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Introduction: Osteosarcoma is the most common malignant bone tumor. It is currently treated with pre-and postoperative chemotherapy, associated with surgical resection of the tumor.Area covered: Re...

Introduction Surgical resection of pulmonary metastases has been associated with increased survival at 5 years for osteosarcoma, but limited information is available on long-term outcome, role of repeated metastasectomies, and surgical sequelae in a pediatric population. We analyzed a consecutive series of children, adolescents, and young adults (AYA) treated by repeated lung metastasectomies during a period >40 years to estimate the clinical benefit and potential cure rate of salvage surgery. Methods All patients who underwent lung metastasectomy for osteosarcoma at the IRCCS Istituto Ortopedico Rizzoli of Bologna, University of Modena, and IRCCS Istituto Nazionale Tumori of Milan from May 1973 to January 2014 were included. Overall survival (OS) at 20 years from the first metastasectomy was calculated. Results A total of 463 consecutive children and AYA were analyzed. Median age was 15.9 years (range 0.2–23.2 years) and median follow-up 18.6 years. The 5- and 20-year OS were 34.0% and 29.7% (95% CI 25.5–34.0%). Among the 138 (29.8%) alive patients, 42 (30.4%) had disease recurrence cured by repeated metastasectomies. Disease-free interval from primary tumor, number of metastases, and complete resection were the most relevant survival predictors at multivariable model analysis. Discussion The extended follow-up of this consecutive series shows that repeated lung metastasectomy can achieve a permanent cure when offered to properly selected patients with metastases from osteosarcoma.

A 71-year-old male former smoker was referred for worsening hemoptysis from a hilar left tumor without radiologic or bronchoscopic identification of the bleeding source. He underwent an urgent upper lobectomy extended to the pericardium and left phrenic nerve to control active bleeding. Histologic analysis revealed a malignant triton tumor, a rare aggressive subtype of malignant peripheral nerve sheath tumors. This is a case report of unusual pulmonary involvement associated with hemoptysis. Despite radical surgery and multimodal treatment with adjuvant chemotherapy the patient died of systemic dissemination 10 months after surgery, with a disease-free survival of 3 months.

The extra-pleural pneumonectomy (EPP) is a standardised surgical procedure born for pleural tuberculosis and later used in pleural cancer treatment, especially in malignant pleural mesothelioma (MPM). This systematic review aimed to focus on the actual overall EPP role in surgical oncology. The literature search was performed from January 1985 to January 2018 In PubMed, Embase, and Cochrane according to PRISMA protocol. The search was restricted to publications in English with the research words “extrapleural pneumonectomy”, “malignant pleural mesothelioma”, “pleural malignancies”. The results were then filtered focusing only on papers with series of patients treated with EPP, for mesothelioma and non-mesothelioma malignancies. The search was restricted to publications in English. We found a 5-year overall survival (OS) ranging from 0 to 78%. The peri-operative mortality and morbidity ranged from 0 to 11.8% and 0 to 82.6%, respectively. The most represented and described post-operative complications reported were ARDS, pericardial tamponade, cardiac herniation, pulmonary embolism, respiratory infections, respiratory failure, atrial arrhythmia, myocardial infarction. In referral centres and selected patients, EPP is a cytoreductive or radical surgical treatment in extended pleural malignancies. Prospective studies are needed to standardise the timing of the procedure in a multimodality treatment program, according to the oncological and functional indications, to keep an acceptable complications rate and post-operative quality of life status.

Pulmonary metastasectomy has become a standard procedure for pediatric patients with certain types of solid tumors. Surgeons, expert pediatric oncologists and radiation oncologists contribute with their different skills to the management of pulmonary metastases. Patients are usually scheduled for surgery in case of primary tumor control, in absence of metastases in other organs and when a complete resection is achievable. Nodules are removed through precision resections using electrocautery or laser methods in order to ensure radical surgery with adequate margins. With these techniques, it is possible to preserve the surrounding parenchyma and cause a limited volumetric distortion as compared with staplers. Anatomical resections (segmentectomy, lobectomy or pneumonectomy) should be reserved for selected cases, since major lung resection can only be justified if it leads to a real oncological advantage. Repeated thoracotomies are possible, since there is no theoretical limit to reinterventions. Surgery of lung metastases has a therapeutic and curative role for some histology with acceptable rate of complications but it finds its role only in an aggressive multimodality approach. Indications can be discussed case by case and exceptions can be evaluated also in presence of different evidences. Children affected by metastatic tumors need to be managed by expert multidisciplinary oncological team in referral center with large experience.

Background and purpose Adenoid cystic carcinoma (ACC) of salivary glands is characterized by long-term distant metastasis, most commonly in lungs. No agreement has been reached about the role of surgical treatment of pulmonary lesions. We evaluated the long-term results of lung metastasectomy for ACC in order to identify factors that should be taken into account in selecting patients eligible for surgery and treatment planning. Patients and methods A retrospective study was conducted on 109 patients selected from our institutional experience and from the International Registry of Lung Metastases. Survival was calculated by Kaplan-Meier estimate and prognostic factors endowed with a predictive power for most other metastatic cancers were investigated. Results The cumulative survival was 66.8% at 5 years and 40.5% at 10 years. In patients with a disease-free interval (DFI) greater than 36 months, the overall survival was 76.5% at 5 years. Survival in case of complete surgical resection was 69.5% at 5 years. Multivariate analysis confirmed DFI and completeness of resection resulted in the best prognostic variables. Discussion Lung metastasectomy should be considered as a therapeutic option to achieve local control of disease when 2 conditions are met: (1) complete surgical resection is feasible and (2) the time to pulmonary relapse after primary tumor treatment is greater than 36 months. Symptomatic benefits of an incomplete lung resection in slow-growing tumors such as ACC remain uncertain. The turning point in the management of disseminated cancers will be clarified with biological profiling of ACC and the development of targeted therapies.

Background: Three-dimensional (3D) vision systems are available for video-assisted thoracic surgery (VATS). It is unclear whether 3D-VATS is superior to bidimensional (2D) VATS systems. Methods: We analyzed patients who received 3D-VATS ( n = 171) or 2D-VATS ( n = 228) lobectomy in a single institutional retrospective comparative study of 399 patients with resectable lung cancer conducted from June 2012 to December 2017. The operative and perioperative data were compared between the 2 groups. Results: Operative time, length of hospital stay, number of dissected lymph nodes, and rate of postoperative complications were similar in both groups. In the 3D group, there was no conversion to thoracotomy for intraoperative major vascular injuries, while conversion to an open procedure for uncontrolled bleeding was recorded in 4 (1.7%) patients in the 2D group. Reoperation for hemostasis and/or aerostasis occurred in 6 (2.6%) patients of the 2D group ( p = 0.04). Conclusion: Nonrandomized comparison of different surgical approaches is challenging. In our experience, 3D-VATS was safe and effective and offered excellent operative perception and sensitivity, enabling safer dissection of hilar structures. The 3D-VATS system helped skilled surgeons beyond the boundaries of more oncologically aggressive surgery.

The neoplasms arising from the neural crest-derived cells in the adrenal medulla or extra-adrenal paraganglia include peripheral neuroblastic tumours, pheochromocytoma and paraganglioma.

To improve the poor prognosis for children with metastatic osteosarcoma (OS), interleukin-2 (IL-2) was added to the standard treatment due to its capacity to activate lymphocytes and differentiate lymphocyte subsets into lymphokine-activated killer (LAK) cells that are capable of recognizing and killing various tumor cells. This study concerns a cohort of unselected patients aged

Background: To synthesize the concept of muscle-sparing thoracotomies for major pulmonary resections and to explore the relationship between Kraissl’s lines and skin incisions perpendicular to them.

Background Extensive clinical experience has demonstrated the potential usefulness of autologous fat tissue (AFT) graft in tissue reconstruction, repair or regeneration. In the present study, we evaluated the feasibility and safety of AFT in the repair of surgically injured lung surface. Methods Eighty consecutive procedures of pulmonary metastasectomy by laser precision resection, were performed in 66 patients between March 2010 and December 2012. In the first 20 procedures, AFT graft was applied on the wounded pulmonary surface without closure of parenchymal surface. The following 40 procedures were carried on without AFT (20 leaving the resection margins open and 20 closing the resection margins with a running suture). In the remaining 20 procedures, AFT was applied and the resection margins closed. The efficacy of this technique was evaluated by comparing the AFT group with the non-AFT group, with respect to prolonged alveolar air leakage (PAAL), time to drain removal, length of hospital stay, and patient survival at four years. Results The occurrence of PAAL was lower in the AFT group as compared to non-AFT group (17.5% versus 42.5%, p = 0.027), and median time to drain removal shorter (4 versus 6 days respectively, p = 0.016). Overall 4-year survival was 70% for AFT group, and 59% for non-AFT group (p = 0.34). Conclusions This prospective cohort observational study demonstrated the feasibility and safety of AFT pulmonary grafting after laser metastasectomy. AFT graft improved pulmonary healing, by reducing the incidence and severity of PAAL. Moreover, there was no evidence of tumor promotion in the metastatic setting, with a similar overall survival at 4 years.

Large intrathoracic tumors may occasionally present with massive infiltration of the lung and chest wall that would require pneumonectomy and total removal of the rib cage to obtain radical surgical excision, but this operation carries a prohibitive risk of death for cardiopulmonary failure in the absence of adequate chest wall reconstruction. We report here four consecutive cases of thoracopleuropneumonectomy (TPP) with en-bloc resection of the entire lung, chest wall, and diaphragm and immediate riblike reconstruction for recurrent thoracic sarcomas. Patients had undergone the initial thoracic surgical resection with curative intent 2–14 years before TPP. There was no postoperative mortality, and all patients were alive and free of disease 8–21 months after TPP. To our knowledge, this is the first report in the medical literature of such an extensive operation, demonstrating technical feasibility, tolerability, and efficacy of one-stage resection and reconstruction by a semirigid three-dimensional riblike prosthesis modeled on a human-derived aluminum cast. Selected patients with advanced low-intermediate thoracic sarcomas are the ideal candidates for this extreme procedure, to maximize the chance of long-term tumor control and possibly cure.

Osteosarcoma is the most common malignant bone tumor, currently treated with pre-and postoperative chemotherapy in association with the surgical removal of the tumor. About 15-20% of patients have evidence of metastases at diagnosis, mostly in the lungs. Patients with metastatic disease still have a very poor prognosis, with approximately 20-30% of long-term survivors, as compared with 65-70% of patients with localized disease. The optimum management of these patients has not been standardized yet due to several patterns of metastatic disease harboring different prognosis. Complete surgical resection of all sites of disease is mandatory and predictive of survival. Patients with multiple sites of disease not amenable to complete surgery removal should be considered for innovative therapeutic approaches because of poor prognosis.

An estimated 20% to 30% of all neuroendocrine tumours originate in the bronchial tree and lungs. According to the 2015 World Health Organization categorization, these tumours are separated into four subtypes characterized by increasing biological aggressiveness: typical carcinoid, atypical carcinoid, large-cell neuroendocrine carcinoma and small-cell carcinoma. Although typical and atypical lung carcinoids account for less than 1-5% of all pulmonary malignancies, the incidence of these neoplasms has risen significantly in recent decades. Surgery is the treatment of choice for loco-regional disease but for advanced lung carcinoids there is no recognized standard of care and successful management requires a multidisciplinary approach. The aim of this review is to provide a useful guide for the clinical management of lung carcinoids.

Background Genetic alterations for targeting therapy are largely unexplored issues in pulmonary sarcomatoid carcinoma (PSC), a life-threatening tumor subset. Methods EGFR , HER2 , KRAS , p53 , CTNNB1 , BRAF and PIK3CA mutations were assessed by direct sequencing, ALK , EGFR and HER2 gene status by fluorescence in situ hybridization (FISH), and ALK protein expression by immunohistochemistry (IHC) in 20 pleomorphic carcinomas (PLC), two pulmonary blastomas (PB) and one carcinosarcoma (CS). Surgical specimens and, in case of positivity, the corresponding preoperative biopsies were analyzed. Furthermore, 51 consecutive metastatic lung adenocarcinomas (MELAD) were used as controls for FISH and IHC assays of ALK gene. Results While no rearrangements of ALK were detected in PSC, relevant amplification was identified 5/23 (22%) surgical specimens and paired biopsies (four PLC and one PB, two females and three males, four current and one never smoker, aged 30–83 years). Considering tumor heterogeneity, the percentage of ALK amplified tumor cells ranged from 11% to 43%, with a mean gene copy gain (GCG ± SD) of 6.9 ± 0.8 and no signal differences between the epithelial (6.5 ± 0.9) and the sarcoma-like components (6.8 ± 0.9) of tumors. In the remaining 18 non-amplified PSC, the relevant value was 2.9 ± 0.5 in 1–80% tumor cells ( p ALK amplification was closely associated with chromosome 7 ( EGFR ) or 17 ( HER2 ) polysomy ( p p = 0.026) and only one amplified ( p = 0.009). No amplified tumors, either PSC or MELAD, expressed the relevant protein by IHC, while the 10 ALK-rearranged MELAD were strongly positive. TP53 , KRAS and CTNNB1 mutations accounted for 30%, 22%, and 4% of cases, respectively, with no significant relationship with ALK amplification. No mutations for EGFR , HER2 , BRAF or PIK3CA gene were observed. Conclusion ALK gene amplification is a nonrandom and clonally related event in a subset of PSC, but its biologic rationale deserves further investigation. KRAS mutation could represent a novel tool for therapy of such so deadly tumors with MEK inhibitors.

Aims and Background There are few papers on the cytostructural effects of surgical instruments used during pulmonary resections. The aim of the present study was to evaluate the parenchymal damage caused by different surgical instruments: a new generation electrosurgical scalpel and two different-wavelength lasers. Methods Six surgical procedures of pulmonary resection for nodules were performed using a new generation electrosurgical scalpel, a 1318 nm neodymium (Nd:YAG) laser or a 2010 nm thulium laser (two procedures for each instrument). Specimens were analyzed using optical microscopy and scansion electronic microscopy. Results Severe cytostructural damage was found to be present in an average of 1.25 mm in depth from the cutting surface in the patients treated using electrosurgical cautery. The depth of this zone dropped to less than 1 mm in patients treated by laser, being as small as 0.2 mm using the laser with a 2010 nm-wavelength and 0.6 mm with the 1318 nm-wavelength laser. Discussion These preliminary findings support the use of laser to perform conservative pulmonary resections (i.e., metastasectomies), since it is more likely to avoid damage to surrounding structures. Controlled randomized trials are needed to support the clinical usefulness and feasibility of new types of lasers for pulmonary resections.

http://hdl.handle.net/20.500.11768/96459 Computed tomography (CT) screening of lung cancer allows the detection of early tumors. The objective of our study was to verify whether initial asymptomatic lung cancers, identified by high-resolution low-dose CT (LD-CT) on a high-risk population, show genetic abnormalities that could be indicative of the early events of lung carcinogenesis. We analyzed 78 tumor samples: 21 (pilot population) from heavy smokers with asymptomatic non-screening detected early-stage lung cancers and 57 from 5203 asymptomatic heavy smoker volunteers, who underwent a LD-CT screening study. During surgical resection of the detected tumors, tissue samples were collected and short-term cultures were started for karyotype evaluation. Samples were classified according to the normal (NK) or aneuploid (AK) karyotype. The NK samples were further analyzed by the Affymetrix single-nucleotide polymorphisms (SNPs) technology. Metaphase spreads were obtained in 73.0% of the selected samples: 80.7% showed an AK. A statistically significant correlation was found between presence of vascular invasion and abnormal karyotype. A total of 10 NK samples were suitable for SNPs analysis. Subtle genomic alterations were found in eight tumors, the remaining two showing no evidence to date of chromosomal aberrations anywhere in the genome. Two common regions of amplification were identified at 5p and 8p11. Mutation analysis by direct sequencing was conducted for the K-RAS, TP53 and EGFR genes, confirming data already described for heavy smokers. We show that: (i) the majority of screening-detected tumors are aneuploid; (ii) early-stage tumors tend to harbor a less abnormal karyotype; (iii) whole genome analysis of NK tumors allows for the detection of common regions of copy number variation (such as amplifications at 5p and 8p11), highlighting genes that might be considered candidate markers of early events in lung carcinogenesis. Oncogene (2011) 30, 1117-1126; doi:10.1038/onc.2010.478; published online 25 October 2010

VATS or thoracotomy lobectomy? This issue is well addressed in this RCT. This is a value of great importance to really understand the merits and disadvantages for this “new” technique: the authors could have tackled this topic by collecting data retrospectively with observational studies instead of pursuing a demanding and time consuming non-inferiority, phase 3, multicenter randomized clinical trial (1).

Objective After pneumonectomy, quality of life may be impaired in a proportion of patients because of the presence of symptoms causing severe limitations in daily activities. This is a prospective study on patients who have undergone pneumonectomy for cancer, assessing quality of life modifications 6 months after surgery. Methods Beginning in August 2006, candidates for pneumonectomy had their quality of life assessed by the European Organization for Research and Treatment of Cancer questionnaire (QLQ-C30 + LC13) preoperatively and at 1, 3, and 6 months after surgery. Poor quality of life at 6 months was defined as global health values 10% or more below baseline values. The impact of several clinical variables was tested to discover predictors of poor postoperative quality of life. Results Forty-one of the 50 patients enrolled in the study had a complete quality of life follow-up by January 2008, representing the population of the study. Six months after pneumonectomy, global health showed a minimal impairment in the whole population (baseline 60.4 ± 26.5, at 6 months 56.3 ± 24.2, P = .15). Ten patients (24.4%) were identified as having poor quality of life at 6 months. Age of 70 years or more was identified as a significant risk factor for poor 6-month quality of life using multivariate analysis (odds ratio, 1.13; 95% confidence interval, 1–1.26). The baseline global health score was the strongest predictor of postoperative global health quality of life (odds ratio, 0.16; 95% confidence interval, 0.02–0.46; P = .0086). Conclusion The overall quality of life after pneumonectomy was impaired in 25% of surviving patients at 6 months after surgery; thus, this aspect of recovery should be routinely discussed with patients before pneumonectomy. Patients aged 70 years or more and those with low preoperative quality of life seem to be at risk for unsatisfactory quality of life after surgery.

Objective Pneumonectomy is not always sufficient for the radical resection of cancer. In the present study, pneumonectomy may be associated with an extended resection of mediastinal or parietal structures. The postoperative risk and the oncologic benefits of such an extended procedure have not been sufficiently demonstrated. Methods We have defined "extended" pneumonectomy (EP) as the removal of the entire lung, associated with one or more of the following structures: superior vena cava, tracheal carina, left atrium, aorta, chest wall, or diaphragm. Our clinical database was retrospectively reviewed to identify patients who underwent EP to assess their postoperative morbidity, mortality, and long-term survival. Results Between 1998 and 2005, 47 EPs were performed. The "extended" procedure included left atrium resection in 15 patients, combined SVC and carinal resection in 9 patients, aortic resection in 8 patients (in 3 patients with prosthetic replacement), chest wall or diaphragmatic resection in 6 patients, SVC resection in 4 patients, and carinal resection in 4 patients. A partial esophageal muscular resection was performed in 1 patient. Overall 60-day mortality was 8.5%. Major postoperative complications occurred in 8 patients (17%). The 2- and 5-year survival rates for the overall population were 42% and 22.8%, respectively. Interestingly, long-term survivors were recorded only in the group of patients who received induction treatment. Conclusions Extended pneumonectomy is a feasible procedure with an acceptable risk factor. To improve the selection of patients, all candidates should undergo preoperative mediastinoscopy and induction chemotherapy. In patients with positive response to chemotherapy or stable disease, extended pneumonectomy may afford a radical resection in more than 80% of cases and may result in a permanent cure in some instances.

Summary Between 1998 and 2003 we observed 15 women who underwent full thickness chest wall resection (FTCWR) followed by plastic reconstruction for locally recurrent or primary breast cancer. Preoperative symptoms were: pain (5 patients), malodorous ulceration (3 patients), presence of tumour mass (4 patients) and thoracic deformity (2 patients). One patient was asymptomatic. Surgery was partial sternectomy with rib resection in 9 patients, rib resection alone in 5, and total sternectomy in one. No perioperative mortality or major morbidity occurred; minor complications occurred in 3 patients (20%). Five of the six surviving patients reported a positive overall outcome in a telephonic interview. Median overall and disease-free survival were 23.4 and 17.5 months, respectively. In conclusion, FTCWR is a safe procedure with low morbidity and mortality that can provide good symptoms palliation in patients with locally advanced breast malignancies, so it should be considered more often by interdisciplinary care providers in those patients who fail to respond to classic multimodality treatment.

Objective: A higher mortality has been reported after pneumonectomy over the age of 70. The aim of the study was to quantify the additional riskduetoageafterstandardpneumonectomyforlungcancerbyacase—controlstudy.Methods:Ourclinicaldatabasewasreviewedtosearchfor patients aged 70 years or more who underwent standard pneumonectomy for lung cancer between 1998 and 2005. A control group of patients younger than 70 (one case/two controls) was matched for sex, cardiovascular disease, American Association of Anaesthetists score, respiratory function, side of pneumonectomy, induction chemotherapy and stage. Overall mortality and morbidity were compared. Long-term survival data were also analysed. Results: During the considered period, 35 patients aged 70 years or more underwent pneumonectomy (30 males, median age 73 years, 15 right-sided procedures). The control group was composed of 70 patients. The two groups were homogeneous in the variables used for matching. Overall mortality and morbidity were 11.4 and 54.2% in the elderly group as compared to 4.3 and 41.6% in controls (p-value not significant). Elderly patients experienced a higher rate of respiratory complications (25.7%) as compared to controls (8.3%, p = 0.01). At univariate analysis, the only risk factor for death was the occurrence of respiratory complications (OR 6.5, CI 1.8—18.2). At multivariate analysis, age 70 years (OR 5.36, CI 1.48—19.3) and preoperative chemotherapy (OR 7.65, CI 2.04—28.6) were confirmed as predictors of respiratory complications. Five-year survival was 17.5% in the elderly group and 53.6% in the control group (p = 0.003). Elderly patients with a better respiratory function (FEV1 > 70%) had a 5-year survival of 45.4%. Conclusions: In the elderly patients, the risk of respiratory complications after pneumonectomy is increased as compared to younger patients with equivalent respiratory function. Age and preoperative chemotherapy are independent risk factors for respiratory complications. A lower mortality and a better long-term survival are obtained in elderly patients with a better respiratory function (FEV1 70%). # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

The aim of this review is to analyze recent evidence for optimal treatment of elderly patients with non-small cell lung cancer, focusing on surgery, and possibly to foresee the future strategies to apply in these patients.Surgery in elderly patients affected by non-small cell lung cancer is safe and feasible when careful preoperative respiratory and cardiac studies have been carried out and the disease has been properly staged. The surgical treatment is not to be denied in elderly patients due to age per se, but when a major contraindication to surgery has been recognized. Long term survival for elderly patients with early stage lung cancer treated by anatomical pulmonary resection is comparable to the survival rate of younger patients. Pneumonectomy, extended surgical procedure or preoperative induction chemotherapy are major risk factors for an increased postoperative morbidity and mortality rate. When co-morbidities are present or a patient is 80 years or older, there is evidence that a non-anatomical resection can be performed without affecting long-term results.Due to the aging of the general population, elderly patients will become a large percentage of the cases of non-small cell lung cancer to be treated. Implementing preoperative cardiologic studies and redefining selective respiratory criteria specifically could dramatically improve results.

PURPOSE: We aimed to evaluate the validity of lung lobe weight assessment via computed tomography (CT) by comparing CT-derived and ex vivo measurements. MATERIALS AND METHODS: Unenhanced CT scanning was performed in 30 consecutive patients before lobectomy for lung cancer. The CT images were analyzed using research software after allowing for lobar weight quantitation. The lobar weight estimated by CT was then compared with that measured after surgery using a precision scale (ex vivo measurement). Comparisons as well as assessment of intra- and interoperator variability were conducted using the Bland-Altman method and the coefficient of repeatability (CR). Correlations were examined using Pearson's correlation analysis. RESULTS: Comparison analyses were feasible for 28 cases. The ex vivo lobe weight was 186.2±57.3 g, whereas the weights measured by the two operators by CT were 190.0±55 and 182.4±58.2 g, respectively. As compared with ex vivo weights, the CR was 36.4 for operator 1 and 50.4 for operator 2; the mean differences were 3.8 and -3.8 for operators 1 and 2, respectively. The intraoperator and interoperator CR were 20.9 and 36.6, respectively. The mean differences for the intra- and interoperator analysis were -1.5 and -7.5, respectively. The correlation was very high between CT-based and ex vivo measurements (r=0.95 and r=0.90 for operators 1 and 2, respectively; P < 0.001). CONCLUSION: Estimation of lung lobe weight by semi-automated CT analysis is sufficiently reproducible and in agreement with ex vivo measurements.

Aims and background Chest wall reconstruction after surgical resection for malignancies in children is a challenge for surgeons because of growth-related complications. The aim of this study is to analyze the surgical treatment and outcomes of 30 pediatric and adolescent patients treated at Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy, over a 30-year period. Methods Pediatric patients undergoing chest wall resection were retrospectively reviewed and selected for malignant primary tumor. Endpoints were survival, recurrences, and long-term results. We also reported the use of the innovative rib-like technique in 2 young patients. Results Twenty-one patients were male. Median age was 13.7 years. Eleven patients (37%) presented with a chest wall mass. Twenty-six (87%) had Ewing sarcoma family tumors. Twenty-eight (94%) received neoadjuvant chemotherapy after histologic diagnosis. One rib was resected in 13 cases; 2 or 3 contiguous ribs in 8 cases. No postoperative mortality was observed and the complication rate was 40%. Overall survival was 85.2% (95% confidence interval [CI] 65.2%-94.2%) at 5 and 10 years. Relapse occurred in 7 patients. The 5-year disease-free survival rate was 82% (95% CI 62%-92%). Conclusions Long-term survival is achievable for chest wall tumors in a high-volume referral center where a multimodal treatment should be set to reach the best result. As advances in medical treatment have increased survival, surgical techniques must ensure a lasting functional result. When refining the reconstruction techniques, such as the rib-like approach, it is necessary to expand the options of curative surgery for young patients.

The role of complete surgery for lung metastases in patients with high-grade osteosarcoma is well established, while it is unclear whether surgery is always indicated, regardless of the number of lesions or when an early relapse occurs [1–3]. Hence, our present study reports on two cases of children with osteosarcoma. The first was a 13-year-old female with localized femur osteosarcoma treated with high-dose methotrexate, adriamycin and cisplatin (MAP), plus surgery with wide margins. Necrosis after chemotherapy was very poor (\15 %). Immediately after completing the treatment, chest CT scan showed bilateral lung metastases. The patient received three cycles of high-dose ifosfamide with her lung disease remaining stable, and then, she underwent right lateral thoracotomy and the removal of 38 lesions (all revealing vital tumor). The patient was discharged on the seventh day after surgery. She was then given another course of high-dose ifosfamide followed by left thoracotomy and the removal of 33 tumor lesions and was again discharged 7 days later. To date (42 months after diagnosis), she continues to be disease free. The second patient was a 17-year-old male with tibia osteosarcoma, synchronous bilateral lung metastases and hilar adenopathy. He was treated with MAP chemotherapy and surgery with wide margins, showing a post-chemotherapy necrosis of 70 %. After two more chemotherapy cycles, he underwent right thoracotomy with the precision resections of 57 nodules and excision of the hilar adenopathy. The male continued on chemotherapy, completing five cycles of high-dose ifosfamide, with substantially stable disease in the left lung. He consequently underwent left thoracotomy, involving 142 precision resections, and he was discharged on the sixth day afterwards. Histology showed a necrosis [90 %. He remains disease free 36 months after diagnosis. These cases prompted lively debate among clinicians and surgeons. The chances of achieving a prolonged and complete pathological and clinical response were considered minimal for both patients. In fact, in the first case, the disease very soon relapsed (9 months after its diagnosis), with bilateral lung involvement ([10 nodules on each side) and the necrosis achieved after preoperative chemotherapy was poor too. In the second, the patient had countless lung lesions and hilar adenopathy already at diagnosis and, here again, the necrosis achieved after chemotherapy was poor. Anyway, we decided to refer both patients to our thoracic surgeon in view of their very good general clinical condition, the potential resectability of all their lesions, and the low morbidity and stability of the disease on the side of the male’s unoperated lung. In conclusion, we would recommend considering the resection of all lung metastases of osteosarcoma, whatever their number, in all cases of stable lung disease—but up to what point we are allowed to push with surgery, in high surgery volume centers, remains debatable.

Objectives: Patients treated surgically for lung cancer can develop either a metachronous cancer or a recurrence. The appearance of a new cancer on the remaining lung after a pneumonectomy poses unique treatment problems, and surgery is often considered contraindicated. We report on the outcome of resections for lung cancer after pneumonectomy performed for lung cancer. Methods: We reviewed the records of patients who underwent a resection of bronchogenic carcinoma on the remaining lung from 1990 to 2002. Results: There were 14 patients (13 males and 1 female) with a median age of 64 years (range 51 – 74). Median preoperative Fev1 was 1.45 (range 1.35 –2.23), corresponding to 59% of predicted Fev1 (range 46 – 80%). Resection was performed between 11 and 264 months after pneumonectomy (median 35.5). The resections performed were: one wedge resection in 11 patients, two wedge resections in two patients and two segmentectomies in two other patients; one patient underwent a third resection. Diagnosis was metachronous cancer in 12 patients and metastasis in two patients. Complications occurred in three patients (21%), while operative mortality was nil. Mean hospital stay was 10.5 days (6 –25). Two patients received chemotherapy (one after local recurrence, one after the third resection). Overall 1, 3 and 5 year survivals were 57, 46 and 30%, respectively (median 21 months). For patients with a metachronous cancer they were 69, 55 and 37% (median 57 months), respectively, while neither patient with a metastatic tumor survived 1 year ðP ¼ 0:03Þ: Conclusions: Limited lung resection on a single lung is a safe procedure associated with acceptable morbidity and mortality rates. In patients with a metachronous lung cancer, long-term survival with a good quality of life can be obtained with limited resection on the residual lung. q 2003 Elsevier B.V. All rights reserved.

Objective: The objective of this study was to assess the results of completion pneumonectomy performed for non-small cell lung cancer, classified as second primary or recurrence/metastasis. Methods: From 1982 to 2000, 59 patients underwent completion pneumonectomy for lung cancer, classified second primary or recurrence/metastasis according to a modified form of Martini's criteria, after a mean interval from first resection of 60 months for second primary lung cancers and 19 months for recurrences/metastases. Results: Operative mortality was 3.4% and complications occurred in 30% of patients. Five-year survival rate for completely resected patients was 25% (median 20 months). No significant difference in long-term survival was detected between second primary and recurrent tumors; survival was not adversely affected by a resection interval of less than 2 years or less than 12 months. Conclusions: Completion pneumonectomy for non-small cell lung cancer is a safe surgical procedure in experienced hands; long-term survival is acceptable and the best results are obtained for stage I lung cancer. Distinction between second primary lung cancer and recurrence failed to demonstrate a prognostic value.

This randomized trial evaluated the feasibility and safety of thulium 2010-nm laser to perform anatomic lung resections in patients with incomplete fissures, as compared to mechanical staplers with or without sealants.Seventy-two patients scheduled for segmentectomy or lobectomy were enrolled. After intraoperative confirmation of the extent of resection and incomplete fissures (Craig type 2, 3 or 4), they were randomized and allocated to one of the following arms: laser resection by thulium (group A) or standard resection with mechanical staplers with or without sealants (group B). The primary endpoints of the study included analysis of intraoperative and postoperative course, and costs.Thirty-eight patients were assigned to group A (32 lobectomies, 6 segmentectomies) and 34 to group B (31 lobectomies, 3 segmentectomies). No 30-day mortality was observed. Median operative times were 145.0 minutes (group A) and 142.5 minutes (group B, P = 0.83). The median time to drainage removal was 5 days (group A) and 4 days (group B), while the median length of hospital stay was the same (7 days). Prolonged air leaks7 days were observed in 12 patients of group A (32%) and 10 patients of group B (29%, P = 0.46). Unpredictable late pneumothorax occurred in 3 patients of group A (2 readmissions, need for 1 repeat thoracotomy). Cost analysis demonstrated an intraoperative advantage for group A (mean 807 ± 212 euro) versus group B (mean 1,047+/-276 euro, P0.0001), but the differences in total costs could be due to chance (P = 0.83).The use of laser to complete fissures can lead to late pneumothorax, even in the absence of postoperative air leaks. Moreover, the use of laser to complete fissures did not prove to reduce overall costs. Trial Registration Identification Number: 41/10 (IRB00001457 - FWA00001798 - IORG0001063).

Sternal resection represents a rare, peculiar subgroup of chest wall operations. Abdominal or lung hernia could be a serious complication after extended chest wall or sternal resection for cancer. We present a case of a late abdominal hernia in the chest underneath the skin, 7 years after a total sternal resection for a sarcoma.

Even though the benefit of superior vena cava resection for lung and mediastinal malignancies remains controversial, the recent international experiences have demonstrated technical feasibility of such an extended surgery with acceptable postoperative morbidity and mortality. Concerning lung cancer, a multicentric international study over a 40-year period reports a risk of developing postoperative complications and mortality of 30% and 12%, respectively, with a 5-year probability of survival of 21%. The same study, analysing the results of the last 10 years, demonstrated an improvement of the outcome with a 6% of postoperative mortality, with a 5-year probability of survival of 28%. With regards to mediastinal malignancies, completeness of surgical resection is still considered one of the most important prognostic factors, and extended SVC resection could improve local control and disease free survival. In conclusion, radical resection of lung cancer and mediastinal malignancies involving SVC, is feasible, and it could lead to permanent cure in carefully selected patients.

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'Is stereotactic ablative radiotherapy equivalent to sublobar resection in high-risk surgical patients with Stage I non-small cell lung cancer?'. Altogether over 318 papers were found, of which 18 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Stereotactic ablative radiotherapy (SABR) and sublobar resection (SLR) offer clear survival benefit in the treatment of early-stage non-small-cell lung cancer (NSCLC) in high-risk patients unsuitable for lobectomy and SABR has shown good results in medically operable patients. No randomized data are available comparing SLR and SABR, and therefore, data from prospective studies were compared. Overall survival at 1 year was similar between patients treated with SABR and SLR (81-85.7 vs 92%); however, overall 3-year survival was higher following SLR (87.1 vs 45.1-57.1%). There was no statistically significant difference in local recurrence in patients treated with SABR compared with SLR (3.5-14.5 vs 4.8-20%). Both treatment modalities are associated with complications. Fatigue (31-32.6%), pneumonitis (2.1-12.5%) and chest wall pain (3.1-12%) were common following SABR; however, serious grade 3 and 4 toxicity were rare. Morbidity following SLR was reported between 7.3 and 33.7%. Thirty-day mortality following SABR was 0%, while predicted 30-day mortality following a lung resection, using the thoracoscore predictive model ranges between 1 and 2.6%. Treatment for early-stage NSCLC should be tailored to individual patients. SABR is an acceptable alternative to SLR in high-risk patients but comparative data are required.

Background External pleural suction is used after lung resection to promote lung expansion and minimize air leak duration. Published randomized trials failed to prove this advantage but they are limited in number and underpowered in many cases. The aim of the AirINTrial study was to test the hypothesis that external pleural suction may reduce the rate of prolonged air leak in a large, randomized cohort. Methods All candidates for lung resection (with the exception of pneumonectomy) were considered eligible for this single-center study. At the end of operation, patients were stratified by the type of resection (anatomic versus nonanatomic) and randomly allocated into the external suction arm ( − 15 cmH 2 O, group A) or into the no external suction arm (control arm, group B) in a 1:1 ratio. Chest drains were maintained for 3 days and then they were either removed or connected to an Heimlich valve, when an air leak was present. The main endpoint was to compare groups in terms of prolonged air leak (defined as the rate of patients having a chest drain still in place by postoperative day 7). Results Starting on February 2011, 500 patients were randomized over a 21-month period, 250 in group A and 250 in group B. Twenty-one patients in group B (8.4%) required pleural suction owing to large pneumothorax or diffuse subcutaneous emphysema. On postoperative day 7, the chest drain was still in place in 25 patients in group A and in 34 patients in group B (10% and 14%, respectively; p = 0.2). Subgroup analysis showed that external pleural suction reduced the prolonged air leak rate in the subgroup of patients who underwent anatomic resection (n = 296, 9.6% in group A and 16.8% in group B; p = 0.05). Conclusions Results from the AirINTrial showed that the routine use of external suction reduces the rate of prolonged air leak after anatomic lung resection. More accurate strategies of pleural suction based on the amount of air flow and the degree of lung expansion should be probably established to improve its effectiveness.

Introduction: Diagnosing non-small cell lung cancer on biopsy/cellblock samples by morphology may be demanding. As sparing material for molecular testing is mandatory, a minimalist immunohistochemistry (IHC)-based diagnostic approach is warranted by means of novel, reliable, and easy-to-assess biomarkers. Methods: Forty-six consecutive biopsy/cellblock samples and the corresponding resection specimens (as the gold standard for morphology and IHC) from 30 adenocarcinomas (AD), 10 squamous carcinomas (SQC), 5 adenosquamous carcinomas (ADSQC), and 1 sarcomatoid carcinoma (SC) were IHC-evaluated for p40 [corresponding to nontransactivating ΔNp63 isoforms] and thyroid transcription factor-1 (TTF1) by semiquantitative assessment. For p40, also immunodecoration intensity was taken into account and dichotomized as strong or low. Results: Nonrandom and overlapping distributions of the relevant markers were found in biopsy/cellblock and surgical specimens, which closely correlated with each other and the diverse tumor categories, with no differences in area under curve-receiver-operating-characteristic curves for each marker between any two samples, including p40 and p63. Diagnostic combinations were p40−/TTF1+ or TTF1− for AD (where p40 was negative, apart from 5/30 AD showing at the best 1–2% tumor cells with low intensity); p40+/TTF1− (p40 strong and by far higher than 50%) for SQC; and p40+/TTF1+ or p40+/TTF1− (p40 strong and less than 50%) for ADSQC. The single SC case was p40−/TTF1−, suggesting glandular lineage. Practically, 41/46 (89%) tumors were correctly classified by IHC on small samples, including 30 AD, 10 SQC, 1/5 ADSQC, and no SC. Underdiagnosis of ADSQC was actually because of sampling error of biopsies/cellblocks rather than insufficient biomarker robustness, whereas underdiagnosis of SC was really because of the failure of either marker to highlight epithelial-mesenchymal transition. Conclusions: This minimalist IHC-based model of p40 and TTF1 on biopsy/cellblock samples was effective to correctly subtype most cases of lung cancer.

The purpose of this study was to compare the efficacy of 320-detector row computed tomography (CT) with that of 64-detector row CT for three-dimensional assessment of pulmonary vasculature of candidates for pulmonary segmentectomy.We included 32 patients who underwent both 320- and 64-detector CT before pulmonary segmentectomy, which was performed by cutting the pulmonary artery and bronchi of the affected segment followed by dissection of the intersegmental plane along the intersegmental vein. Before the operation, three-dimensional pulmonary vasculature images were obtained for each patient, and the arteries and intersegmental veins of the affected segments were identified. Two thoracic surgeons independently assessed the vessels with visual scoring systems, and kappa analysis was used to determine interobserver agreement. The Wilcoxon signed-rank test was used to compare the visual scores for the assessment of the visualization capabilities of the two methods. In addition, the final determination of pulmonary vasculature at a given site was made by consensus from thoracic surgeons during operation, and receiver operating characteristic analysis was performed to compare their efficacy of pulmonary vasculature assessment. Sensitivity, specificity and accuracy of either method were also compared by means of McNemar's test.Of the 32 cases, there were no operative complications, but 1 patient died of postoperative idiopathic interstitial pneumonia. Visualization scores for the pulmonary vessels were significantly higher for 320- than those for 64-detector CT (P0.0001 for the affected arteries and P0.0001 for the intersegmental veins). As for pulmonary vasculature assessment, the areas under the curve showed no statistically significant differences in between the two methods, while the specificity and accuracy of intersegemental vein assessment were significantly better for 320- than those for 64-detector row CT (P0.05). Interobserver agreement for the assessment yielded by either method was almost perfect for all cases.Three hundred and twenty-detector row CT is more useful than conventional 64-detector row CT for preoperative three-dimensional assessment of pulmonary vasculature, especially when we identify the intersegmental veins, in candidates for pulmonary segmentectomy.

We report the case of a 55-year-old woman with thymoma diagnosed after finding of extra limbic encephalitis. She presented neurologic symptoms as seizure and aphasia; magnetic resonance imaging (MRI) of the brain showed multiple lesions located in insular, parietal and temporal lobes (in cortical and sub-cortical area). Brain biopsies confirmed the diagnosis of encephalitis and CT-scan of the thorax showed an anterior mediastinal mass suspected for thymoma. The patient was submitted to thymectomy through a median sternotomy and we assisted to secondary reduction of cerebral lesions and total remission of symptoms.

Introduction Indications and results of salvage surgery in mediastinal tumors are still unclear. This study analyzes a single-center experience to assess its mortality, morbidity, and long-term results. Methods Mediastinal salvage surgery (MSS) was defined as surgical resection of persistent or recurrent primary mediastinal tumors after previous local treatments with curative intent or exclusive chemotherapy in case of bulky tumors. Clinical data of patients undergoing MSS between 1998 and 2005 were analyzed. Overall and disease-specific long-term survival was calculated. Results Twenty-one patients (15 men and 6 women, mean age 41 years) underwent MSS. Eleven patients suffered from thymic tumors (eight thymomas, three thymic carcinoma) whereas 10 patients suffered from nonthymic tumors (one lung adenocarcinoma + thymoma, two mediastinal monophasic sinovial sarcoma, one mediastinal neuroendocrine tumor, one mediastinal teratoblastoma, one mediastinal disgerminoma, one Hodgkin's lymphoma, one mediastinal atypic carcinoid, two medullary thyroid carcinoma). MSS required extended vascular resection in 10 cases and cardiopulmonary bypass in one case. Median operation time was 215 minutes (range 140–720). One postoperative death and four major complications were recorded (overall mortality 4.7%, morbidity 19.0%). With a median follow-up of 30.6 months, overall 1-, 3-, and 5-year Kaplan-Meier survival was 89.7, 71.2, and 56.6%, respectively. Thymic neoplasms had a better prognosis (1-, 3-, and 5-year survival was 100, 87.5, 87.5%, respectively) when compared with others (1-, 3-, and 5-year survival was 77.8, 53.3, 26.7%, respectively—logrank p = 0.0128). Conclusions MSS can offer a chance of curative treatment in selected patients with an acceptable morbidity and mortality. Thymic tumors obtain the best results in term of long-term survival.

Summary Background Indeterminate non-calcified lung nodules are frequent when low-dose spiral computed tomography (LD-CT) is used for lung cancer screening. We assessed the diagnostic utility of a non-invasive work-up protocol for nodules detected at baseline in volunteers enrolled in our single-centre screening trial, and followed for at least 1 year. Methods 5201 high-risk volunteers, recruited over 1 year from October 2004, underwent baseline LD-CT; 4821 (93%) returned for the first repeat LD-CT. Nodules ≤5 mm underwent repeat LD-CT at 1 year; nodules 5.1–8 mm underwent LD-CT 3 months later; lesions >8 mm received combined CT-positron emission tomography (CT-PET). A subset of nodules >8 mm was studied by CT with contrast. Protocol failures were delayed diagnosis with disease progression beyond stage I, and negative surgical biopsy. Results 2754 (53%) volunteers presented one or more non-calcified nodules. Ninety-two lung cancers were diagnosed: 55 at baseline and 37 at annual screening (66% stage I). Among the 37 incident cancers, 17 had a baseline nodule that remained stage I, 7 had a baseline nodule that progressed beyond stage I, and 13 presented a new malignant nodule. Baseline and annual cancers were 79 (1.5%) and 13 (0.2%), respectively. In 15 of 104 (14%) invasive diagnostic procedures, the lesion was benign. Sensitivity, and specificity were 91 and 99.7%, respectively, for the entire protocol; 88 and 93% for CT-PET; and 100 and 59% for CT with contrast. Conclusions The protocol limits invasive diagnostic procedures while few patients have diagnosis delay, supporting the feasibility of lung cancer screening in high-risk subjects by LD-CT. Nevertheless further optimization of the clinical management of screening-detected nodules is necessary.

Objective The main challenge of screening a healthy population with low-dose computed tomography is to balance the excessive use of diagnostic procedures with the risk of delayed cancer detection. We evaluated the pitfalls, difficulties, and sources of mistakes in the management of lung nodules detected in volunteers in the Cosmos single-center screening trial. Methods A total of 5201 asymptomatic high-risk volunteers underwent screening with multidetector low-dose computed tomography. Nodules detected at baseline or new nodules at annual screening received repeat low-dose computed tomography at 1 year if less than 5 mm, repeat low-dose computed tomography 3 to 6 months later if between 5 and 8 mm, and fluorodeoxyglucose positron emission tomography if more than 8 mm. Growing nodules at the annual screening received low-dose computed tomography at 6 months and computed tomography-positron emission tomography or surgical biopsy according to doubling time, type, and size. Results During the first year of screening, 106 patients underwent lung biopsy and 91 lung cancers were identified (70% were stage I). Diagnosis was delayed (false-negative) in 6 patients (stage IIB in 1 patient, stage IIIA in 3 patients, and stage IV in 2 patients), including 2 small cell cancers and 1 central lesion. Surgical biopsy revealed benign disease (false-positives) in 15 cases (14%). Positron emission tomography sensitivity was 88% for prevalent cancers and 70% for cancers diagnosed after first annual screening. No needle biopsy procedures were performed in this cohort of patients. Conclusion Low-dose computed tomography screening is effective for the early detection of lung cancers, but nodule management remains a challenge. Computed tomography-positron emission tomography is useful at baseline, but its sensitivity decreases significantly the subsequent year. Multidisciplinary management and experience are crucial for minimizing misdiagnoses.