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

Vanishing lung syndrome is a rare disease that could be treated successfully in selected cases with bullectomy. Protective ventilation is very important during surgery to achieve optimal post-operative results and to prevent complications. Hypercapnia and respiratory acidosis are the main disadvantages of this ventilator strategy. The use of extracorporeal CO2 removal device has been introduced to support protective and ultra-protective ventilation during respiratory failure in complex cases. In thoracic surgery the intraoperative use of this device is still not widespread. We report a successful case of a giant left lung bullectomy with intraoperative support with Pro-Lung CO2 removal device for the management of hypercapnia during single lung ventilation.

Background Total lung-sparing tracheobronchial sleeve resections are a step forward in the treatment of low-grade bronchial tumors in which minimal resection margins are required to achieve complete control of the disease. Methods This study retrospectively collected data on patients who underwent total lung-sparing procedures for low-grade tracheobronchial tumors at 2 thoracic surgical centers from January 1984 to October 2019. Results The study included 98 patients, 46 –female (47%) and 52 –male (53%), with a median age of 39 years (range, 7 to 70 years). Thirty-four patients underwent operative endoscopy before surgery (32 had laser treatment, and 2 had endobronchial stenting). The surgical resections were as follows: 9 (9%), tracheal carina; 18 (18%), second carina; 31 (32%), left main bronchi; 25 (26%), right main bronchi; and 15 (15%), intermediate bronchus. The median length of the resected bronchus was 2.2 cm. The median postoperative in-hospital stay was 8 days, and no perioperative mortality was observed. Postoperative complications were recorded in 26-patients (27%). The final histologic classification was as follows: 37 typical carcinoids (38%); 10 atypical carcinoids (10%); 29 adenoid cystic carcinomas (30%); 15 mucoepidermoid carcinomas (15%); 6 inflammatory myofibroblastic tumors (6%); and 1 glomic tumor (1%). Twenty-two patients had positive resection margins and underwent adjuvant radiotherapy. Three patients with adenoid cystic carcinoma had recurrences (1 local and 2 systemic). After a median follow-up time of 54.5 months (range, 4 to 360 months), the overall actuarial 5-year survival was 97%. Conclusions Total lung-sparing tracheobronchial sleeve resection for low-grade malignant disease requires advanced surgical skills, but the hospital morbidity and mortality are very low. This technique is adequate and safe for highly selected patients with low-grade endobronchial malignant diseases, and its use should be encouraged in experienced centers.

The concept of enhanced recovery after surgery (ERAS), initially introduced in the field of colorectal surgery, has been developed in order to optimize the postoperative course. In recent years the number of authors analyzing the role of ERAS in lung cancer surgery is increasing, highlighting several interventions with positive effects on the postoperative course. Yet it is still difficult to draw definite conclusions and specific guidelines, as most of these studies largely differ for their methodological aspects and study populations. Herein we focus on the key elements of each single intervention, trying to identify what we can apply in a common pathway, and which aspects are still to be evaluated for the validation of an ERAS program.

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

Sleeve lobectomy represents a safe and effective treatment for central NSCLC to avoid the risks of pneumonectomy. Induction therapy (IT) may be indicated in advanced stages; however, the effect of IT on bronchial anastomoses remains uncertain. The purpose of the study was to evaluate the impact of IT on the complications of the anastomoses. Between 2000 and 2012, 159 consecutive patients were submitted to sleeve lobectomy for NSCLC at our Institution. We retrospectively compared the results of patients who underwent IT before operation with those who received upfront surgery. In the study period, 49 (30.8%) patients received IT (37 chemotherapy, 1 radiotherapy and 11 chemo-radiotherapy) and 110 (69.2%) patients were directly submitted to surgery (S). The two groups were comparable for sex, age, comorbidities, ASA score, pulmonary function, side, type of procedure and histology. Pathological stage was statistically higher for IT group (p = 0.001). No differences between IT and S groups were observed in terms of post-operative mortality (2% vs 0%, p = NS), morbidity (45% vs 38%, p = NS), including early (6% vs 9%, p = NS) and long-term (16% vs 14%, p = NS) bronchial complication rates. Patients undergoing induction mediastinal radiotherapy, however, are at higher risk of bronchial complications. In our experience, the use of induction chemotherapy did not significantly increase mortality and morbidity rates, in particular, neither for early nor for late anastomotic complications. We, therefore, conclude that sleeve lobectomy after induction chemotherapy is safe and reliable procedure for the treatment of locally advanced NSCLC.

Background: In the last decades, the use of video-assisted thoracoscopic surgery (VATS) lobectomy for the treatment of early stage non-small cell lung cancer is continuously growing. This is mainly due to the development of more advanced surgical devices, to the rising incidence of peripheral lung tumors and is also favored by the increased reliability of preoperative staging techniques. Despite this progress, postoperative unexpected nodal upstaging is still a relevant issue. Aim of this study is to identify possible predictors of unexpected nodal upstaging in patients affected by cT1-3N0 NSCLC submitted to VATS lobectomy. Methods: A total of 231 cases of cT1-3N0 patients submitted to thoracoscopic lobectomy at our centre between June 2012 and October 2016 were retrospectively reviewed. All data regarding clinical staging by means of computed tomography (CT) and positron-emission tomography (PET)/CT were collected and reviewed. The subsequent pathological staging has been analyzed, with special regards to the possible type of nodal involvement, and the number of pathological nodal stations. Results: Most of the patients included in this study were in a clinical stage cT1aN0, cT1bN0 (stage IA) and cT2aN0 (stage IB), 86 (37.2%) patients, 73 (31.6%) patients and 62 (26.8%) patients, respectively. Postoperative histopathological analysis showed that the most frequent tumor histotype was adenocarcinoma (192 patients, 83.1%). Thirty-eight (16.5%) patients had a nodal upstaging; among these, 17 (7.4%) patients had N2 disease (8 patients with isolated mediastinal nodal involvement, 9 patients with N1 + N2 disease) and 21 (9.1%) patients had an isolated hilar nodal involvement (N1). At bivariate analysis, the clinical T (cT)-parameter (P=0.023), the histotype (P=0.029) and the pathological T (pT)-parameter (P=0.003) were identified as statistically significant predictors of nodal upstaging. Concerning the type of nodal upstaging, the pT was found to be statistically significant (P=0.042). At bivariate analysis for the number of involved nodal stations, a statistical significance was highlighted for the parameters cT (P=0.030) and pT (P=0.027). With linear logistic regression, histology as well as pT reached statistical significance (P=0.0275 and P=0.0382, respectively). No correlation was found between nodal upstaging and the intensity of FDG uptake in the primary lung tumor or with the timing between PET and surgery. Conclusions: There is a strong correlation between the clinical staging of the parameter T evaluated with CT and the possible unexpected nodal upstaging. The same correlation with nodal upstaging is found for pT. At equal clinical stage, in patients affected by adenocarcinoma of the lung the relative risk of having a postoperative unexpected nodal upstaging is almost 7 times higher than in patients with squamous cell carcinoma.

Background The aim of this study was to assess the prognostic significance of Mib1 expression, Mitosis (Mi) and Apoptosis (Ai) in residual tumour cells after induction chemotherapy in surgically resected IIIA-N2 patients. Methods Between January 2002 and November 2008, we reviewed 50 consecutive patients (39 males) with histologically proven stage IIIA-N2 non-small cell lung cancer (NSCLC), who underwent radical resection following induction chemotherapy. Five-year survival in the series was evaluated in relation to lymph node downstaging, histology, extent of resection, number of chemotherapy cycles, pT status, sex and age. It was then also evaluated in relation to the proliferative indexes (Mi, Ap and Mib 1 expression), dividing the patients into two groups according to whether they were above or below the 50th percentile for each parameter. The associations between mortality and the abovementioned prognostic factors were explored using the Kaplan-Meier method, the log-rank test, and Cox regression analysis. Results The monovariate analysis confirmed the positive prognostic role of lymph node downstaging in terms of 5-yr survival: 31% vs. 12% (P=0.018). However Mi and Mib1 expression under the 50th percentile were also associated with better 5-yr survival: respectively 46% vs. 5% (P=0.007) and 40% vs. 6% (P=0.017). Neither apoptosis nor the other prognostic factors showed any statistical impact on long-term survival. The multivariate analysis showed Mi to be an independent prognostic factor (P=0.005). Conclusions Although lymph node downstaging has been considered the principal prognostic factor after induction chemotherapy and surgical resection, Mi and Mib1 expression in residual tumor can predict long-term survival more accurately.

Thymectomy is the main therapeutic option in the treatment of thymoma. Different surgical techniques have been described, but transternal approach is still considered the gold standard. Anyway, in the last decades, robotic approach has gained attention and nowadays may be considered a standard operation for early stage disease. The improvement of the robotic surgical technique and the introduction of dedicated instruments have allowed challenging resections, thus rendering the robotic approach indicated also for advanced stage thymoma in highly experienced centers.