Indications and developments of video-assisted thoracic surgery in the treatment of lung cancer.

Learning ObjectivesAfter completing this course, the reader will be able to: Discuss the role of thoracoscopy in the evaluation of pulmonary nodules and pleural effusion.Describe the role of thoracoscopy in the staging of lung cancer.Discuss the role of thoracoscopy in surgical resection of early-stage lung cancer.Access and take the CME test online and receive 1 AMA PRA Category 1 Credit™ at CME.TheOncologist.co

Giant lung bulla as a late-onset complication of mild SARS-CoV-2 pneumonia

A 49-year-old Caucasian man was admitted to the Emergency Department for shortness of breath and cough. CT imaging showed bilateral a mild COVID-19 related pneumonia. He was hospitalized in the low-intensity COVID-19 unit where he received O2 therapy and oral corticosteroids (CS). Three weeks after discharge a high-resolution computed tomography (HRCT) find a giant bulla of the inferior lobe. The bulla was resected by video-assisted thoracoscopic surgery (VATS) and the patient recovered completely. In our patient, it is reasonable to suspect that the development of the bulla is a result of SARS-CoV-2 infection, since no bulla was observed in the first HRCT two months before. SARS-CoV-2 related pneumonia may be responsible for lung remodeling due to diffuse alveolar damage and later interstitial myofibroblastic proliferation. Corticosteroids might have played a role in increasing SARS-CoV-2 dystrophic action. COVID-19 leads to pulmonary damages, which are still partially unknown and might result in development of bullae. In fit patient surgical treatment can be carried out safely

Pathophysiological mechanism of post-lobectomy air leaks

Background: Air leak post-lobectomy continues to remain a significant clinical problem, with upper lobectomy associated with higher air leak rates. This paper investigated the pathophysiological role of pleural stress in the development of post-lobectomy air leak.Methods: Preoperative characteristics and postoperative data from 367 consecutive video assisted thoracic surgery (VATS) lobectomy resections from one centre were collected prospectively between January 2014 and March 2017. Computer modelling of a lung model using finite element analysis (FEA) was used to calculate pleural stress in differing areas of the lung.Results: Air leak following upper lobectomy was significantly higher than after middle or lower lobectomy (6.3% versus 2.5%, P=0.044), resulting in a significant six-day increase in mean hospital stay, P=0.004. The computer simulation model of the lung showed that an apical bullet shape was subject to eightyfold higher stress than the base of the lung model.Conclusions: After upper lobectomy, the bullet shape of the apex of the exposed lower lobe was associated with high pleural stress, and a reduction in mechanical support by the chest wall to the visceral pleura due to initial post-op lack of chest wall confluence. It is suggested that such higher stress in the lower lobe apex explains the higher parenchymal air leak post-upper lobectomy. The pleural stress model also accounts for the higher incidence of right-sided prolonged air leak post-resection.peer-reviewe

First Italian Consensus Conference on VATS Lobectomy for NSCLC

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EACTS expert consensus statement for surgical management of pleural empyema

Pleural infection is a frequent clinical condition. Prompt treatment has been shown to reduce hospital costs, morbidity and mortality. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research. The European Association for Cardio-Thoracic Surgery (EACTS) Thoracic Domain and the EACTS Pleural Diseases Working Group established a team of thoracic surgeons to produce a comprehensive review of available scientific evidence with the aim to cover all aspects of surgical practice related to its treatment, in particular focusing on: surgical treatment of empyema in adults; surgical treatment of empyema in children; and surgical treatment of post-pneumonectomy empyema (PPE). In the management of Stage 1 empyema, prompt pleural space chest tube drainage is required. In patients with Stage 2 or 3 empyema who are fit enough to undergo an operative procedure, there is a demonstrated benefit of surgical debridement or decortication [possibly by video-assisted thoracoscopic surgery (VATS)] over tube thoracostomy alone in terms of treatment success and reduction in hospital stay. In children, a primary operative approach is an effective management strategy, associated with a lower mortality rate and a reduction of tube thoracostomy duration, length of antibiotic therapy, reintervention rate and hospital stay. Intrapleural fibrinolytic therapy is a reasonable alternative to primary operative management. Uncomplicated PPE [without bronchopleural fistula (BPF)] can be effectively managed with minimally invasive techniques, including fenestration, pleural space irrigation and VATS debridement. PPE associated with BPF can be effectively managed with individualized open surgical techniques, including direct repair, myoplastic and thoracoplastic techniques. Intrathoracic vacuum-assisted closure may be considered as an adjunct to the standard treatment. The current literature cements the role of VATS in the management of pleural empyema, even if the choice of surgical approach relies on the individual surgeon's preferenc

Robotic resection of mediastinal left vagus neurofibroma

Neurogenic tumors represent 10 to 34% of all mediastinal tumors and among them, neurofibroma originating from the vagus nerve are rare entities. We present a case of a neurofibroma with cystic degeneration originating from the left branch of the vagus nerve in a 27-years-old man without von Recklinghausen disease. A complete robotic resection of the mediastinal mass has been performed, with amputation of the vagus nerve enclosed in the mass. The postoperative course was uneventful and the patient was discharged in two days

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

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.]

COVID-19 in patients with thoracic malignancies (TERAVOLT): first results of an international, registry-based, cohort study

Background: Early reports on patients with cancer and COVID-19 have suggested a high mortality rate compared with the general population. Patients with thoracic malignancies are thought to be particularly susceptible to COVID-19 given their older age, smoking habits, and pre-existing cardiopulmonary comorbidities, in addition to cancer treatments. We aimed to study the effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on patients with thoracic malignancies. Methods: The Thoracic Cancers International COVID-19 Collaboration (TERAVOLT) registry is a multicentre observational study composed of a cross-sectional component and a longitudinal cohort component. Eligibility criteria were the presence of any thoracic cancer (non-small-cell lung cancer [NSCLC], small-cell lung cancer, mesothelioma, thymic epithelial tumours, and other pulmonary neuroendocrine neoplasms) and a COVID-19 diagnosis, either laboratory confirmed with RT-PCR, suspected with symptoms and contacts, or radiologically suspected cases with lung imaging features consistent with COVID-19 pneumonia and symptoms. Patients of any age, sex, histology, or stage were considered eligible, including those in active treatment and clinical follow-up. Clinical data were extracted from medical records of consecutive patients from Jan 1, 2020, and will be collected until the end of pandemic declared by WHO. Data on demographics, oncological history and comorbidities, COVID-19 diagnosis, and course of illness and clinical outcomes were collected. Associations between demographic or clinical characteristics and outcomes were measured with odds ratios (ORs) with 95% CIs using univariable and multivariable logistic regression, with sex, age, smoking status, hypertension, and chronic obstructive pulmonary disease included in multivariable analysis. This is a preliminary analysis of the first 200 patients. The registry continues to accept new sites and patient data. Findings: Between March 26 and April 12, 2020, 200 patients with COVID-19 and thoracic cancers from eight countries were identified and included in the TERAVOLT registry; median age was 68·0 years (61·8-75·0) and the majority had an Eastern Cooperative Oncology Group performance status of 0-1 (142 [72%] of 196 patients), were current or former smokers (159 [81%] of 196), had non-small-cell lung cancer (151 [76%] of 200), and were on therapy at the time of COVID-19 diagnosis (147 [74%] of 199), with 112 (57%) of 197 on first-line treatment. 152 (76%) patients were hospitalised and 66 (33%) died. 13 (10%) of 134 patients who met criteria for ICU admission were admitted to ICU; the remaining 121 were hospitalised, but were not admitted to ICU. Univariable analyses revealed that being older than 65 years (OR 1·88, 95% 1·00-3·62), being a current or former smoker (4·24, 1·70-12·95), receiving treatment with chemotherapy alone (2·54, 1·09-6·11), and the presence of any comorbidities (2·65, 1·09-7·46) were associated with increased risk of death. However, in multivariable analysis, only smoking history (OR 3·18, 95% CI 1·11-9·06) was associated with increased risk of death. Interpretation: With an ongoing global pandemic of COVID-19, our data suggest high mortality and low admission to intensive care in patients with thoracic cancer. Whether mortality could be reduced with treatment in intensive care remains to be determined. With improved cancer therapeutic options, access to intensive care should be discussed in a multidisciplinary setting based on cancer specific mortality and patients' preference