Negative-Pressure Ventilation in Neuromuscular Diseases in the Acute Setting

Mechanical ventilation started with negative-pressure ventilation (NPV) during the 1950s to assist patients with respiratory failure, secondary to poliomyelitis. Over the years, technological evolution has allowed for the development of more comfortable devices, leading to an increased interest in NPV. The patients affected by neuromuscular diseases (NMD) with chronic and acute respiratory failure (ARF) may benefit from NPV. The knowledge of the available respiratory-support techniques, indications, contraindications, and adverse effects is necessary to offer the patient a personalized treatment that considers the pathology's complexity.

Unusual Periaortic Mediastinal Recurrence of Pulmonary Adenocarcinoma: When Making Diagnosis Is Really Necessary

We report an unusual mediastinal recurrence along descending thoracic aorta during oncologic follow-up in a 47-year-old female smoker issued by lung adenocarcinoma with a history of left lower lobectomy and lingulectomy en bloc followed by adjuvant chemotherapy for stage III A-N2. Regional recurrence occurring along the staple line was suspected and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) combined to PET/CT allowed to reach definitive tissue diagnosis. High focal hypermetabolic activity on PET/CT at the site of suspect recurrence was necessary to check the lesion sampling by EBUS-TBNA.

Penetrating pulmonary injury caused by a steel rod

In stable patients with penetrating thoracic trauma, a careful radiological assessment should be taken into account for a correct surgical management.

Low-dose oral etoposide is an active option for patients with heavily pre-treated thymic epithelial tumors

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Background: Platinum based regimens are used in the first line setting for advanced Thymic Epithelial Tumors (TETs). Angiogenesis plays an important role in TETs: VEGF is overexpressed in TETs, and associated with aggressiveness and advanced stage. Etoposide inhibits angiogenesis in vitro and in vivo by decreasing VEGF production and microvessel density. The aim of this study is to assess the activity of metronomic oral etoposide, with identification of circulating predictive and pharmacodynamics biomarkers. Methods: Patients with advanced platinum pretreated TET referred from 2014 to 2019 at Rare Tumors Reference Center of Naples, were prospectively enrolled in this study. Oral etoposide 50 mg daily for 3 weeks on and 1 week off every 28 days, has been delivered until progression of disease, complete response or unacceptable toxicity. Response rate (RR), progression free survival (PFS), toxicity and ratio between time to etoposide progression (TTPe) and time to previous best treatment progression (TTPp) were evaluated. Serum samples were prospectively obtained from ten patients with simultaneously radiological assessment. cfDNA quantification was assessed using Qubit Fluorometric Quantitation. Results: 21 patients were enrolled: median age 59 years range (41 - 88); 70% male, 60% T (4 B1, 3 B2, 4 B3, 1 B1-B2); 40% had TC. A median of 5 (range 1-9) prior therapy regimens had been administered. Median follow-up since etoposide was 5 years (range 0.5-5). Obtaining an overall response rate of 85%, 3 patients achieved complete response and 15 partial response. Median PFS was 16 months [95%CI 3-60] with respectively a median PFS of 12 for T (95%CI 3-38) and 19 for TC (95%CI 6-60). No grade 3-4 related events occurred, G1-2 myelotoxicity has been registered in 20% of patients. Therapy is still ongoing for 15 patients and all are still alive. Median TTPe was 16 months, TTPp was 9 months and TTPe / TTPp ratio equal to 1.7. The median cfDNA of 8 responder patients, before starting therapy, was 2.2 ng/μl (0.178-5.24), dropping dramatically at radiological response to 0.5 ng/μl (0.323-2.56). 2 out of 3 non-responder patients had a median baseline value of 2.49 ng/μl, increasing to 4.6 ng/μl at progression. Variation of circulating VEGF correlates with radiological response. Conclusions: Taking into account that other antiangiogenic drugs, showing some activity in second and further lines treatment, are very expensive and associated with several side effects, we suggest that low dose oral etoposide might become the preferred treatment option in heavily pretreated TETs.

Multiple variations in pulmonary veins during a thoracoscopic right lower lobectomy: A case report

A knowledge of pulmonary vein anatomy variants allows an appropriate preoperative radiological assessment and safe surgical management of vascular anomalies in patients undergoing major lung resections. In our case, multiple pulmonary vein variations were identified pre- and intraoperatively in a patient undergoing thoracoscopic right lower lobectomy and included superior and common basal veins from the right lower lobe draining separately into the left atrium, middle lobe veins joining the superior segment right lower lobe vein and additional superior segment right lower lobe vein draining directly into the left atrium. The recognition of these anatomical abnormalities in pulmonary veins may help thoracic surgeons avoid surgical complications in patients undergoing anatomical lung resections.

Left lower lobectomy and partial preservation of segmental arteries of left upper lobe: A strategy to avoid pneumonectomy in selected cases

In this article we report two cases of left lower lobe lung cancer undergoing a surgical procedure that allowed the preservation of lung parenchyma and avoided pneumonectomy. The first case concerned a left lower lobe non‐small cell lung cancer with extracapsular spread in a metastatic interlobar lymph node and the second a left lower lobe lung cancer with invasion of the pulmonary artery at the origin of lobar branches to the lower lobe. In both cases, a lung‐sparing surgical treatment was preferred and a left lower lobectomy was performed with division of lingular arteries and the interlobar artery, preserving the remaining arterial branches to the upper lobe.

Management of chest impalement injury

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Impalement injuries are a challenging scenario involving several specialities.

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Surgeons were forced to operate in an even circumstances, not being able to turn the patient in a lateral position.

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The double thoracotomy and the expedient of the haemostatic plug allowed to control bleeding with absolute safety margins.

Presentation of case

We will describe the case of a man who impaled himself on a greenhouse pole by falling off a ladder.

Discussion

The belated radiological exclusion of any spine and neck lesions forced the surgeons to operate with the patient supine and on a spine board, which prevented them from performing the classic thoracotomy and reaching the entry hole in the right scapula area.

Conclusion

A double thoracotomy and the expedient of a haemostatic plug, positioned simultaneously with the extraction of the pole, allowed to control bleeding with absolute safety margins.

Hybrid robotic thoracic surgery for excision of large mediastinal masses

Between April 2016 and October 2017, we retrospectively reviewed all patients undergoing excision of large mediastinal masses using a hybrid robotic thoracic approach at the Unit of Thoracic Surgery of Monaldi Hospital in Naples. The inclusion criteria for this approach were: evident unilateral predominance of the mass; absence of invasion to surrounding structures. Planned conversion to sternotomy was necessary in one patient for tenacious adhesions between the mediastinal goiter and the left innominate vein. In all cases the postoperative course was uneventful. The hybrid robotic approach, adopted in our Unit, consists of a thoracic procedure performed completely with articulated surgical instruments under three-dimensional vision and followed by final extension of a port-site incision to retrieve the voluminous specimen. This approach uses all the advantages of robotic technology that enables to perform a fine dissection in the small space of the anterior mediastinum and at the same time, through the simple extension of a minimally invasive access, avoids the painful sequelae of thoracotomy. In selected cases, with increased experience in robotic surgery, it can be proposed for excision of large mediastinal masses, although a longer follow-up period is necessary to validate our findings.

Antero mediastinal retrosternal goiter: surgical excision by combined cervical and hybrid robot-assisted approach

Most intrathoracic goiters are located in the anterior mediastinum. Surgical resection is usually recommended in case of morbidity associated with the goiter's mass effect or for suspicion of malignancy difficult to diagnose without resection. Intrathoracic goiters are usually resected through a cervical approach, with sternotomy needed in selected cases. We report a case of antero mediastinal retrosternal goiter in old age patient undergoing surgical excision by combined cervical and hybrid robot-assisted approach. All steps of the thoracic procedure were completely performed using the da Vinci robot system with final extension of a port-site incision to extract the specimen. This approach provides more advantages than sternotomy regarding post operative clinical benefits and allows a more accurate surgical resection in the antero-superior mediastinum than conventional thoracoscopy.

Anterior bronchogenic mediastinal cyst as priority procedure for robotic thoracic surgery

We report a case of anterior bronchogenic mediastinal cyst (ABMC) in old age patient underwent Robotic Thoracic Surgery (da Vinci Surgical System). Video-assisted thoracoscopic surgery (VATS) represents the routine approach in posterior bronchogenic mediastinal cyst, but some limitation for resection of mediastinal mass located in the anterior mediastinum has been reported. The introduction of da Vinci surgical system has overcome the surgical limits of VATS as two dimensional vision (2D) and the use of long rigid instruments with poor maneuverability in case of fine dissection.

Anterior mediastinal solitary fibrous tumor resection by da Vinci® Surgical System in obese patient

INTRODUCTION

Solitary fibrous tumors are uncommon soft tissue tumors initially reported only in the pleura but, in recent years, they have been described at many extra pleural sites, such as mediastinum. The treatment of choice is the extensive surgical resection that is curative for most benign lesions.

PRESENTATION OF THE CASE

We present the case of solitary fibrous tumor of the anterior mediastinum in obese patient (BMI: 34.3) undergoing complete surgical resection by robotic-assisted thoracoscopic surgery with da Vinci^® Surgical System.

DISCUSSION/CONCLUSION

Robotic-assisted thoracoscopic surgery with da Vinci^® Surgical System is an interesting option for obese patient, at higher risk for deep sternal wound infection.

Diagnostic value of carbohydrate antigens in supernatants and sediments of pleural effusions

A panel of tumour markers including carcinoembryonic antigen (CEA), carbohydrate antigen (Ca)15-3, Ca125 and Ca19-9 were measured in the lysate of sediments and in the supernatants of pleural effusions of patients with benign and malignant disease. The tumour markers were also measured in the serum of the same patients. Of these patients, 32 had benign diseases (12 trasudative effusions associated with cirrhosis and 20 with non-malignant exudates: 12 pleuritis and 8 other inflammations) and 103 had malignant effusions (37 breast cancers, 29 lung cancers, 10 ovary cancers, 6 kidney cancers, 11 mesotheliomas and 10 lymphomas). We showed the highest level of CEA in pleural effusions of lung cancer followed by that in pleural effusions of breast cancer; whereas Ca15-3 was very high in the pleural effusions of breast and lung cancer. Concerning the lysate of sediment, CEA was high in the pleural effusions of patients with lung cancer and Ca15-3 in those of patients with breast cancer. The other markers are much less useful. For the remaining tumours, none of the markers tested appear to aid in the diagnosis of disease. In conclusion, our data suggest that the combined determination of tumour markers on supernatants and sediments of pleural effusion may provide additional information on the nature of pleural effusion, especially for cases with negative cytology.

Gelatinolytic activities (matrix metalloproteinase-2 and -9) and soluble extracellular domain of Her-2/neu in pleural effusions

Matrix metalloproteinases (MMPs) are proteolytic enzymes that are implicated in multiple stages of cancer progression including invasion and metastasis. MMPs exert these effects by cleaving a diverse group of substrates, which include not only structural components of the extracellular matrix, but also growth factor receptors. By gelatin zymography we verified MMP activity in the pleural effusions of patients with benign and malignant disease. Of these patients, 32 had malignant pleural effusion, consisting of 20 breast cancer, 6 non-small cell lung carcinoma, 4 ovarian carcinoma, and 2 colonic adenocarcinoma, and 10 had benign pleural effusion (5 pleurisy and 5 cirrhosis). Zymography showed the constant presence of a substantial amount of MMP-2 in all samples analyzed, whereas MMP-9 was present to lesser quantities. MMP-2 activity was enhanced in pleural effusions from patients with benign diseases compared with cancer patients. MMP-9 was present in 59% of cancer patients and the lytic activity was enhanced in pleurisy and absent in cirrhosis. Furthermore, we determined the pleural effusion levels of the soluble extracellular domain of HER-2/neu. The levels of HER-2/neu ECD were above the cut-off value in breast cancer patients. No correlation between gelatinolytic activities and high HER-2/neu ECD values was found.