, surgical treatment as far as technical details, postoperative course and follow-up. Results: The Eastern Cooperative Oncology Group (ECOG) performance status was 0.27. Uni-portal approach was used in 332 patients, three-portal approach in 3,825 and bi-portal approach in 547. Lymphadenectomy was performed in 4,704 patients: a sampling nodal dissection in 1,180 patients and a radical nodal dissection in 3,524 cases. Conversion rate was in 9.99% of cases. Adenocarcinoma is the most common histologic type (53.34%), followed by squamous carcinoma (15.53%). Conclusions: The structure of the Italian Registry of VATS Lobectomy makes it a valid source to draw on for statistical studies for scientific purposes.

Background: In surgically fit non-small cell lung cancer (NSCLC) patients, pulmonary lobectomy still represents the standard of care. In recent years, the development of minimally invasive video-assisted techniques has reduced perioperative surgical stress, including patients previously thought to be unfit for surgery. Methods: We carried out a review of literature in order to evaluate the role of the preoperative parameters in functionally compromised patients and the effectiveness of video-assisted thoracoscopic surgery (VATS) compared to the “muscle sparing” axillary mini-thoracotomy in major lung resections. Results: Of 99 analyzed papers, we considered the 24 most significant, according to the preoperative functional status evaluation and, especially cardiac and respiratory reserve. Conclusions: In patients with a reduced cardio-respiratory function undergoing pulmonary resection, VATS guarantees results superimposable to mini-thoracotomy and represents a valid alternative to be taken into consideration.

Video-assisted thoracoscopic surgery (VATS) lobectomy represents, nowadays, the gold standard for the treatment of early-stage non-small cell lung cancer (NSCLC). This approach provides a viable alternative to open lobectomy, in terms of radical oncological surgery and of low incidence of complications, as a consequence of sustained innovations and improvements, due to the new available technology devices. Aim of the study was to evaluate the benefits and feasibility of such minimally invasive approaches throughout a careful review of the literature.

Lung cancer is one of the most frequent neoplastic diseases. To date, most lung cancer is diagnosed at an advanced stage, making it difficult to choose the diagnostic and therapeutic strategy. Surgical resection represents the best therapeutic solution. However, the best results are obtained only in the early stages of the disease. Lymph node involvement conditions the treatment (surgical or non-surgical approach). Mediastinoscopy is an effective and widely used method for mediastinal staging but does not allow us to reach many mediastinal lymph nodes. Endobronchial ultrasound/transbronchial needle aspiration (EBUS-TBNA) allows us to reach more lymph nodes and is referred to as a first-choice exam for mediastinal staging.

In the setting of a stage IV non-small cell lung cancer (NSCLC), oligometastatic patients represent a heterogeneous group whose incidence is increasing as far as with the adoption of new therapeutic regimens, the improvement of the molecular characterization assays and the increasing number of long-survivor patients. The oligometastatic state undergone a major revision with the introduction of the new TNM lung cancer staging system, being characterized by a different prognosis compared to multi-metastatic patients. Furthermore, the presence of a limited number of metastases imposes a local control especially when clonal selections occur during adjuvant therapy. In this regard, the review seeks to clarify the indications for surgical treatment by organ according to recent guidelines, by analyzing prognostic factors and outcome of patients. Although accurate patient stratification is mandatory, aggressive local control strategies represent a valid therapeutic approach in patients with oligometastatic NSCLC. At the same time, persevering with ablative strategies raises both medical and ethical issues about limits and reiteration, which certainly requires a deep reflection, being, on the other hand, in front of a metastatic disease.

We standardised a Ventilation Mechanical Test (VMT) after video-assisted thoracoscopic surgery (VATS) lobectomy that classifies intraoperative alveolar air leaks (IOAALs) in mild, moderate and severe. We assumed that mild IOAALs (400 mL/min) must be treated. An IOAAL between 100 and 400 mL/min was defined moderate and constituted the study population of a prospective multicentre randomised trial on the use of a polymeric biodegradable sealant (ProgelTM Pleural Air Leak Sealant, Bard Davol, USA) in case of moderate IOAAL compared with no treatment. We assumed that the standardised VMT allows to accurately selected patients needing treatment, thus limiting unnecessary sealant use. We analysed data of the randomised trial to assess the cost-effectiveness of Progel treatment in VMT selected patients. This is a multicenter randomised controlled trial. Patients with moderate IOAAL were randomised to Progel (group A) or “no treatment” (group B).The primary efficacy endpoint of the study was the postoperative duration of air leakage. The secondary outcome measures included: mean time to chest drain removal, mean length of hospitalisation, the percentage of postoperative complications occurring within two months, and cost of treatment. Between January 2015 and January 2017, 255 VATS lobectomies were performed in 4 centres, 55 met the inclusion criteria, and they were randomly assigned to 2 different groups (28 in the Progel and 27 in the control group). The mean air leakage duration was statistically different between the two groups: in the group A was 1.60 vs. 5.04 days in group B (P

Video-assisted thoracoscopic (VAT) procedures are emerging for treatment of both benign and malignant thoracic diseases and substituting classical approaches, such as thoracotomies, thanks to several advantages concerning postoperative morbidity rates and overall patients’ outcome (i.e., postoperative pain, chronic pain and quality of life). However, a VAT approach needs an established learning curve making procedures as safe as in open surgery. With regard of trainee surgeons, notwithstanding an increasing number of learning tools and strategies, such as simulation programs (i.e., black-boxes, wet labs, cadaver or animal labs, 3D virtual reality simulators) and direct observation both of live surgery and videos with a supportive evidence base from benchtop studies, there remains inconsistent adoption in surgical educations.

Pleural empyema represents a frequent disease, characterized sometimes by blurred and unspecific signs or symptoms but requiring timely diagnosis in order to plan the most appropriate therapeutic regimen. Several classifications have proposed and the most widely used is the American Thoracic Society (ATS) one, according to increasing severity depending of the extent of disease. Different therapeutic strategies such as conservative regimens (antibiotic therapy and chest tube placement) and surgical one (empyemectomy with pleural decortication) were applied. To this date, minimally invasive surgery is assuming an important role in the management of empyema and represents the gold standard in stage II disease and a valid alternative to the classical approach in stage III in absence of a complete obliteration of the pleural space. Aim of the work is to define, through a comprehensive review of literature, the role of video-assisted thoracoscopic surgery according to limits and advantages compared to conservative methods and the most invasive surgical approaches.