Misdiagnosis of anomalous pulmonary venous connections in a patient with lung cancer and a review of the literature

A partial anomalous pulmonary venous connection (PAPVC) is a rare congenital defect in which at least one pulmonary vein doesn't drain into the left atrium but into a systemic vein or even into the right atrium, causing a left-to right shunt. PAPVC with a small amount of shunt are usually asymptomatic, and can not be detected during lifetime. Nevertheless, if those patients undergo a major lung resection, the surgical procedure could precipitate right heart failure if this anomalous shunt remains uncorrected. Therefore, it is considered to be very important preoperative diagnosis. In case report, we present a case of a 54-year-old woman with a right upper lobe non-small cell lung cancer and previous history of left lung resection for tuberculosis. During surgery, an anomalous pulmonary vein branch draining into the superior vena cava was incidentally detected. The abnormality was diagnosed as a PAPVC. A right upper open lobectomy was performed. The anomaly was corrected and the surgery was successful without postoperative complications. Surgeons should be aware of this rare anomaly and carefully evaluate preoperative images CT scans of the pulmonary veins

EGF and IGF1 affect Sunitinib activity in BP-NEN: new putative targets beyond VEGFR?

Broncho-Pulmonary Neuroendocrine Neoplasms (BP-NENs) are neoplasms orphan of an efficient therapy. Available medical treatments derived from clinical trials are not specific for the management of this malignancy. Sunitinib is a multi-receptor tyrosine-kinases (RTKs) inhibitor that has already shown its efficacy in NENs but there are not available data about its action in BP-NENs. Therefore, our aim was to understand the effects of RTKs inhibition promoted by Sunitinib in order to evaluate new putative targets useful in malignancy treatment. Since our results underlined a role for EGFR and IGF1R in modulating Sunitinib antiproliferative action, we investigated the effects of Erlotinib, an EGFR inhibitor, and Linsitinib, an IGF1R inhibitor, in order to understand their function in regulating cells behaviour. Cell viability and caspase activation were evaluated on two immortalized human BP-NEN cell lines and primary cultures. Our results showed that after treatment with Sunitinib and/or IGF1, EGF and VEGF, the antiproliferative effect of Sunitinib was counteracted by EGF and IGF1 but not by VEGF. Therefore, we evaluated with alpha-screen technology the phosphorylated EGFR and IGF1R levels in primary cultures treated with Sunitinib and/or EGF and IGF1. Results showed a decrease of p-IGF1R after treatment with Sunitinib and an increase after co-treatment with IGF1. Then, we assessed cell viability and caspase activation on BP-NEN cell lines after treatment with Linsitinib and/or Erlotinib. Results demonstrate that these two agents have a stronger antiproliferative effect compared to Sunitinib. In conclusion, our results suggest that IGF1R and EGF1R could represent putative molecular targets in BP-NENs treatment

Primary Pulmonary Epithelioid Hemangioendothelioma: A Rare Cause of PET-Negative Pulmonary Nodules

We report here a case of primary pulmonary epithelioid hemangioendothelioma diagnosed in a 67-year-old Caucasian man, presenting with exertion dyspnoea, dry cough, and multiple bilateral pulmonary nodules revealed by computed tomography. At the 18F-fluorodeoxyglucose positron emission tomography, these nodules were negative. The histopathological diagnosis was made on a pulmonary wedge resection (performed during video-thoracoscopic surgery)

Inflammatory Microenvironment in Early Non-Small Cell Lung Cancer: Exploring the Predictive Value of Radiomics

Patient prognosis is a critical consideration in the treatment decision-making process. Conventionally, patient outcome is related to tumor characteristics, the cancer spread, and the patients’ conditions. However, unexplained differences in survival time are often observed, even among patients with similar clinical and molecular tumor traits. This study investigated how inflammatory radiomic features can correlate with evidence-based biological analyses to provide translated value in assessing clinical outcomes in patients with NSCLC. We analyzed a group of 15 patients with stage I NSCLC who showed extremely different OS outcomes despite apparently harboring the same tumor characteristics. We thus analyzed the inflammatory levels in their tumor microenvironment (TME) either biologically or radiologically, focusing our attention on the NLRP3 cancer-dependent inflammasome pathway. We determined an NLRP3-dependent peritumoral inflammatory status correlated with the outcome of NSCLC patients, with markedly increased OS in those patients with a low rate of NLRP3 activation. We consistently extracted specific radiomic signatures that perfectly discriminated patients’ inflammatory levels and, therefore, their clinical outcomes. We developed and validated a radiomic model unleashing quantitative inflammatory features from CT images with an excellent performance to predict the evolution pattern of NSCLC tumors for a personalized and accelerated patient management in a non-invasive way

Erratum to nodal management and upstaging of disease. Initial results from the Italian VATS Lobectomy Registry

[This corrects the article DOI: 10.21037/jtd.2017.06.12.]

Total Laparoscopic Management of Large Epiphrenic Diverticulum

<p>Introduction</p><p>Laparoscopic management of epiphrenic diverticula seems to be as safe and effective as the traditional, open transthoracic approach. However, in cases of large diverticula, the difficulty of dissection and the potential of the pleura to rupture with subsequent pneumothorax represent possible disadvantages. This video shows the safety of the laparoscopic approach for Heller myotomy and Dor fundoplication, combined with an epiphrenic diverticulectomy.</p><p>Materials and Methods</p><p>A 66-year-old woman presented to the authors’ institution complaining of dysphagia to solid foods, retrosternal pain, and weight loss. The preoperative examinations revealed a large diverticulum of the lower esophagus, approximately 4 cm above the lower esophageal sphincter (LES). Esophageal manometry showed lack of peristalsis and LES hypertension consistent with achalasia.</p><p>The patient was placed in the lithotomic position, with the operator standing between the patient’s legs. The first assistant was at the right of the surgeon, and the second assistant at his left. Pneumoperitoneum was established and five operating ports were placed as usual. The authors started with the dissection of the gastrohepatic ligament and continued until the right diaphragmatic pillar, with a complete dissection of the phrenoesophageal ligament. Afterwards, the lower esophagus was extensively mobilized in order to identify the diverticulum and the right mediastinal pleura was separated from the diverticulum laterally. When the diverticulum was completely free from its surrounding attachments, a 60 mm stapler was used to resect the diverticulum at its base, taking care to not narrow the esophagus.</p><p>After completion of the diverticulectomy, an anterior myotomy was performed, beginning at the upper level of the diverticular transection and ending 1.5-2 cm caudally into the gastric wall. The short gastric vessels of the fundus were divided along the fundus up to the left diaphragmatic crus using the harmonic scalpel. An anterior wrap (Dor fundoplication) was then performed by sewing the edges of the wrap to the edges of the myotomy with a suture. The wrap was then secured to the right crus of the diaphragm, superiorly.</p><p>Results and Conclusions</p><p>The operative time was 200 minutes. On postoperative day three, a barium swallow demonstrated that the esophagus was widely patent and had no leakage from either the diverticulectomy suture line or the myotomy. After a follow-up period of 14 months the patient is symptom free. In the authors’ opinion, this operation can be performed as a minimally invasive surgical procedure regardless of diverticula size. Technical factors also support this choice, including: better visualization of the esophagogastric junction, easier myotomy and performance of antireflux wrap, and better alignment of the stapler cartridge to the longitudinal axis of the esophagus. The only limiting factor is represented by the impossibility to extensively mobilize the lower esophagus.</p

Voluminous abdominal gastrointestinal stromal tumor of unknown origin manifested with bleeding in a young man: synchronous management of the emergency and oncological approach-case report

Gastrointestinal stromal tumors (GISTs) are rare tumors of the gastrointestinal tract, which cover about 1-2% of gastrointestinal neoplasms with an unadjusted incidence of around 1/100,000/year. They are also the most common non-epithelial neoplasms of the gastrointestinal tract and they are associated with a high rate of malignant transformation. They are more common in the stomach (40-60%) while a minor part repeatedly involves jejunum/ileus (25-30%), duodenum (5%), colorectal (5-15%) and esophagus (&lt;1%). There are also much rarer extragastrointestinal stromal tumor (EGIST): these tumors have immunohistochemical and molecular characteristics similar to GISTs and for this reason, they are called this way, EGIST can involve retroperitoneum, mesentery, and omentum, without affecting the gastrointestinal tract. The clinical presentation depends on the primary localization of the neoplasm, however in 18% it is asymptomatic, and it is accidentally discovered during endoscopies, radiological examinations or surgical operations performed for other reasons, especially if it is small in size. More often, they are associated with non-specific symptoms such as early satiety, nausea or vomiting. Gastrointestinal bleeding is the most dangerous complication, often necessitating emergency surgery. The purpose of this case report is to describe our experience in the management of a young patient with gastrointestinal bleeding caused by an unknown voluminous retroperitoneal GIST with metastatic progression using a combined endovascular embolization and debulking-surgery approach for emergency and imatinib therapy combined with radiofrequency for the oncological approach. GIST requires multidisciplinary management, which improves both prognosis and quality of life

Total Laparoscopic Management of Large Epiphrenic Diverticulum

<p>Introduction</p><p>Laparoscopic management of epiphrenic diverticula seems to be as safe and effective as the traditional, open transthoracic approach. However, in cases of large diverticula, the difficulty of dissection and the potential of the pleura to rupture with subsequent pneumothorax represent possible disadvantages. This video shows the safety of the laparoscopic approach for Heller myotomy and Dor fundoplication, combined with an epiphrenic diverticulectomy.</p><p>Materials and Methods</p><p>A 66-year-old woman presented to the authors’ institution complaining of dysphagia to solid foods, retrosternal pain, and weight loss. The preoperative examinations revealed a large diverticulum of the lower esophagus, approximately 4 cm above the lower esophageal sphincter (LES). Esophageal manometry showed lack of peristalsis and LES hypertension consistent with achalasia.</p><p>The patient was placed in the lithotomic position, with the operator standing between the patient’s legs. The first assistant was at the right of the surgeon, and the second assistant at his left. Pneumoperitoneum was established and five operating ports were placed as usual. The authors started with the dissection of the gastrohepatic ligament and continued until the right diaphragmatic pillar, with a complete dissection of the phrenoesophageal ligament. Afterwards, the lower esophagus was extensively mobilized in order to identify the diverticulum and the right mediastinal pleura was separated from the diverticulum laterally. When the diverticulum was completely free from its surrounding attachments, a 60 mm stapler was used to resect the diverticulum at its base, taking care to not narrow the esophagus.</p><p>After completion of the diverticulectomy, an anterior myotomy was performed, beginning at the upper level of the diverticular transection and ending 1.5-2 cm caudally into the gastric wall. The short gastric vessels of the fundus were divided along the fundus up to the left diaphragmatic crus using the harmonic scalpel. An anterior wrap (Dor fundoplication) was then performed by sewing the edges of the wrap to the edges of the myotomy with a suture. The wrap was then secured to the right crus of the diaphragm, superiorly.</p><p>Results and Conclusions</p><p>The operative time was 200 minutes. On postoperative day three, a barium swallow demonstrated that the esophagus was widely patent and had no leakage from either the diverticulectomy suture line or the myotomy. After a follow-up period of 14 months the patient is symptom free. In the authors’ opinion, this operation can be performed as a minimally invasive surgical procedure regardless of diverticula size. Technical factors also support this choice, including: better visualization of the esophagogastric junction, easier myotomy and performance of antireflux wrap, and better alignment of the stapler cartridge to the longitudinal axis of the esophagus. The only limiting factor is represented by the impossibility to extensively mobilize the lower esophagus.</p

Laparoscopic reversal of Hartmann's procedure: A single-center experience

INTRODUCTION: Laparoscopic reversal of Hartmann's procedure (LHR) is considered a technically complex major surgical procedure. We present a retrospective analysis of a single-institution experience that assesses the treatment patterns and outcomes of patients who underwent LHR. MATERIALS AND SURGICAL TECHNIQUE: The study involved patients who underwent LHR between January 2004 and December 2017. All patients had previously undergone a conventional Hartmann's procedure for acute complicated diverticulitis or cancer. Patients were placed in a supine position with their legs spread apart and their left arm out to the side. Access into the abdomen was obtained through open laparoscopy, with a 12-mm trocar for a 30° laparascope inserted at the periumbilical site. We placed between three and five trocars depending on the level of operative difficulty encountered. The first surgical step was to dissect any existing adhesions, and then rectal mobilization was systematically performed to ensure the feasibility of the end-to-end anastomosis and to avoid bladder injury. The stoma was mobilized on the level of the abdominal wall and then freed from the fascia. We used a circular stapler to reestablish a tension-free anastomosis. Over 13 years, 20 patients underwent LHR. No patient required a temporary colostomy or ileostomy. DISCUSSION: Reversal of Hartmann's procedure involves high operative morbidity and mortality, and usually only relatively young and healthy patients are eligible for reversal. Our results are consistent with previously published literature regarding the advantages of LHR compared to the conventional technique. However, high-level evidence is still needed