Management of tracheal chondrosarcoma almost completely obstructing the airway: a case report

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Original "double-step" technique for large superior sulcus tumors invading the anterior chest wall without subclavian vessels involvement

Background: In some patients with complex Superior Sulcus tumors, a combination of surgical accesses may be required. For patients with very large tumors which invade the first ribs anteriorly and without subclavian vessels involvement, we developed a "double-step" technique to facilitate resection and reduce surgical trauma. Methods: The technique was performed on five patients with a bulky non-small cell lung cancer (NSCLC), four of whom had a Superior Sulcus tumor. All patients received a radical wide thoracectomy en-bloc with an upper lobectomy. Neither significant flail chest nor postoperative respiratory complications were observed. The method is based on the possibility of interrupting the medial extremity of the first rib beneath the clavicle through a limited, preliminary parasternal incision. The remaining ribs involved in the resection are also interrupted at the costo-chondral junction, leaving the sternum and clavicle intact. Once the medial limit of the involved ribs has been sectioned, multiple stitches are placed through the peristernal tissues and temporarily left inside the chest. Through a second posterior incision, the en-bloc chest wall and lung resection is easily completed. The previously placed peristernal stitches are collected and used for the medial fixation of the prosthesis. Results: Using this technique the resection was radical in all cases. No major postoperative complications were registered. Conclusions: The technique has several advantages: trauma related to double access is negligible, radical resection is facilitated, anterior chest wall resection is accomplished without sternal or clavicular injury, enbloc chest wall and lung resection is made straightforward despite the extended area of resected ribs attached to the tumor, released within the chest cavity; chest wall stabilization is simple and reliable. The only disadvantage is that the patient's surgical position needs to be changed

Dynamic titanium prosthesis based on 3D-printed replica for chest wall resection and reconstruction

3D-printing technologies can assist the surgical planning and prosthesis engineering for the management of extended chest wall resection. Different types of prosthesis have been utilized over time, but some concerns remain about their impact on the respiratory function. Here we present a new kind of 3D-printed titanium prosthesis designed to be either strong and flexible. The prosthesis was created on a 1:1 3D-printed anatomic replica of the chest, used to delineate surgical margins and to define the reconstructive requirements

Chest wall resection and reconstruction for tumors: Analysis of oncological and functional outcome

Background: Tumors of the chest wall have a large spectrum of well-assessed indications for resection. However, whether a reconstruction is required or not is not always clear. Complications after chest wall resection and reconstruction (CWRR) are described in literature and potentially severe. There is no evidence of how non-reconstructive management may influence the post-operative complication rate. Methods: A total of 71 patients underwent thoracic demolition for tumors between April 2000 and October 2016. The patients were divided into two groups based on pathological findings: group 1: primary chest wall tumors; group 2: non-small cell lung cancer (NSCLC) invading the thoracic wall. They were then retrospectively analyzed by means of following criteria: TNM staging, histology, infiltration depth, 5-year survival, overall survival (OS), disease-free survival (DFS), relapse rate, R-0 resection, number of resected ribs, site of surgical resection and post-operative respiratory complications, flail chest, chronic pain, deformity of the chest wall and cosmetic results. Results: Five-year survival, OS, DFS and risk of relapse showed a significant correlation with the presence of free surgical margins in both groups. In group 2, another parameter which correlated to survival, risk of relapse and DFS was lymph-nodal status. Moreover, the risk of post-operative respiratory complications was directly correlated with non-reconstruction after demolition of the chest wall in certain topographical sites. Conclusions: free surgical margins are the main oncological prognostic factor in these patients. In patients who underwent resection of two or more ribs in a critical area, reconstruction of the bony thorax can significantly reduce the post-operative respiratory complication rate

Bedside sonography assessment of extravascular lung water increase after major pulmonary resection in non-small cell lung cancer patients

Background: Extra vascular lung water (EVLW) following pulmonary resection increases due to fluid infusion and rises in capillary surface and permeability of the alveolar capillary membranes. EVLW increase clinically correlates to pulmonary oedema and it may generate impairments of gas exchanges and acute lung injury. An early and reliable assessment of postoperative EVLW, especially following major pulmonary resection, is useful in terms of reducing the risk of postoperative complications. The currently used methods, though satisfying these criteria, tend to be invasive and cumbersome and these factors might limit its use. The presence and burden of EVLW has been reported to correlate with sonographic B-line artefacts (BLA) assessed by lung ultrasound (LUS). This observational study investigated if bedside LUS could detect EVLW increases after major pulmonary resection. Due to the clinical association between EVLW increase and impairment of gas exchange, secondary aims of the study included investigating for associations between any observed EVLW increases and both respiratory ratio (PaO2/FiO2) and fluid retention, measured by brain natriuretic peptide (BNP). Methods: Overall, 74 major pulmonary resection patients underwent bedside LUS before surgery and at postoperative days 1 and 4, in the inviolate hemithorax which were divided into four quadrants. BLA were counted with a four-level method. The respiratory ratio PaO2/FiO2 and fluid retention were both assessed. Results: BLA resulted being increased at postoperative day 1 (OR 9.25; 95% CI, 5.28-16.20; P<0.0001 vs. baseline), and decreased at day 4 (OR 0.50; 95% CI, 0.31-0.80; P=0.004 vs. day 1). Moreover, the BLA increase was associated with both increased BNP (OR 1.005; 95% CI, 1.003-1.008; P<0.0001) and body weight (OR 1.040; 95% CI, 1.008-1.073; P=0.015). Significant inverse correlations were observed between the BLA values and the PaO2/FiO2 respiratory ratios. Conclusions: Our results suggest that LUS, due to its non-invasiveness, affordability and capacity to detect increases in EVLW, might be useful in better managing postoperative patients

Bronchiolitis obliterans organizing pneumonia after radiation therapy for lung cancer. A case report

Bronchiolitis obliterans organizing pneumonia (BOOP), also known as cryptogenic organizing pneumonia, has mainly been described in patients with breast cancer who received radiotherapy after breast-conserving surgery. In this rare case, a 70-year-old man with left apical squamous lung cancer developed BOOP after radiotherapy and only one cycle of concomitant chemotherapy. This case report draws attention to the development of this syndrome in the unusual setting of lung cancer, advising prompt steroid treatment when diagnostic images reveal the characteristic signs of the disease

TRPA1 mediates aromatase inhibitor-evoked pain by the aromatase substrate androstenedione

Aromatase inhibitors (AI) induce painful musculoskeletal symptoms (AIMSS), which are dependent upon the pain transducing receptor TRPA1. However, as the AI concentrations required to engage TRPA1 in mice are higher than those found in the plasma of patients, we hypothesized that additional factors may cooperate to induce AIMSS. Here we report that the aromatase substrate androstenedione, unique among several steroid hormones, targeted TRPA1 in peptidergic primary sensory neurons in rodent and human cells expressing the native or recombinant channel. Androstenedione dramatically lowered the concentration of letrozole required to engage TRPA1. Notably, addition of a minimal dose of androstenedione to physiologically ineffective doses of letrozole and oxidative stress byproducts produces AIMSS-like behaviors and neurogenic inflammatory responses in mice. Elevated androstenedione levels cooperated with low letrozole concentrations and inflammatory mediators were sufficient to provoke AIMSS-like behaviors. The generation of such painful conditions by small quantities of simultaneously administered TRPA1 agonists justifies previous failure to identify a precise link between AIs and AIMSS, underscoring the potential of channel antagonists to treat AIMSS