Mediastinal lymph node metastases in thyroid cancer: surgery without limits

Metastases to lymph nodes of the superior mediastinum have been found in up to 10% of patients with thyroid carcinoma. The treatment of mediastinal lymph node metastases in thyroid cancer is still far from being standardized. However, in selected cases, especially in case of radioiodine ablation and radiation therapy failure, a surgical resection may improve the patients’ survival in addition to the symptomatic benefits. We report our experience in four consecutive patients who underwent extended mediastinal surgery for large lymph node metastases from thyroid cancer during the last year. All patients were pre-operatory evaluated by a multidisciplinary team involving endocrinologist, anaesthesiologist and surgeons. Surgery was carried out in all cases in two steps, firstly through a cervicotomy in order to remove the eventual local recurrence and ensure a radical neck dissection bilaterally and then by sternotomy, in order to dissect all the lymphadenopathies from the mediastinal structures. Two patients (50%) had an extended vascular infiltration and the extracorporeal circulation (ECC) and, at least, one vascular graft, were needed. No intraoperative or perioperative mortality occurred in this series. Two patients (50%) presented a sternal dehiscence that required a second surgery and a prolonged postoperative hospital stay. In all cases the surgery was radical, and the histological report revealed a macroscopic complete resection and, up to date, no recurrences were found. When feasible, surgery is more effective than systemic therapy in the treatment of thyroid cancer recurrences, especially for medullary thyroid cancer in which radioiodine therapy is ineffective and should always be evaluated in case of vascular infiltration or symptomatic patients. Moreover, due to diversity and complexity of the cervical and mediastinal structures that may be involved, a multidisciplinary medical team should always be guaranteed during the surgery

Hypertermic Intrathoracic Chemotherapy (HITHOC) for thymoma: a narrative review on indications and results

Objective: With this narrative review, we retraced the history of hypertermic intrathoracic chemotherapy (HITHOC) since the beginning, analyzing literature on operative technique, feasibility and efficacy of this treatment. Moreover, we report the fifteen-year experience of our center in this relatively new technique, for what concerns both early postoperative results and long-term oncological outcomes. Background: Thymomas are frequently misdiagnosed and recognized in advanced stage, often with pleural dissemination, especially when not associated to Myasthenia Gravis that allows an early diagnosis during the initial assessment. Moreover, the natural history of locally advanced thymoma is characterized by a high rate of pleural or pericardial relapses. Surgery has always been considered a milestone in thymoma's treatment, even in case of serous dissemination or relapses, although his role as exclusive therapy does not guarantee an acceptable local disease control. In case of disseminated disease, different multidisciplinary protocols have been experimented, from chemotherapy to radiation therapy, alone or associated to surgery, in order to increase overall and disease-free survival, but the breakthrough happened in the early 90s with the introduction of HITHOC following surgery. Combination of surgery and HITHOC resulted in less toxic than systemic chemotherapy and providing a good local disease control in patients with stage IVa thymomas or thymoma's pleural recurrences. Methods: We searched PubMed for relevant literature, up to January 2020, on hypertermic intrapleural chemotherapy for thymomas (TPR or DNT), selecting only those reporting information about HITHOC protocol used, postoperative course and oncological outcomes. Conclusions: HITHOC is a safe and feasible procedure, with a very low complication rate and negligible systemic effects of chemotherapeutic agents, effective in controlling both TPR and DNT, in particular as regards local disease-free survival. Keywords: Hypertermic intrathoracic chemotherapy (HITHOC); thymoma; intracavitary chemotherapy; hyperthermia; redo-surgery

An asymptomatic giant AB thymoma in a patient with Down syndrome: a case report

Background: Mediastinal mass management may represent a real challenge for all the physicians who deal with it. Mediastinum, in fact, contains different vital structures which are often involved by growing neoplasms with increasing severity. Therefore, up to 60% of the patients with mediastinal mass are symptomatic, according to the structure involved. Different neoplasms may arise essentially from all mediastinal organs, whereas thymic epithelial tumors and lymphomas represent more than 90% of mediastinal tumors. Case Description: We report the first case described of a giant asymptomatic mediastinal mass in a 43-year-old male affected by Down syndrome (DS), turned out to be a thymoma, treated exclusively and successfully with radical surgery. Despite the absence of any symptoms, the giant thymoma infiltrated the diaphragm, the pericardium, the upper lobe of the left lung together with the left phrenic nerve resulting in the compression of heart and great vessels. Conclusions: To date, this is the first description of a thymic malignancy in a patient with DS, that usually is characterized by a low-incidence of solid tumor except for germ-cells ones. Surgery has been extremely challenging, due the clinical condition of the patient together with the tumor features; nevertheless, oncological radicality criteria were completely fulfilled. After four years from surgery, the patient is alive and still disease-free, highlighting the importance of rad

Pathological and clinical features of multiple cancers and lung adenocarcinoma: a multicentre study

OBJECTIVES: Lung cancer is increasingly diagnosed as a second cancer. Our goal was to analyse the characteristics and outcomes of early-stage resected lung adenocarcinomas in patients with previous cancers (PC) and correlations with adenocarcinoma subtypes.METHODS: We retrospectively reviewed data of patients radically operated on for stage I-II lung adenocarcinoma in 9 thoracic surgery departments between 2014 and 2017. Overall survival (OS) and time to disease relapse were evaluated between subgroups.RESULTS: We included 700 consecutive patients. PC were present in 260 (37.1%). Breast adenocarcinoma, lung cancer and prostate cancer were the most frequent (21.5%, 11.5% and 11.2%, respectively). No significant differences in OS were observed between the PC and non-PC groups (P = 0.378), with 31 and 75 deaths, respectively. Patients with PC had smaller tumours and were more likely to receive sublobar resection and to be operated on with a minimally invasive approach. Previous gastric cancer (P = 0.042) and synchronous PC (when diagnosed up to 6 months before lung adenocarcinoma; P = 0.044) were related, with a worse OS. Colon and breast adenocarcinomas and melanomas were significantly related to a lower incidence of high grade (solid or micropapillary, P = 0.0039, P = 0.005 and P = 0.028 respectively), whereas patients affected by a previous lymphoma had a higher incidence of a micropapillary pattern (P = 0.008).CONCLUSIONS: In patients with PC, we found smaller tumours more frequently treated with minimally invasive techniques and sublobar resection, probably due to a more careful follow-up. The impact on survival is not uniform and predictable; however, breast and colon cancers and melanoma showed a lower incidence of solid or micropapillary patterns whereas patients with lymphomas had a higher incidence of a micropapillary pattern

Impact of High‑Grade Patterns in Early‑Stage Lung Adenocarcinoma: A Multicentric Analysis

Objective The presence of micropapillary and solid adenocarcinoma patterns leads to a worse survival and a signifcantly higher tendency to recur. This study aims to assess the impact of pT descriptor combined with the presence of high-grade components on long-term outcomes in early-stage lung adenocarcinomas. Methods We retrospectively collected data of consecutive resected pT1-T3N0 lung adenocarcinoma from nine European Thoracic Centers. All patients who underwent a radical resection with lymph-node dissection between 2014 and 2017 were included. Diferences in Overall Survival (OS) and Disease-Free Survival (DFS) and possible prognostic factors associated with outcomes were evaluated also after performing a propensity score matching to compare tumors containing non-highgrade and high-grade patterns. Results Among 607 patients, the majority were male and received a lobectomy. At least one high-grade histological pattern was seen in 230 cases (37.9%), of which 169 solid and 75 micropapillary. T1a-b-c without high-grade pattern had a signifcant better prognosis compared to T1a-b-c with high-grade pattern (p=0.020), but the latter had similar OS compared to T2a (p=0.277). Concurrently, T1a-b-c without micropapillary or solid patterns had a signifcantly better DFS compared to those with high-grade patterns (p=0.034), and it was similar to T2a (p=0.839). Multivariable analysis confrms the role of T descriptor according to high-grade pattern both for OS (p=0.024; HR 1.285 95% CI 1.033–1.599) and DFS (p=0.003; HR 1.196, 95% CI 1.054–1.344, respectively). These results were confrmed after the propensity score matching analysis. Conclusions pT1 lung adenocarcinomas with a high-grade component have similar prognosis of pT2a tumors

Il ruolo della chirurgia timica nel controllo della miastenia gravis

I timomi si ritrovano in circa il 10-15% dei pazienti affetti da Miastenia Gravis, mentre in oltre il 65% dei casi si osserva un’iperplasia timica non neoplastica. Entrambe le patologie timiche vengono trattate mediante la chirurgia. L’efficacia della timectomia nel raggiungimento di un miglioramento clinico, così come della remissione totale, nei pazienti miastenici, è stata largamente dimostrata. Con questa tesi, si vuole studiare come l’intervento di timectomia per via sternotomica influenzi il decorso clinico neurologico dei pazienti affetti da Miastenia Gravis. Metodi: sono state analizzate retrospettivamente, in seguito a un follow-up di almeno tre anni, le condizioni cliniche dei pazienti miastenici sottoposti a intervento di timectomia per via sternotomica presso l’U.O. Chirurgia Toracica di Pisa, sia per timoma che per iperplasia timica, tra il 1990 e il 2012

Trattamento chirurgico delle stenosi tracheali durante la pandemia da SARS-CoV2 e confronto con l'esperienza precedente.

Tracheal stenosis is a life-threatening condition, often secondary to invasive mechanical ventilation, which needs multidisciplinary management in referral centers. Tracheal resection with primary end-to-end anastomosis (R/A) is a valid therapeutic option although related to a challenging post-operative care. During the SARS-CoV2 pandemic, the large use of invasive mechanical ventilation determined a marked increase of post-intubation or post-tracheostomy stenosis requiring surgical treatment. Data of those patients operated on for tracheal stenosis in our tertiary referral Center during the pandemic were collected, analyzed, and compared with previous series. In the biennium 2020-2021, 11 patients underwent tracheal R/A. All benign stenosis were iatrogenic complications of mechanical ventilation. Six(75%) patients had previously been affected by severe respiratory failure due to SARS-CoV2 pneumonia. There were no differences between patients who have had Covid-19 and patients who did not, regarding intra-and postoperative outcomes. At the endoscopic exam in 30th postoperative day no anastomosis complication was detected. Prevention of SARS CoV2 diffusion is fundamental to avoid the rise of tracheal stenosis incidence. However, although tracheal R/A still remains a complex surgical procedure with potentially high morbidity rates, it has proved to be safe and effective even in the more challenging subset of Covid-19 patients, in referral high-volume Centers

Case report: A giant lung leiomyosarcoma: From an accurate diagnosis to a successful surgery. A rare case and brief literature review

Primary pulmonary leiomyosarcomas (PPLs) are incredibly rare tumors, characterized by an often-aggressive clinical behavior. Diagnosis is frequently incidental. Whenever present, symptoms are nonspecific, thus PPLs are usually misdiagnosed as other more common respiratory diseases or lung cancer subtypes. Surgery is the best treatment choice and in the therapeutic strategy, timeliness and radicality are of major importance. We report the case of a huge left PPL, successfully treated with salvage surgery after a careful multidisciplinary preoperative assessment, which permitted a prompt diagnostic path and surgery