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Aim: To investigate the safety and efficacy of the application of enhanced recovery after surgery (ERAS) protocols in the perioperative period of abdominal and thoracic localized neuroblastomas (NBs)., Methods: In this retrospective study, 68 children with NBs who underwent surgical resection of the tumor were enrolled. The ERAS protocols for NB excision were implemented in the ERAS group (n = 39) and the consequences were compared with children treated with traditional care (n = 29, TRAD group). The main outcomes of our interest included the incidence of surgery-related complications, the postoperative length of stay (LOS), and the Face/Legs/Activity/Cry/Consolability (FLACC) quantitative table from postoperative days (POD) 1-5. We also evaluated the median intraoperative fluid volume and anesthesia recovery time; blood glucose levels at the beginning of anesthesia, POD1, and 3; WBC counts, CRP values, and the concentration of plasma nutritional indicators on POD1 and 3; time of early ambulation, first anal exhaust, total enteral nutrition (TEN), and discontinue intravenous infusion postoperatively; usage proportion and duration of abdominal and thoracic drainages, nasogastric decompression tubes and urinary catheters; cost of hospitalization, parental satisfaction rate, and readmission rate of surgery ward within 30 days., Results: Compared to the TRAD group, the ERAS group had lower surgery-related complications, albeit not significantly (P > 0.05); the median postoperative LOS decreased from 11.0 to 8.0 days (P < 0.001), the LOS of abdominal NB was significantly shortened (P < 0.001) compared to thoracic NB (P = 0.07) between the two groups; the FLACC scores decreased significantly from POD1-5 (all P < 0.01). The ERAS group had an improved median intraoperative infusion speed (5.0 mL/kg/h vs 8.0 mL/kg/h), time of early ambulation (1.0 days vs 3.0 days), first anal exhaust (2.0 days vs 2.0 days), TEN (5.0 vs 7.0 days), discontinuation of intravenous infusion (5.0 days vs 8.0 days), and total cost of hospitalization (33,897.2 Yuan vs 38,876.3 Yuan); (all P < 0.01). The usage proportion and duration of surgical drainages and tubes were apparently reduced. The mean blood glucose level was higher at the beginning of anesthesia but lower on POD1 and 3 in the ERAS group (P < 0.01). No statistically significant difference was detected in WBC counts and concentrations of hemoglobin and albumin between the two groups of patients (P > 0.05), while the concentrations of prealbumin on POD3 were higher and the CRP level on POD1 was lower in the ERAS group than the TRAD group (P < 0.01). The satisfaction rate of parents was only slightly higher, but the difference was not statistically significant (P = 0.730). No obvious differences were observed in the aspects of NB resection (P = 0.462) and 30-day readmissions of surgery ward (P = 1.000)., Conclusion: The application of ERAS protocols has a significant potential to accelerate perioperative rehabilitation in children undergoing abdominal and thoracic NBs' surgical resection., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Context.—: Primary thoracic neoplasms are rare in children, whereas nonneoplastic mass lesions or cysts and metastases are more common, and there is a relative paucity of comprehensive histopathologic and molecular data., Objective.—: To define the clinicopathologic spectrum of neoplastic and nonneoplastic diseases observed in resected mass lesions in the chest of pediatric patients, and to identify somatic alterations observed in primary neoplasms., Design.—: Clinicopathologic features of thoracic mass lesions (n = 385) resected from 373 patients aged ≤21 years in a 25-year period (1993-2018) were included. Primary neoplasms having sufficient material were tested by a laboratory-developed comprehensive genomic profiling assay that assesses tumor mutational burden, microsatellite instability, somatic sequence variants, gene amplifications, fusions, and specific transcript variants., Results.—: The most commonly resected space-occupying lesions were nonneoplastic mass lesions and cysts or malformations, resected in 117 (31.4%) and 58 of 373 patients (15.5%) respectively. Metastatic neoplasms were observed in 169 of 373 patients (45.3%; mean age 14.4 years, range 1-21 years); the most common was osteosarcoma (68 of 169; 40.2% of metastases). Primary lung neoplasms occurred in 24 of 373 patients (6.4%; mean age 14.5 years, range 6 months-21 years), and 16 patients had primary extrapulmonary thoracic tumors. Carcinoid tumor was the most common primary lung neoplasm (7 typical, 3 atypical). Molecular testing showed a prevalence of somatic pathogenic or likely pathogenic mutations and copy-number alterations. No fusions or splice variants were identified. Tumors were microsatellite-stable with low tumor mutational burden., Conclusions.—: Resected pediatric thoracic mass lesions are more likely to be metastatic lesions, congenital cysts or malformations, or nonneoplastic lesions compared to primary thoracic neoplasms, which are encountered at a low frequency and tend to have relatively simple genetic profiles., Competing Interests: The authors have no relevant financial interest in the products or companies described in this article., (© 2024 College of American Pathologists.)

Background: Resection of intrathoracic tumor with cardiopulmonary bypass (CPB) remains a relatively under-reported intervention in literature, and its role in managing locally advanced mediastinal and lung cancers is a topic of ongoing debate. Our aim was to review our experience and assess the role of CPB for treating locally advanced mediastinal and lung cancers., Methods: Between 2015 and 2020, this study initially included 10 patients with primary locally advanced thoracic malignancies with apparent adjacent cardiovascular invasion demonstrated by thoracic imaging scans. Operation was performed based on a multidisciplinary tumor board consensus. Eventually, 8 patients (3 primary lung cancers and 5 mediastinal cancers) received either salvage or elective resection with CPB; two completed surgery without requiring CPB., Results: Regarding the extent of adjacent structure involvement, 4 patients presented with involvement of the superior vena cava (SVC), 1 involved the right atrium (RA), 2 involved the SVC and RA, and 1 involved the SVC, the origin of main pulmonary artery, and the ascending aorta. Thirty-day mortality occurred in two of three patients receiving salvage surgery due to respiratory insufficiency. With the long-term follow-up, one patient died of recurrence 25 months postoperatively, one survived with recurrence 30 months postoperatively, and four were alive without recurrence for 35, 36, 49, and 107 months after operations., Conclusion: In certain patients, particularly for elective surgical candidates rather than salvage resection, CPB allows for extended resection of locally advanced thoracic cancers with acceptable perioperative safety and survival., (© 2024. The Author(s).)

Background: Chest wall tumors are uncommon. The surgical objective is local disease control and the relief of symptoms. Due to the heterogeneity of cases, the great variety of reconstructions, size of resection, and clinical and surgical outcomes are still uncertain., Methods: Patients were submitted to sternectomies for tumors between 1997 and 2019. Oncological, and surgical characteristics were taken into consideration. The outcomes were related to the size of resection and classified into local and systemic complications. The authors used univariate and multivariate analyses to determine predictors of complications. Survival analysis and Kaplan-Meier curves were obtained., Results: Thirty resections were performed due to metastatic disease. Partial sternectomy was accomplished in 48.8 %, followed by subtotal in 40 %. Primary closure using Pectoralis major was performed in 48.8 %, and Latissimus dorsi in 35.5 %. Polypropylene mesh was used in 86.6 % of reconstructions. The prosthesis removal was necessary in 6.66 %. Respiratory failure was evidenced in 6.66 %. The resection area was a predictor of local and systemic complications (p = 0.0029; p = 0.0004 respectively) in univariate analysis. However, the size of resection was the only predictor of systemic complications regarding multivariate analysis (p = 0.014, 95 % CI 1.00‒1.07)., Conclusion: The size of the resection was related to systemic complications, and the mesh reconstruction resulted in a low percentage of prosthesis removal and respiratory failure. This suggests a high resistance to local issues and a low respiratory failure rate., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (Copyright © 2024 HCFMUSP. Published by Elsevier España, S.L.U. All rights reserved.)

Resection of thoracic wall tumors results in significant defects in the chest wall, leading to various complications. In recent years, the use of three-dimensional (3D) printed titanium alloy prostheses in clinical practice has demonstrated enhanced outcomes in chest wall reconstruction surgery. A cohort of seven patients with sternal tumors was identified for this study. Following a helical CT scan, a digital model was generated for the design of the prosthesis. Subsequently, the tumors were then removed together with the affected sternum and ribs. The chest wall was then reconstructed using 3D-printed titanium alloy prosthesis for bone reconstruction, mesh for pleural reconstruction, and flap for soft tissue reconstruction. Patients were monitored for a period of one year post-surgery. In the seven cases examined, the tumors were found in various locations with varying degrees of invasion. Based on the scope of surgical resection and the size of the defect, 3D-printed titanium alloy prosthesis was custom-designed for chest wall reconstruction. Prior to bone reconstruction, pleural reconstruction was achieved with Bard Composix E/X Mesh, while soft tissue repair involved muscle flap and musculocutaneous flap procedures. A one-year follow-up assessment revealed that the utilization of the 3D-printed titanium alloy prosthesis led to secure fixation, favorable histocompatibility, and enhanced lung function. The findings demonstrate that the utilization of 3D printed titanium alloy prostheses represents a significant advancement in the field of chest wall reconstruction and thoracic surgical procedures., (© 2024. The Author(s).)

Introduction: Chest wall reconstruction in children after large resection of tumors may be performed with rigid or soft materials. Cementoplasty is commonly used with the "Sandwich" method i.e. gore-tex meshes surrounding both faces of the cement., Hypothesis: Is antibiotic loaded single-side gore-tex "Tartine" methyl-methacrylate cementoplasty an interesting alternative to the double-side "sandwich" method for chest wall reconstruction?, Material and Methods: Consecutive patients who were treated from 2011 to 2023 in our hospital were included., Results: Among the ten children treated with a median 5.6 years follow-up, there were no surgical complications related to the reconstruction, loss of function, infections, post operative complications (versus 22.7% in meta-analysis encompassing the 50 rigid reconstructions reported worldwide) nor scoliosis (versus 25%). Three patients have an asymmetric chest wall appearance., Discussion: "Tartine" cementoplasty is a simple, low-cost technique for pediatric chest wall reconstruction. It is well tolerated and checks key demands for chest wall reconstructions., Level of Evidence: IV; retrospective case series., (Copyright © 2024. Published by Elsevier Masson SAS.)

Purpose: We sought to evaluate the toxicity and efficacy of stereotactic body radiation therapy (SBRT) for ultracentral thoracic tumors at our institution., Methods and Materials: Patients with ultracentral lung tumors or nodes, defined as having the planning target volume (PTV) overlapping or abutting the central bronchial tree and/or esophagus, treated at our institution with SBRT between 2009 and 2019 were retrospectively reviewed. All SBRT plans were generated with the goal of creating homogenous dose distributions. The primary endpoint was incidence of SBRT-related grade ≥3 toxicity, defined using the Common Terminology Criteria for Adverse Events (V5.0). Secondary endpoints included local failure (LF), progression-free survival (PFS), and overall survival. Competing risk analysis was used to estimate incidence and identify predictors of severe toxicity and LF, while the Kaplan-Meier method was used to estimate PFS and OS., Results: A total of 154 patients receiving 162 ultracentral courses of SBRT were included. The most common prescription was 50 Gy in 5 fractions (42%), with doses ranging from 30 to 55 Gy in 5 fractions (BED10 range, 48-115 Gy). The incidence of severe toxicity was 9.4% at 3 years. The most common severe toxicity was pneumonitis (n = 4). There was 1 possible treatment-related death from pneumonitis/pneumonia. Predictors of severe toxicity included increased PTV size, decreased PTV V95%, lung V5 Gy, and lung V20 Gy. The incidence of LF was 14% at 3 years. Predictors of LF included younger age and greater volume of overlap between the PTV and esophagus. The median PFS was 8.8 months, while the median overall survival was 44.0 months., Conclusions: In the largest case series of ultracentral thoracic SBRT to date, homogenously prescribed SBRT was associated with relatively low rates of severe toxicity and LF. Predictors of toxicity should be interpreted in the context of the heterogeneity in toxicities observed., (Crown Copyright © 2024. Published by Elsevier Inc. All rights reserved.)

The replacement of the superior vena cava and thoracic outlet vessels for thoracic malignancies often becomes necessary for radical oncological surgery. The pulmonary artery can be directly infiltrated by the tumor or affected by metastatic hilar lymph nodes. In some cases, it must be resected and reconstructed to achieve oncological radicality and/or avoid pneumonectomy. This study reflects a single-surgeon, retrospective experience spanning 6 years (2017-2023). We reviewed data from patients undergoing early anticoagulant therapy after superior vena cava or thoracic outlet vessels bypass and from patients undergoing early antiaggregation therapy following pulmonary artery reconstruction or resection. This series comprises 41 patients treated by a single surgeon. Fourteen patients underwent superior vena cava and thoracic outlet vessel procedures. Among these, eight patients received superior vena cava replacement (six for thymic malignancies and two for lung cancer), and six patients underwent jugular and subclavian artery/vein resection or replacement (all six had sarcomas). There was one death due to respiratory failure, not associated with bleeding or bypass closure. Additionally, there was one graft closure in a patient with severe coagulopathy and three instances of hemothorax (two patients had undiagnosed complex coagulopathies not evident in pre-operative routine blood tests). Following bleeding incidents, anticoagulation was initiated the next day in one case and based on hematological indications in the two coagulopathic patients. In the pulmonary artery series, 27 patients were involved: 20 underwent direct suture after tangential resection, and 7 received pericardial patch reconstruction. Only one case experienced bleeding necessitating redo-surgery. All these patients received early and chronic antiaggregation therapy after pulmonary artery reconstruction. We conclude that major thoracic oncological vascular surgery is safe and feasible with appropriate technical skills. However, achieving optimal results requires integration with correct early anticoagulant therapy or antiaggregation to maintain the patency of bypasses/grafts and prevent life-threatening risks associated with closure of the "new vessels.", (© 2024. Italian Society of Surgery (SIC).)

Background: Scoliosis is one of the long-term consequences of surgical resection of pediatric chest wall tumors. This study aimed to identify the risk factors associated with scoliosis development following the resection of chest wall tumors., Methods: Retrospective cohort study of 64 children who underwent resection of malignant chest wall tumors from 2009 to 2022. Univariate and multivariate analyses were used to investigate factors associated with scoliosis development., Results: The median age at the time of surgery was 7 years (range, 3-21), with 33 (51.6%) patients undergoing surgery before the age of 10 years. The most common histology was Ewing sarcoma (n = 57). A median of 3 (range, 1-5) contiguous ribs were resected. A total of 34 (53.1%) patients had anterior CWTs and 30 (46.9%) had posterior CWTs. Concomitant partial lung and diaphragmatic resection were performed in 12 patients (lung, n = 7; diaphragm, n = 5). Scoliosis convex towards the resection side developed in 21 (32.8%). The primary risk factors for scoliosis were resecting 3 or more ribs (OR 6.44) and resection of the posterior rib segment (OR 5.49). Patients with a tumor resection below 10 years old were not associated with a higher risk of scoliosis., Conclusions: Scoliosis following resection of a primary malignant pediatric chest wall tumor is associated with resection involving three or more ribs and resection of the posterior rib sector., Type of Study: Retrospective observational., Level of Evidence: IV., Competing Interests: Conflict of interest The authors declare there are no competing interests related to this work., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: A reconstructive option for extensive chest wall reconstruction is the free myocutaneous vastus lateralis muscle (VL) flap which can be performed in isolation or in conjunction with a fasciocutaneus anterolateral thigh (cVLALT) and/or myofasciocutaneous tensor fascia lata flap (cVLTFL). We aimed to directly compare the outcomes of these reconstructive options., Methods: Patients who underwent oncological chest wall reconstruction with a free VL, cVLALT, or cVLTFL flap between February 2010 and 2022 were included in this retrospective study. Patient demographics, surgical characteristics, as well as medical and reconstructive outcomes, were evaluated. The operative outcomes between myocutaneous VL, cVLALT, and cVLTFL flap reconstructions were compared., Results: A total of 41 patients underwent chest wall reconstruction with a free myocutaneous VL (n = 25; 61%), cVLALT (n = 14; 34%), or cVLTFL Three acute flap thromboses occurred in the entire cohort (3/41, 7%), with one myocutaneous VL flap failing because of recurrent venous thrombosis during the salvage procedure. Total flap necrosis was seen in two cases (5%; VL flap: n = 1; cVLALT flap: n = 1), and partial flap necrosis in one VL flap (1/25, 4%) and in the distal ALT portion of three cVLALT flaps (3/14, 21%). No significant difference was seen between isolated VL and conjoined VL flaps regarding the partial (p = .28) or total flap necrosis rate (p = .9)., Conclusion: The free (conjoined) VL flap provides reliable outcomes for obliterating dead space achieving durable reconstruction of complex chest wall defects., (© 2024 Wiley Periodicals LLC.)

Purpose: The hemiclamshell (HCS) approach provides a comprehensive view of the anterior mediastinum, whereas the transmanubrial osteomuscular sparing approach (TMA) allows sufficient exposure of the cervico-thoracic transition. We assessed the effectiveness and the outcomes of the combined HCS plus TMA approach to resect thoracic malignant tumors., Methods: We reviewed five patients with thoracic malignant tumors invading the thoracic outlet who underwent surgery using an HCS and TMA approach between 2018 and 2021., Results: The preoperative diagnosis was myxofibrosarcoma, lung cancer, thymic cancer, thymoma, and neurofibromatosis type1 in one patient each, respectively. Cardiovascular reconstruction was done on the aortic arch in two patients, on the descending aorta in one, and on the superior vena cava in one, combined with resection of the vagus nerve in three patients, of the phrenic nerve in two, and of vertebra in one, with overlap in some cases. The TMA was added because all patients required dissection of the periphery of the subclavian artery, and two had tumor extension to the neck. Macroscopic complete resection was achieved in four patients. There was no postoperative mortality., Conclusion: The combination of the HCS and TMA approaches at the same operation provides a comprehensive view of the mediastinum, lung, and cervico-thoracic transition and allows safe access to the thoracic great vessels and subclavian vessels., (© 2024. The Author(s).)

Background and Aims: We aimed to review current literature on the impact of Preoperative Identification (POI) of the Adamkiewicz Artery (AKA) in solid pediatric Posterior Thoracic Tumors (PTT), comprising a spectrum of neuroblastic tumors and neuroblastoma, with particular focus on Complete Macroscopic Excision (CME) and Neurologic Complications/Sequelae (NCS)., Methods: A systematic review in accordance with PRISMA guidelines was undertaken. The study included reports on pediatric patients providing available data on POI of the AKA in PTT., Results: Among 838 records screened, 33 full-texts underwent evaluation, and 8 papers were included. Among 49 tumors (N = 49 patients), 30 were neuroectodermic tumors. Spinal angiography (SA) was undertaken in four studies for 32 (65%) patients. No SA-related morbidity was recorded. Otherwise, a combination of CT and/or MRI imaging was described. The lack of detailed reporting on CT/MRI imaging, hindered a feasible detailed comparative analysis among non-SA imaging modality techniques. The overall success rate of AKA POI was 65%, 71% with SA and 33% with non-SA studies. CME was achieved in 73% of SA and 80% non-SA groups. Overall, 5 children experienced NCS, 60% of those who had dumbbell tumors. All NCS occurred in patients without successful POI of the AKA. Furthermore, no SA patient had NCS, while 33% of the non-SA sustained NCS., Conclusions: Successful POI of the AKA may play a key role in prevention of NCS. SA showed the utility of deploying POI, without added morbidity. Furthermore, SA appeared to have a preventive impact on NCS. SA may have a key role on CME which may also be operator dependent., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Malignant chest wall tumors need to be excised with wide resection to ensure tumor free margins, and the reconstruction method should be selected according to the depth and dimensions of the tumor. Vascularized tissue is needed to cover the superficial soft tissue defect or bone tissue defect. This study evaluated differences in complications according to reconstruction strategy., Methods: Forty-five patients with 52 operations for resection of malignant tumors in the chest wall were retrospectively reviewed. Patients were categorized as having superficial tumors, comprising Group A with simple closure for small soft tissue defects and Group B with flap coverage for wide soft tissue defects, or deep tumors, comprising Group C with full-thickness resection with or without mesh reconstruction and Group D with full-thickness resection covered by flap with or without polymethyl methacrylate. Complications were evaluated for the 52 operations based on reconstruction strategy then risk factors for surgical and respiratory complications were elucidated., Results: Total local recurrence-free survival rates in 45 patients who received first operation were 83.9% at 5 years and 70.6% at 10 years. The surgical complication rate was 11.5% (6/52), occurring only in cases with deep tumors, predominantly from Group D. Operations needing chest wall reconstruction (p = 0.0016) and flap transfer (p = 0.0112) were significantly associated with the incidence of complications. Operations involving complications showed significantly larger tumors, wider areas of bony chest wall resection and greater volumes of bleeding (p < 0.005). Flap transfer was the only significant predictor identified from multivariate analysis (OR: 10.8, 95%CI: 1.05-111; p = 0.0456). The respiratory complication rate was 13.5% (7/52), occurring with superficial and deep tumors, particularly Groups B and D. Flap transfer was significantly associated with the incidence of respiratory complications (p < 0.0005). Cases in the group with respiratory complications were older, more frequently had a history of smoking, had lower FEV1.0% and had a wider area of skin resected compared to cases in the group without respiratory complications (p < 0.05). Preoperative FEV1.0% was the only significant predictor identified from multivariate analysis (OR: 0.814, 95%CI: 0.693-0.957; p = 0.0126)., Conclusions: Surgical complications were more frequent in Group D and after operations involving flap transfer. Severe preoperative FEV1.0% was associated with respiratory complications even in cases of superficial tumors with flap transfer., (© 2024. The Author(s).)

Introduction: Robotic-assisted minimally invasive surgery (RA-MIS) for tumor resection is an emerging technology in the pediatric population with significant promise but unproven safety and feasibility., Methods: A multi-center retrospective review of patients ≤18 years undergoing RA-MIS tumor resection from December 2015-March 2023 was performed. Patient demographics, perioperative variables, and complication rates were analyzed., Results: Thirty-nine procedures were performed on 38 patients (17 thoracic, 22 abdominal); 37% female and 68% non-Hispanic White. Median age at surgery was 8.3 years (IQR 5.7, 15.7); the youngest was 1.7 years-old. Thoracic operations included resections of neuroblastic tumors (n = 16) and a single paraganglioma. The most common abdominal operations included resections of neuroblastic tumors (n = 5), pheochromocytomas (n = 3), and angiomyolipomas (n = 3). Six patients underwent retroperitoneal lymph node dissection (RPLND) for paratesticular tumors. Median operating time for the cohort was 2:52 h (IQR 2:04, 4:31). Two thoracic cases required open conversion due to poor visualization and lack of working domain. All patients underwent complete tumor resection; one had tumor spillage from a positive margin (Wilms tumor). Median LOS was 1.5 days (IQR 1.1, 3.0). Postoperatively, one patient developed a chyle leak requiring interventional radiology drainage, but none required a return to the operating room., Conclusions: Robotic-assisted surgery is safe and feasible for tumor resection in carefully selected pediatric patients, achieving complete resection with minimal morbidity and short LOS. Resection should be performed by those with robotic expertise for optimal outcomes., Level of Evidence: IV., Type of Study: Original Clinical Research., Competing Interests: Conflicts of interest Dr. Marc Michalsky is a stockholder and educational honorarium with Intuitive Surgical. He also is on the Childhood Obesity Advisory Board for Lilly USA, LLC. No other authors have any disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Surgical treatment of pediatric chest wall tumors requires accurate surgical planning and tumor localization to achieve radical resections while sparing as much healthy tissue as possible. Augmented Reality (AR) could facilitate surgical decision making by improving anatomical understanding and intraoperative tumor localization. We present our clinical experience with the use of an AR system for intraoperative tumor localization during chest wall resections. Furthermore, we present the pre-clinical results of a new registration method to improve our conventional AR system., Methods: From January 2021, we used the HoloLens 2 for pre-incisional tumor localization during all chest wall resections inside our center. A patient-specific 3D model was projected onto the patient by use of a five-point registration method based on anatomical landmarks. Furthermore, we developed and pre-clinically tested a surface matching method to allow post-incisional AR guidance by performing registration on the exposed surface of the ribs., Results: Successful registration and holographic overlay were achieved in eight patients. The projection seemed most accurate when landmarks were positioned in a non-symmetric configuration in proximity to the tumor. Disagreements between the overlay and expected tumor location were mainly due to user-dependent registration errors. The pre-clinical tests of the surface matching method proved the feasibility of registration on the exposed ribs., Conclusions: Our results prove the applicability of AR guidance for the pre- and post-incisional localization of pediatric chest wall tumors during surgery. The system has the potential to enable intraoperative 3D visualization, hereby facilitating surgical planning and management of chest wall resections., Level of Evidence: IV TYPE OF STUDY: Treatment Study., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction and Objectives: Postchemotherapy residual tumor resection (PC-RTR) is an important part of the multimodal treatment for patients with metastatic germ cell tumors. Simultaneous retroperitoneal and thoracic metastases often require consecutive surgical procedures. This study analyzes the histologic findings after abdominal and thoracic surgery in order to tailor the sequence and intensity of surgery., Patients and Methods: From a total of 671 PC-RTRs from 2008 to 2021 we analyzed 50 patients with stage III non-seminomatous germ cell tumor (NSGCT) who had undergone both retroperitoneal and thoracic postchemotherapy residual tumor resection after first-line and salvage chemotherapy., Results: All patients included had stage III NSGCT. 39 and 11 patients received first-line and salvage chemotherapy, respectively. 45 (90%) patients received retroperitoneal resection first, followed by thoracic surgery. Three patients (6%) underwent thoracic surgery before retroperitoneal surgery and two patients (4%) underwent simultaneous surgery. Overall, the histology of retroperitoneal and thoracic specimens was discordant in 23% of cases. After first-line chemotherapy, of fourteen patients with necrosis in retroperitoneal histology, four patients had vital carcinoma in lung histology. In patients with teratoma in the retroperitoneum, the thoracic findings were concordant in most cases (78%). When teratomatous elements were also present in the orchiectomy specimen, concordance was 100%. After salvage chemotherapy, the discordance rate was 55%., Conclusion: The data presented in this study underline that retroperitoneal residual masses with necrosis cannot reliably predict histologic findings of thoracic specimens. Patients with teratoma in the retroperitoneum have a high likelihood of teratoma in the thoracic specimen., (© 2024. The Author(s).)

Ewing sarcoma (ES) represents the second most common primary osseous malignancy in children and young adults, most often occurring in the diaphysis of the long bones. While rare, ES can present as an osseous tumor of the ribs and/or chest wall. These tumors are known as Askin's tumors and most commonly present with symptoms resembling pneumonia. We report the case of a 26-year-old man who was found to have a right lung mass extending into his anterolateral chest wall after presenting to the hospital for evaluation of unremitting chest pain. Biopsy was performed and the patient diagnosed with ES. After completion of neoadjuvant chemotherapy, the patient underwent resection of the right chest wall mass. The chest wall was reconstructed in a novel fashion with titanium plates and a reinforced tissue matrix patch. Due to a paucity of cases, no treatment or reconstruction algorithm currently exists for management of these malignancies., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Chest wall tumors are a heterogeneous group of tumors that are managed by surgeons from diverse specialties. Due to their rarity, there is no consensus on their diagnosis and management., Materials: This retrospective, descriptive analysis includes patients with malignant chest wall tumors undergoing chest wall resection. Tumors were classified as primary, secondary, and metastatic tumors. The analysis includes clinicopathological characteristics, resection-reconstruction profile, and relapse patterns., Results: A total of 181 patients underwent chest wall resection between 1999 and 2020. In primary tumors (69%), the majority were soft tissue tumors (59%). In secondary tumors, the majority were from the breast (45%) and lung (42%). Twenty-five percent of patients received neoadjuvant chemotherapy, and 98% of patients underwent R0 resection. Soft tissue, skeletal + soft tissue, and extended resections were performed in 45%, 70%, and 28% of patients, respectively. The majority of patients (60%) underwent rib resections, and a median of 3.5 ribs were resected. The mean defect size was 24 cm 2 . Soft tissue reconstruction was performed in 40% of patients, mostly with latissimus dorsi flaps. Rigid reconstruction was performed in 57% of patients, and 18% underwent mesh-bone cement sandwich technique reconstruction. Adjuvant radiotherapy and chemotherapy were given to 29% and 39% of patients, respectively., Conclusions: This is one of the largest single-institutional experiences on malignant chest wall tumors. The results highlight varied tumor spectra and multimodality approaches for optimal functional and survival outcomes. In limited resource setting, surgery, including reconstructive expertise, is very crucial., (© 2023. Society of Surgical Oncology.)

Background: Chest-wall sarcomas are treated with extensive resections and complex defect reconstruction to restore chest-wall integrity. It is a difficult surgical procedure that incorporates a multidisciplinary approach for the best outcome, preventing paradoxical chest movement issues and reducing complications., Objective: We aimed to describe our experience of chest-wall reconstruction using polypropylene mesh (Marlex® Mesh) combined with methyl-methacrylate and soft-tissue coverage with a latissimus dorsi flap following sarcoma resection., Patients and Methods: Among the 53 patients treated for primary chest-wall sarcomas at the European Institute of Oncology (IEO) in Milan, Italy, from 1998 to 2020, 14 cases underwent chest-wall resection and reconstruction using polypropylene mesh, methyl-methacrylate and the latissimus dorsi flap. Patients with locally advanced breast cancers, locally advanced lung cancers, squamous cell carcinomas, and other secondary chest-wall malignancies were excluded from the study, as were the patients with different types of chest-wall reconstruction., Results: In this study, 14 patients (6 men and 8 women) with various primary chest-wall sarcomas were enrolled. On an average, 2 ribs (range: 1-5) were removed during the surgeries, and the chest-wall defects ranged from 20 to 150 cm 2 with an average size of 73 cm 2 . The mean follow-up period for these patients was approximately 63.80 months CONCLUSION: The combination of Marlex® mesh filled with methyl-methacrylate and covered using latissimus dorsi myocutaneous flap provides safe, low-cost and effective single-stage chest-wall reconstruction after surgery for primary sarcomas., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: Thoracic neurogenic tumors usually present as benign nerve sheath tumors that can be resected via transthoracic or posterior approaches, depending on the anatomical location. Robot-assisted thoracic surgery (RATS) is increasingly being used for the transthoracic approach, but evidence is very limited. The authors initiated the current study to evaluate the efficacy and safety of RATS for thoracic neurogenic tumors., Methods: This retrospective study is based on a prospectively created database that includes all RATS surgeries between 2018 and 2023. All patients with histologically confirmed neurogenic tumors were included in the study. The patients' medical and surgical records as well as radiological and pathological findings were analyzed., Results: During a 5-year period, 27 patients underwent robotic resection of neurogenic tumors at a high-volume thoracic surgery center. Two patients had previously undergone posterior laminectomy for resection of the intraspinal components. The pathologies included schwannomas (18, 64%), ganglioneuromas (8, 29%), 1 paraganglioma, and 1 neurofibroma occurring close to a schwannoma unilaterally in the same patient. The median tumor size was 4.7 cm (range 0.9-11.4 cm). The median operating time was 69 minutes (range 27-169 minutes), and the median postoperative stay was 3 days (range 1-19 days). There was one conversion due to adhesions after a previous surgery. No major bleeding occurred. There was no perioperative mortality. Morbidity included a lymphatic fistula (n = 1), pneumonia (n = 1), prolonged air leak (n = 1), and 4 cases of postoperative pain persisting for more than 4 weeks. Neurological complications were mostly observed in patients with tumors located at the thoracic apex: 2 cases of Horner's syndrome, 2 cases with compensatory hyperhidrosis, 1 patient with paresis of the recurrent laryngeal nerve, and a T1 lesion resulting in a minor motor deficit of the small hand muscles (Medical Research Council grade 4) and hypoesthesia of the respective dermatome., Conclusions: RATS for thoracic neurogenic tumors is feasible and safe. Tumors at the thoracic apex are at high risk of neurological deficit and should be approached with care. Close interdisciplinary collaboration between neurosurgeons and thoracic surgeons is necessary for optimal patient selection and a good postoperative outcome.

Background and Objectives: As one of the cutting-edge advances in the field of reconstruction, three-dimensional (3D) printing technology has been constantly being attempted to assist in the reconstruction of complicated large chest wall defects. However, there is little literature assessing the treatment outcomes of 3D printed prostheses for chest wall reconstruction. This study aimed to analyze the surgical outcomes of 3D custom-made prostheses for the reconstruction of oncologic sternal defects and to share our experience in the surgical management of these rare and complex cases., Methods: We summarized the clinical features of the sternal tumor in our center, described the surgical techniques of the application of 3D customized prosthesis for chest wall reconstruction, and analyzed the perioperative characteristics, complications, overall survival (OS), and recurrence-free survival of patients., Results: Thirty-two patients with the sternal tumor who underwent chest wall resection were identified, among which 13 patients used 3D custom-made titanium implants and 13 patients used titanium mesh for sternal reconstruction. 22 cases were malignant, and chondrosarcoma is the most common type. The mean age was 46.9 years, and 53% (17/32) of the patients were male. The average size of tumor was 6.4 cm, and the mean defect area was 76.4 cm 2 . 97% (31/32) patients received R0 resection. Complications were observed in 29% (9/32) of patients, of which wound infection (22%, 7/32) was the most common. The OS of the patients was 72% at 5 years., Conclusion: We demonstrated that with careful preoperative assessment, 3D customized prostheses could be a viable alternative for complex sternal reconstruction., (© 2024 Wiley Periodicals LLC.)

Background: Very large chest wall resections can lead to acute thoracic insufficiency syndrome due to the interdependence of lung expansion and thoracic volume. Chest wall tumor surgeries often encounter complications, with the size of the chest wall defect being a significant predictor. Several methods for large chest wall reconstruction have been described, aiming to provide stability, prevent flail chest, and ensure airtight closure. However, no single method fulfills all requirements. Composite chest wall reconstruction using titanium plates and Gore-Tex patches has shown the potential to minimize physiologic abnormalities caused by extensive defects., Case Presentation: A 42-year-old man with myxofibrosarcoma underwent multiple surgeries, chemotherapies, and radiation therapies due to repeated local recurrences. After right arm amputation and resection of the right third to fifth ribs, a local recurrence was detected. A 30 × 40 cm chest wall defect was resected en bloc, and a titanium plate was used for three-dimensional formability, preventing flail chest and volume loss. The Gore-Tex patch was then reconstructed into an arch shape, allowing lateral thoracic mobility. The patient recovered well and did not experience respiratory dysfunction or local recurrence but later succumbed to distant metastasis., Conclusions: In this case, the combination of a titanium plate and a Gore-Tex patch proved effective for reconstructing massive lateral chest wall defects. The approach provided stability, preserved thoracic volume, and allowed for lateral mobility. While the patient achieved a successful outcome in terms of local recurrence and respiratory function, distant metastasis remained a challenge for myxofibrosarcoma patients, and its impact on long-term prognosis requires further investigation. Nevertheless, the described procedure offers promise for managing extensive chest wall defects., (© 2024. The Author(s).)

Objective: To assess factors associated with increased pleural fluid and air evacuation, longer duration of thoracostomy tube usage, and longer hospitalization in dogs and cats following surgery for thoracic neoplasms., Animals: 62 dogs and 10 cats., Methods: Medical records were reviewed for dogs and cats undergoing thoracic surgeries between August 1, 2019, and June 30, 2023, for resection of suspected neoplasia in which a thoracostomy tube was placed. Data collected included patient signalment, type of procedure performed, histologic diagnosis of the primary mass removed, volume of fluid and air evacuated from the thoracostomy tube, and time in hospital., Results: Median sternotomy was associated with increased total fluid evacuation (median, 12.1 mL/kg; IQR, 15.4 mL/kg; P = .012), whereas rib resection was associated with increased total air evacuation (median, 2.1 mL/kg; IQR, 13.6 mL/kg; P = .06). The presence of preoperative pleural effusion was associated with higher total fluid evacuation (20.6 mL/kg; IQR, 32.1 mL/kg; P = .009), longer duration with a thoracostomy tube in place (42.5 hours; IQR, 41.9 hours; P = .027), and longer hospitalization period (61 hours; IQR, 52.8 hours; P = .025). Cats had a thoracostomy tube in place for a longer time compared to dogs (median, 42.6 hours; IQR, 23.5 hours; P = .043)., Clinical Relevance: Animals undergoing median sternotomy and rib resection may be expected to have higher fluid and air volumes, respectively, evacuated postoperatively. This often leads to an increased duration of thoracostomy tube usage and a longer period of hospitalization.

The authors present treatment of rhabdomyosarcoma of the gluteal region with secondary lesion of the lung and chest wall. Features of chest wall defect closure are analyzed.

Introduction: Primary chest wall tumors account for 5% of all thoracic neoplasms and 1% of all primary tumors. Chondrosarcoma is a rare solid tumor, with an annual incidence of <0.5 per million people per year. It predominantly occurs in the pelvis and femur, occasionally occurs in flat bones such as the sternum and ribs, and rarely invades lung tissue. Chest wall chondrosarcomas represent only 5-15% of all chondrosarcomas. Radical surgery often leads to a large range of chest wall defects, especially when the range exceeds 6 cm × 6 cm and involves the sternum, spine, or multiple consecutive ribs. The reconstruction of the chest wall bone should be considered to restore the integrity and stability of the chest, prevent chest wall softening and abnormal breathing, and ensure the stability of respiratory circulation. Chest wall reconstruction can help restore thoracic hardness and integrity, prevent lung hernia and abnormal breathing, while also ensuring a positive aesthetic outcome. The chest wall reconstruction includes reconstruction of the pleura, bony structures, and soft tissues., Case Report: In our case of an adult male, after the resection of the third and fourth anterior rib chondrosarcoma, the common anatomical plate was shaped and fixed to the stump of the third rib with screws to ensure the stability of the thorax while retaining the mobility of the thorax. After applying hernia mesh pruning, the chest wall defect was stitched to complete the pleural reconstruction of the defect area. This procedure can effectively maintain the stability of the pleural cavity, provide more effective support for the chest wall soft tissue, and promote the recovery of upper limb function and lung function., Conclusion: The radical surgery of giant chest wall chondrosarcoma often leads to a large range of chest wall defects. Chest wall reconstruction needs to be carried out at the same time to restore the integrity and stability of the chest wall, to avoid chest wall softening and abnormal breathing, and to ensure the stability of respiratory circulation. Using the "sandwich" method for chest wall reconstruction, in which an anatomical plate is combined with hernia mesh and muscle soft tissue, and during which pleura, bony structure, and soft tissues are reconstructed, can provide more effective support for chest wall soft tissue, effectively prevent postoperative muscle tissue collapse, avoid postoperative abnormal breathing, and promote the recovery of postoperative upper limb function and lung function. It is a very effective method for chest wall reconstruction.

Chest wall resection is performed for a variety of diseases, for primary rib and soft tissue tumors, metastatic lesions, or locally invasive growth of lung and mediastinal tumors being the most common indications. Following the resection phase, it is essential to determine the method of chest wall reconstruction that will restore the structural function, preserve pulmonary biomechanics, reduce the likelihood of residual pleural space, pulmonary hernia, and protect intrathoracic organs. The main objective of this study is to investigate the outcomes of chest wall resection with reconstruction using Codubix material., Material and Methods: This retrospective multicenter study included 22 patients who underwent chest wall tumor resection with subsequent Codubix rib endoprosthesis reconstruction from 2019 to 2023. Four medical institutions participated in the study: P.A. Herzen Moscow Cancer Research Institute, Sverdlovsk Regional Oncology Hospital, Morozov Children's City Clinical Hospital and Kaluga Regional Oncology Hospital. Inclusion criteria were the presence of chest wall tumors, both primary and secondary, removal of more than 2 ribs, resection of the rib arch and the sternum., Results: The median age was 60 years (48-66), 11 (50%) patients were females and 11 (50%) males. Operations for chest wall sarcoma, metastatic lesions, and lung cancer were performed in 9 (40.9%), 4 (18.2%), and 3 (13.6%) patients, respectively. The median number of removed ribs was 3 (2-4), with a maximum of 7. Sternotomy was performed in 9 (40.9%) patients, and subtotal resection of the body or handle of the sternum was carried out in 77.7%. Combined resections were performed in 14 (63.6%) patients. Radical tumor removal (R0) was achieved in 21 (95.5%) patients. Complications were observed in 9 (40.9%) patients, with intermuscular seroma being the most common in three (33.3%), followed by hydrothorax in 2 (22.2%), bilateral pneumonia, acute respiratory failure, and postoperative delirium in 1 (11.1%) patient each. One patient had the Codubix plate removed due to postoperative wound infection. The median overall and recurrence-free survival was not reached, and the 1-year recurrence-free survival was 63.9%, with an overall survival of 86.8%., Conclusion: Reconstruction with Codubix material allows for satisfactory functional and cosmetic results, characterized by a low complication rate and good adaptive properties.

An appropriate reconstruction strategy after surgical resection of chest wall tumors in children is important to optimize outcomes, but there is no consensus on the ideal approach. The aim of this study was to provide an up-to-date systematic review of the literature for different reconstruction strategies for chest wall defects in patients less than 18 years old. A systematic literature search of the complete available literature was performed and results were analyzed. A total of 22 articles were included in the analysis, which described a total of 130 chest wall reconstructions. All were retrospective analyses, including eight case reports. Reconstructive options were divided into primary closure ( n  = 21 [16.2%]), use of nonautologous materials ( n  = 83 [63.8%]), autologous tissue repair ( n  = 2 [1.5%]), or a combination of the latter two ( n  = 24 [18.5%]). Quality of evidence was poor, and the results mostly heterogeneous. Reconstruction of chest wall defects can be divided into four major categories, with each category including its own advantages and disadvantages. There is a need for higher quality evidence and guidelines, to be able to report uniformly on treatment outcomes and assess the appropriate reconstruction strategy., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Intrathoracic neurogenic tumors arise from sympathetic nerve trunks and intercostal nerves; more than 90% are benign. Schwannomas are the most common histological variety, but fatalities due to giant schwannomas are rare., Case Presentation: We report a case of a 65-year-old woman who presented with chest pain and cough. Computed tomography (CT) revealed a large left chest wall mass of 130-mm in size, and the patient was referred to our department. Tumor biopsy was performed under local anesthesia, and a diagnosis of schwannoma was made. Ten years previously, a 30-mm tumor had been noted in the left third intercostal space by a previous doctor, but follow-up had been interrupted owing to depressive disorder. Although we planned to perform intercostal artery embolization followed by chest wall tumor resection, the patient did not consent to surgery due to uncontrolled depression. After four months, she developed respiratory failure caused by compression due to an enlarged tumor and died. Autopsy also revealed a benign schwannoma with no malignant findings., Conclusions: Although schwannomas are benign tumors, there are some very rare cases in which they can become huge and life-threatening. Therefore, a benign tumor should not be neglected, and if surgery is not possible at the time of diagnosis, a regular follow up is necessary, in order not to miss the right timing for surgery., (© 2023. The Author(s).)

Background: Minimally invasive esophagectomy (MIE) has been used widely for the treatment of esophageal cancer. However, the optimal extent of lymphadenectomy for esophagectomy in MIE remains unclear. This trial aimed to investigate the 3-year survival and recurrence outcomes in a randomized controlled trial comparing MIE with either three-field lymphadenectomy (3-FL) or two-field lymphadenectomy (2-FL)., Methods: Between June 2016 and May 2019, 76 patients with resectable thoracic esophageal cancer were enrolled in a single-center randomized controlled trial and randomly assigned to MIE that included either 3-FL or 2-FL at a 1:1 ratio (n = 38 patients each). The survival outcomes and recurrence patterns were compared between the two groups., Results: The 3-year cumulative overall survival (OS) probability was 68.2 % (95 % confidence interval [CI], 52.72-83.68 %) for the 3-FL group and 68.6 % (95 % CI, 53.12-84.08 %) for the 2-FL group. The 3-year cumulative probability of disease-free survival (DFS) was 66.3 % (95 % CI, 50.03-82.57 %) for the 3-FL group and 67.1 % (95 % CI, 51.03-83.17 %) for the 2-FL group.. The OS and DFS differences in the two groups were comparable. The overall recurrence rate did not differ significantly between the two groups (P = 0.737). The incidence of cervical lymphatic recurrence in the 2-FL group was higher than in the 3-FL group (P = 0.051)., Conclusions: Compared with 2-FL in MIE, 3-FL tended to prevent cervical lymphatic recurrence. However, it was not found to add survival benefit for the patients with thoracic esophageal cancer., (© 2023. Society of Surgical Oncology.)

Purpose: Esophagectomy for esophageal cancer has a high incidence rate of early postoperative recurrence and death. This study aimed to identify the clinical and pathological features in early recurrence cases and to confirm the usefulness of prediction using these factors for effective adjuvant therapy and postoperative surveillance., Methods: One hundred and twenty five patients who developed postoperative recurrence after undergoing radical esophagectomy for thoracic esophageal cancer were classified into two groups as follows: those with early recurrence at ≤ 6 months and those with nonearly recurrence at > 6 months after surgery. After identifying related factors of early recurrence, usefulness of these factors for prediction were examined in all patients with and without recurrence., Results: The analysis cohort consisted of 43 and 82 patients in the early and nonearly recurrence groups, respectively. In multivariate analysis, factors associated with early recurrence were higher initial levels of tumor markers (squamous cell carcinoma [SCC] ≥ 1.5 ng/ml in tumors, except for adenocarcinoma, and carcinoembryonic antigen [CEA] ≥ 5.0 ng/ml in adenocarcinoma) and higher venous invasion (v), i.e., ≥ 2 (p = 0.040 and p = 0.004, respectively). The usefulness of these two factors for recurrence prediction was confirmed in 378 patients, including 253 patients without recurrence. Patients with at least one of the two factors had significantly higher early recurrence rates than those without any factors in pStages II and III (odds ratio [OR], 6.333; p = 0016 and OR, 4.346; p = 0.008, respectively)., Conclusions: Early recurrence of thoracic esophageal cancer (i.e., during ≤ 6 months after esophagectomy) was associated with higher initial tumor marker levels and pathological findings of v ≥ 2. The combination of these two factors is useful as a simple and critical predictor of early postoperative recurrence., (© 2023. The Author(s) under exclusive licence to The Japan Esophageal Society.)

Background: Complex surgical resection and reconstruction for rare thoracic cancers (RTCs) represent a major challenge, given their very low frequency, extreme variability of presentation, multi-modality treatment options and inadequate outcome prediction. We analysed the experience of a tertiary referral centre on a consecutive series of patients with thoracic germ cell tumours, thymomas and sarcomas, with the aim of reporting the long-term outcome by cancer type and complexity of surgical procedures., Methods: From Jan 2003 to Dec 2018, 768 surgical procedures were performed with curative intent on 644 RTC patients. Study endpoints were: post-operative hospital stay (Pod), 30-day and 90-day mortality, 5-year and 10-year overall survival (OS). Median follow-up of alive patients was 7.2 years., Results: Median Pod was 7 days, with a 1.2% 30-day and 2.9% 90-day mortality. OS was 90.8% at one year, 74.2% at five years and 62.8% at 10 years. Ten-year OS was 73.0% in low, 65.3% in intermediate, and 55.6% in high complexity score (Log-rank tests p<0.0001); 66.6% in patients with one or two reconstructions and 46.4% in patients with three or more reconstructions (p<0.0001); 46.0% with vascular and 50.0% with chest wall reconstruction; 71.8% in germ cell tumours, 64.6% in thymoma and 51.3% in sarcoma (p<0.0001)., Conclusion: Complex surgical resection and reconstruction was associated with acceptable 90-day mortality and good 10-year survival in all RTC types. A predictive score based on surgical complexity and cancer type can help the clinical decision making.

Surgery for mediastinal and chest wall tumors requires various approaches, including open and thoracoscopic, depending on the size and localization of the tumor. While robotic surgery for anterior mediastinal tumors has become a standardized approach, the approaches for tumors of the superior, middle, and posterior mediastinum, in particular, have not been generalized. Our institution introduced robotic surgery in 2017 and has performed 785 robot-assisted surgeries until November 2022. In this report, we describe our clinical experience with robotic surgery for mediastinal tumors, which required an atypical approach, as well as a case of hybrid robot-assisted extended surgery combined with an open chest procedure for lung cancer with chest wall invasion.

Purpose: SMARCA4-deficient thoracic tumors are rapid aggressive malignancies, often diagnosed at an advanced and inoperable stage. The value of pulmonary resection for resectable SMARCA4-deficient thoracic tumors is largely unknown., Methods: In this observational study, we included 45 patients who received surgery for stage I-III SMARCA4-deficient tumors. We compared the molecular, clinicopathological characteristics and survival between SMARCA4-dNSCLC and SMARCA4-deficient undifferentiated tumor (SMARCA4-dUT) patients., Results: Thirty-four SMARCA4-dNSCLC and 11 SMARCA4-dUT patients were included in this study. Molecular profiles were available in 33 out of 45 patients. The most common mutated gene was TP53 (21, 64%), and followed by STK11 (9, 27%), KRAS (5, 15%), FGFR1 (4, 12%) and ROS1 (4, 12%). There were 3 patients that harbored ALK mutation including 1 EML4-ALK rearrangement. There were 2 patients that harbored EGFR rare site missense mutation. SMARCA4-dUT patients had significance worse TTP (HR = 4.35 95% CI 1.77-10.71, p = 0.001) and OS (HR = 4.27, 95% CI 1.12-16.35, p = 0.022) compared to SMARCA4-dNSCLC patients. SMARCA4-dUT histologic type, stage II/III, R1/2 resection and lymphovascular invasion were independent poor prognostic predictors for both TTP and OS. There were 8 patients who received immunotherapy, the objective response rate was 50%. The SMARCA4-dNSCLC patient with ALK rearrangement was treated with crizotinib as second-line therapy, and achieved stable disease for 9.7 months., Conclusion: Patients with SMARCA4-deficient tumors have a high probability of early recurrence after surgery, except for stage I patients. Immunotherapy seems to be a valuable strategy to treat recurrence., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Resection of pediatric chest wall tumors can result in large defects requiring reconstruction for function and cosmesis. Multiple reconstructive methods have been described. We performed a systematic review of the literature to describe commonly used approaches and outcomes., Methods: A systematic literature search was performed for English-language publications describing chest wall tumor resection and reconstruction using implantable materials in patients ≤21 years, excluding soft tissue resection only, sternal resection, and reconstruction by primary repair or muscle flaps alone. Data were collected on diagnoses, reconstructive method, and outcomes. Rigid chest wall reconstruction was compared to mesh reconstruction., Results: There were 55 articles with 188 patients included. The median age was 12 years. Most tumors were malignant (n = 172, 91.5%), most commonly Ewing's sarcoma (n = 65, 34.6%), followed by unspecified sarcomas (n = 34, 18.1%), Askin's tumor (n = 16, 8.5%; a subset of Ewing's sarcoma) and osteosarcoma (n = 16, 8.5%). A median of 3 ribs were resected (range 1-12). Non-rigid meshes were most common (n = 138, 73.4%), followed by rigid prostheses (n = 50, 26.6%). There were 19 post-operative complications (16.8%) and 22.2% of patients developed scoliosis. There were no significant differences in complications (20.5% rigid vs. 10.6% non-rigid, p = 0.18) or scoliosis (22.7% vs. 14.0%, p = 0.23) by reconstruction method, but complications after rigid reconstruction were more likely to require surgery (90.0% vs. 53.9%, p = 0.09). The median follow-up duration was 24 months., Conclusions: In this review of the literature, there were no significant differences in overall post-operative complications or scoliosis development by reconstruction method, yet complications after rigid reconstruction were more likely to require surgical intervention., Level of Evidence: Level IV., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: Noninvasive coronary CT angiography (CCTA) was used to retrospectively analyze the characteristics of coronary artery disease (CAD) in patients with thoracic tumors and the impact of the results on clinical surgery decision-making, thus increasing the understanding of perioperative cardiac risk evaluation., Method: A total of 779 patients (age 68.6 ± 6.6 years) with thoracic tumor (lung, esophageal, and mediastinal tumor) scheduled for non-cardiac surgery were retrospectively enrolled. Patients were divided into two groups: accepted or canceled surgery. Clinical data and CCTA results were compared between the two groups, and multivariate logistic regression analysis was performed to determine predictors of the events of cancellations of scheduled surgeries., Results: 634 patients (81.4%) had non-significant CAD and 145 patients (18.6%) had significant CAD. Single‑, 2‑, and 3‑ vessel disease was found in 173 (22.2%), 93 (11.9%) and 50 (6.4%) patients, respectively. 500 (64.2%), 96 (12.3%), 96 (12.3%), 56 (7.2%) and 31 (4.0%) patients were rated as CACS 0, 1-99, 100-399, 400-999 and > 1000, respectively. Cancellations of scheduled procedures continue to increase based on the severity of the stenosis and the number of major coronary artery stenosis. The degree of stenosis and the number of vascular stenosis were independent predictors of cancelling scheduled surgery., Conclusions: For patients with thoracic tumors scheduled for non-cardiac surgery, the results suggested by CCTA significantly influenced surgery planning and facilitated to reduce perioperative cardiovascular events., (© 2023. The Author(s).)

Esophagectomy is a highly invasive surgical procedure; however, anastomotic leakage is one of the major surgical complications that should be prevented. Institutions have their own inherited or specialized anastomosis methods. The superior anastomosis procedure remains unknown despite the many studies to determine the optimal method. The present study enrolled 341 patients who underwent esophagectomy at Keio University Hospital, Tokyo, Japan, between January 2009 and January 2019. The anastomosis method was changed from circular stapled anastomosis to hand-sewn anastomosis in February 2014 to reduce the risk of anastomotic leakage. We retrospectively compared short-term results (anastomotic leakage and stricture) between hand-sewn and circular stapled anastomoses. Analysis of heterogeneity after propensity score matching between the 107 patients in the hand-sewn anastomosis group and 107 patients in the circular stapled anastomosis group revealed almost equal distributions. The incidence rate of anastomotic leakage was significantly lower in the hand-sewn anastomosis group than in the circular stapled anastomosis group (9 vs. 20%, hazard ratio: 2.521; 95% confidence interval: 1.112-5.716; P = 0.027). No significant difference was found in the incidence of anastomotic stricture (16 vs. 18%, P = 0.844). Furthermore, no significant difference was found in the incidence of anastomotic leakage in any of the tumor locations between the two anastomosis procedures. For esophagogastric anastomosis in the neck after esophagectomy, hand-sewn anastomosis is superior to circular stapled anastomosis with regard to reducing the risk of anastomotic leakage., (© The Author(s) 2022. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aim: To report our experience in treating elastofibroma, an uncommon lesion, usually arising into subscapular area; it has been included between soft tissue tumors and is characterized by progressive growth and benign behavior METHODS: Patients with an histologically proved elastofibroma, operated at our ward unit over a 3-year period, entered this study. Early results of surgical treatment have been analyzed and compared to those of Literature, focusing on selection criteria, hospital morbidity and relative risk factors RESULTS: Fourteen surgical procedures have been performed on 11 patients; EF presented as bilateral on 3 patients (27.3%) and these patients were treated with sequential 2-stages excision. All patients received complete surgical resection according to marginal excision technique; mean operative time was 75.8 ± 21.4 min. (range 55-135) while mean size of resected EF was 8.57 ± 2.2 cm. (range 5-12). Three patients developed significative postoperative seroma (21.4%), while neither hemorrhages nor recurrences have been observed. Increased B.M.I. was the only factor significantly related to hospital morbidity at univariate analysis (p = 0.0339) CONCLUSIONS: Patients carring elastofibroma larger than 5 cm. and symptomatic should undergo surgical treatment; marginal excision represents the standard technique; we recommend the use of ultrasound energy device for tissue dissection: its current use seems to prevent postoperative bleeding. Development of postoperative seroma seems related to increased patient's B.M.I. and to larger size of EF, rather than to different methods of dissection., Key Words: Chest wall tumors, Elastofibroma dorsi, Elastin, Marginal resection, Soft-tissue tumors.

Objective: To analyse safety and expediency of cardiac surgical technologies including cardiopulmonary bypass (CPB) in patients with locally advanced lung cancer and invasive tumors of the mediastinum., Material and Methods: Cardiac surgical techniques and CPB were used in 23 patients (group 1) with locally advanced thoracic tumors between 2005 and 2015. For the same period, there were 22 patients (group 2) who underwent combined surgeries and could have had similar techniques. However, these techniques were not used for various reasons. Mediastinal malignancies and non-small cell lung cancer were diagnosed in 26 (57.8%) and 19 (42.2%) patients, respectively. Invasion of superior vena cava ( n =15), aorta ( n =13) and pulmonary artery ( n =12) was the most common. Lesion of innominate vein ( n =8), left atrium ( n =6) and innominate artery ( n =4) was less common. A total of 21 pneumonectomies were performed (14 in the first group and 7 in the second group). Lobectomy was less common (one patient in each group). Sublobar lung resection was performed in 10 patients (2 patients in the first group and 8 ones in the second group). All resections were total in the first group (R0) that was confirmed by routine morphological examination of resection margins of different organs and vessels. The situation was worse in the second group (R1 in 19 (86.4%) patients, R2 in 3 (13.6%) patients)., Results: Total postoperative morbidity was 53.3%, mortality - 8.2%. These values are higher compared to patients undergoing surgical treatment for thoracic malignancies. Incidence of postoperative complications was higher in the first group (16 (69.6%) and 8 (36.4%), respectively). Four patients died in the first group. Sepsis ( n =2), acute right ventricular failure ( n =1) and acute myocardial infarction ( n =1) caused death. There were no lethal outcomes in the second group. Various postoperative complications were diagnosed only in 8 (36.4%) patients. The long-term results were followed-up in 80% of patients. In the first group, 3- and 5-year survival rates were 30.5% and 25%, respectively (median 43.8 months). In the second group, these values were 25% and 2%, respectively (median 24.9 months). Long-term mortality in the second group was caused by progression of malignant process, including local recurrence, after palliative surgery (R1, R2 resection)., Conclusion: Higher risk of postoperative complications and mortality in patients undergoing on-pump surgery is compensated by significantly better long-term results. Further progress is associated with higher safety of CPB, as well as solving some organizational and educational problems.

Objective: To analyze the outcomes after different methods of post-resection chest wall defect reconstruction., Material and Methods: The study included 41 patients aged 22-73 years who underwent chest wall repair with local tissues and synthetic materials. Twelve (29.3±7.1%) patients had sarcoma, 9 (21.9±5.9%) - non-small cell lung cancer (NSCLC) with invasion of the chest, 9 (21.9±5.9%) - metastatic lesions, 8 (19.5±6.2%) - benign tumors, 2 (4.8±3.4%) - breast cancer with invasion of the chest wall, 1 (2.4±2.4%) - desmoid tumor. Seven patients were diagnosed with T3N0M0, 1 - T3N2M0, 1 - T2N0M1b (oss). Among patients with NSCLC with invasion into the chest wall, squamous cell cancer was verified in 4 (44.4±16.6%) patients, adenocarcinoma - in 4 (44.4±16.6%), neuroendocrine tumor - in 1 (11.2±10.5%) patient. Stages of surgeries are presented., Results: We analyzed treatment outcomes in 41 patients. Five (12.2%) patients had seroma, hemothorax, thoracopleural fistula, subcutaneous emphysema and fatal asystole. There were no postoperative complications associated with paradoxical breathing., Conclusion: Accurate morphological verification prior to treatment is valuable to determine the stages of combined treatment of chest wall tumors. Chest wall defect closure with own tissues and synthetic materials is necessary after extensive resections. A multidisciplinary approach involving thoracic and plastic surgeons is needed.

Objective: To determine the impact of tumor characteristics and treatment approach on (1) local recurrence, (2) scoliosis development, and (3) patient-reported quality of life in children with sarcoma of the chest wall., Summary of Background Data: Children with chest wall sarcoma require multimodal therapy including chemotherapy, surgery, and/or radiation. Despite aggressive therapy which places them at risk for functional impairment and scoliosis, these patients are also at significant risk for local recurrence., Methods: A multi-institutional review of 175 children (median age 13 years) with chest wall sarcoma treated at seventeen Pediatric Surgical Oncology Research Collaborative institutions between 2008 and 2017 was performed. Patient-reported quality of life was assessed prospectively using PROMIS surveys., Results: The most common diagnoses were Ewing sarcoma (67%) and osteosarcoma (9%). Surgical resection was performed in 85% and radiation in 55%. A median of 2 ribs were resected (interquartile range = 1-3), and number of ribs resected did not correlate with margin status ( P = 0.36). Local recurrence occurred in 23% and margin status was the only predictive factor(HR 2.24, P = 0.039). With a median follow-up of 5 years, 13% developed scoliosis (median Cobb angle 26) and 5% required corrective spine surgery. Scoliosis was associated with posteriorrib resection (HR 8.43; P= 0.003) and increased number of ribs resected (HR 1.78; P = 0.02). Overall, patient-reported quality of life is not impaired after chest wall tumor resection., Conclusions: Local recurrence occurs in one-quarter of children with chest wall sarcoma and is independent of tumor type. Scoliosis occurs in 13% of patients, but patient-reported quality of life is excellent., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Chest wall sarcomas are a rare group of tumours. Surgical resection is considered the mainstay of curative treatment, however, resection and reconstruction of chest wall defects presents complex issues for the clinician., Methods: A retrospective analysis of 59 patients undergoing surgical management of chest wall sarcoma between December 1996 and July 2020 was conducted across a multidisciplinary sarcoma service in Melbourne, Australia. Patient demographics, pathologic data, and long-term outcomes were recorded., Results: Mean age at surgery was 48.4 years (SD 18.3), and 66.1% were male. Median follow-up was 29 months (IQR 11.8, 51.0 months). Fifty-one patients presented with primary tumours, while the others had secondary tumours resected. Most tumours arose in bone (72.9%) as opposed to soft tissues (27.1%). Chondrosarcoma was the most common histologic subtype (50.8%). The most common reconstructive techniques involved the use of mesh (79.7%) or mesh supplemented with bone cement (33.9%). Overall survival at 1 and 5 years was 92% and 70%, respectively. Seven patients died of metastatic sarcoma during the follow up period with a median survival time of 27 months. Twelve patients had evidence of disease recurrence during the follow-up period. Stage 4 disease, soft tissue tumours, secondary tumours, leiomyosarcoma and UPS subtypes, and plating reconstruction were associated with increased disease recurrence., Conclusions: The results suggest that outcomes for chest wall sarcoma are similar to extremity sarcomas and may be treated in a similar manner. Patients requiring adjuvant radiotherapy and those who develop disease-recurrence are more likely to have worse overall survival outcome despite complete surgical resection., (© 2022 Royal Australasian College of Surgeons.)

Purpose: Resection of pediatric posterior thoracic tumors (PTTs) can be complicated by Artery of Adamkiewicz (AKA) injury. Post-op spinal ischemia occurs in approx. 3.2% of patients, typically due to iatrogenic vascular injury. Pre-op angiography (PSA) may help to avoid this complication. Herein, we aim to evaluate outcomes after initiation of routine PSA prior to PTT resection., Methods: A single-institution retrospective review identified 25 children (< 18 years) treated for PTTs from 2009 to 2021. PTTs included: posterior mediastinum, paraspinal thorax and posterior chest wall tumors. PSA patients were compared to those without pre-operative angiography (NA). Demographics, perioperative and long-term outcomes and event-free survival (EFS) were assessed., Results: Prior to 2012, eleven patients were treated without PSA. However, the last developed post-operative paraplegia secondary to spinal ischemia. Since this event, PSA has become routine for all PTTs (n = 14) identifying six AKAs and nine accessory spinal arteries. Resection was performed in ten (90.1%) NA patients and eight (57.1%) PSA patients. Based on PSA findings, resection was not offered to six patients and planned partial resection was performed in three patients. Five PSA patients required radiation therapy for local control vs two NA patients. There were no differences in recurrence or overall EFS., Conclusion: PSA aids in identifying patients with high-risk thoracic vascular anatomy and may prevent risk of post-operative paraplegia associated with PTT resection., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: One of the difficulties in the treatment of esophageal cancer surgery is the high rate of postoperative recurrence. After esophagectomy, distant metastatic recurrence frequently occurs in the lung. This study aimed to determine the clinical features of a recurrence pattern with lung metastasis., Methods: The current study analyzed data from 138 patients who had postoperative recurrence of esophageal cancer after a radical esophagectomy. According to the recurrence pattern at the time of initial diagnosis, the patients were classified into two groups as follows: those with lung metastasis and those without., Results: Twenty-three of the 138 investigated patients had a recurrence pattern with lung metastasis. Salvage surgery and postoperative pneumonia (p = 0.041 and 0.030, respectively) were identified as risk factors for recurrence pattern with lung metastasis in multivariate analysis. When we compared the sites of primary esophageal tumors, we found that the frequencies of distant metastases, such as lung and liver metastases, as well as pleural/peritoneal dissemination, were higher in the mid and distal esophageal tumors. Patients with a recurrence pattern showing lung metastasis alone had a better overall and post-recurrence survival than those with other recurrence patterns (p < 0.001 and p < 0.001)., Conclusions: In patients who had postoperative recurrence after esophagectomy for thoracic esophageal cancer, salvage surgery, and postoperative pneumonia were significantly related to recurrence pattern with lung metastasis. Postoperative recurrence with lung metastasis alone had a better prognosis than other recurrence patterns; therefore, when pulmonary recurrence is suspected, performing intensive examinations for early diagnosis is critical., (© 2022. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Purpose: In this article, we aimed to reconstruct the cervical-thoracic junction plane (CTJP) using a three-dimensional (3D) reconstruction system. Thus, the CTJP can be judged during surgery to better distinguish cervical-thoracic lymph nodes., Methods: We included patients in Fujian Medical University Union Hospital from December 2019 to March 2020. All patients underwent a thin-slice and enhanced computed tomography scan of the chest with 3D reconstruction using the IQQA system (EDDA technology) to reconstruct the CTJP, brachiocephalic trunk, right common carotid artery, and right subclavian artery. The distance from the intersection of the right subclavian artery and the CTJP to the origin of the right subclavian artery (ORSA) was measured, and the relationship between this distance and the patient's sex, BMI and height was analyzed., Results: Seventy-three patients were enrolled, of whom 12 had ORSA above the CTJP, while 61 had ORSA below the plane. There was a significant difference in age between the two groups (p = 0.04), compared with height, weight and BMI (p > 0.05). In 61 patients with the ORSA below the CTJP, the average distance was 24.7 ± 7.6 mm. The difference between the distance and BMI (p = 0.02) was statistically significant, and it was increased with increasing BMI., Conclusions: The relationship between the ORSA and CTJP can be clarified through 3D reconstruction. The cervical-thoracic recurrent laryngeal nerve lymph nodes can be distinguished clearly in minimally invasive esophagectomy, contributing to the accurate N staging of middle-thoracic esophageal cancer., (© 2022 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Objectives: This retrospective study was designed to investigate the optimal extent of dissection for thoracic esophageal cancer (EC) based on the incidence of lymph node metastasis (LNM)., Methods: We retrospectively identified 1014 patients with thoracic esophageal carcinoma who underwent esophagectomy at our institution between May 2018 and November 2020. Also, the location and rate of LNM in relation to the postoperative pathological results were retrieved. We separately counted the metastasis rates of routinely excised lymph node stations according to the Japan Esophageal Society (JES) staging system., Results: A total of 1666 consecutive patients were screened, and 1014 were enrolled. Generally, the rates of LNM in thoracic EC may be arranged in the descending order of station 7 > station 106recR > station 2 > station 106recL. Esophageal cancer in the middle and lower thoracic segment also had a high rate of LNM along bilateral recurrent laryngeal nerve. Stations 106tbL and 111 were the lowest frequent sites of metastasis with rate less than 5%; only the patients with clinically positive LNs need to dissect. The cT3-4, cN+, or G3 were independent risk factors for LNM and neoadjuvant therapy did not change the distribution of LNM for thoracic EC cases., Conclusions: This study accurately identified the distribution of LNM for thoracic EC patients. Neoadjuvant therapy could not change the overall distribution of LNM in thoracic EC patients. However, whether LNs dissection at stations 106tbL and 111 is related to the survival of thoracic EC or not, needs a long follow-up time to verify., (© 2022. Society of Surgical Oncology.)

Background: In this matched-cohort study, we investigated the short-term outcome of robot-assisted minimally invasive esophagectomy (RAMIE) compared with conventional minimally invasive thoracoscopic esophagectomy (MIE) in esophageal cancer patients., Methods: One hundred eighty-nine patients with thoracic esophageal cancer scheduled to undergo thoracic esophagectomy between 2020 and 2021 were assigned to either RAMIE or MIE. Then, we retrospectively evaluated the postoperative surgical complications between two groups in a propensity-matched analyzation., Results: Based on the propensity-matched score, 50 patients who underwent RAMIE or MIE were selected. Thoracic surgery time in RAMIE/MIE group were 233.1/173.3 min (p < 0.01), respectively. No significant intergroup differences were observed regarding incisional anastomotic leakage (RAMIE group 4.0% vs. MIE group 6.0%) and pneumonia (RAMIE group 8.0% vs. MIE group 12.0%; p = 0.68). The respective incidences of recurrent laryngeal nerve paralysis were 34.0 and 8.0% in the MIE and RAMIE groups, respectively (p < 0.01). In the matched cohort, no differences were observed between the groups in the success accomplishment of the clinical management pathway (RAMIE group 94.0% vs. MIE group 88.0%)., Conclusions: Although patients who underwent RAMIE had longer operation times, the incidence of recurrent laryngeal nerve paralysis was lower than with MIE. Further study in a prospective multi-institutional setting are required to confirm the superiority of RAMIE compared with MIE., (© 2022. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Primary lung and chest wall tumours as well as lung metastases are rare diseases in children. As part of multimodal cancer treatment, thoracic surgery can significantly improve survival in children suffering from paediatric solid tumours. The aim of the review article is to summarise the indications and the current surgical treatment options for malignant chest wall and lung tumours as well as to shed light on the current role of pulmonary metastasectomy in children., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)