Endobronchial ultrasound-transbronchial needle aspiration: effectiveness and accuracy in non-small cell lung cancer staging

INTRODUCTION

Endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) has a cardinal role in the diagnosis and staging of non-small cell lung cancer (NSCLC), providing an accurate nodal staging in a less invasive way than surgical biopsy. The aim of this study was to assess the diagnostic accuracy of EBUS-TBNA in the pre-operative NSCLC mediastinal staging, as well as to evaluate EBUS-TBNA specificity and sensibility in our cohort.

METHODS

We retrospectively analyzed data of NSCLC patients who underwent EBUS-TBNA followed by major pulmonary resection between January 2020 and December 2022. EBUS-TBNA was performed in patients with NSCLC (central T ≤ 3 cm, peripheral/central T > 3 cm), following the ESTS guidelines. The target nodes were selected on the basis of their radiologic/metabolic characteristics. Each procedure was conducted together with rapid on-site cytological evaluation (ROSE).

RESULTS

Twenty-five patients were included (M/F = 17/8). At least three needle passages on each target lymph node were performed. No complications during or after the procedures occurred. We found a 100% correspondence between ROSE on the sampled nodes and postoperative pathologic findings. An upstaging occurred in three cases (12%) because of the involvement of stations 5 and 6 (not accessible via EBUS), while the only case of downstaging (N2 → N0, 4%) was probably due to intercurrent neoadjuvant chemotherapy. In all cases, EBUS-TBNA has proved to achieve a diagnostic procedure on the target nodes.

CONCLUSIONS

EBUS-TBNA is a safe and effective procedure that offers high sensitivity and specificity when performed together with ROSE, which improves the accuracy of sampling. Doubt on nodal stations 5 and 6 involvement should be settled by other techniques.

TNM Staging System in Thymoma: A Critical Appraisal?

Thymomas are rare tumors of the anterior mediastinum with peculiar clinical and pathological features. They have been deeply analyzed by pioneer authors, who strictly linked their name to the main pathological and staging classifications. Before the latest edition of the WHO classification of thymic epithelial tumors, the history of thymoma pathological classification inherited the name of the pathologists who systematically addressed the issue, from Levine-Rosai to Muller-Hermelink. Similarly, the thymoma staging system is intimately related to the name of two surgeons, Masaoka and Koga, who historically dealt with this disease. More recently, the traditional tumor-nodes-metastasis (TNM) system has been developed for the staging of this condition, in a rational attempt to put thymomas in conformity with the other solid tumors. The efforts of the International Thymic Malignancies Interest Group (ITMIG) and the Thymic Domain of the Staging and Prognostic Factors Committee (TD-SPFC) of the International Association for the Study of Lung Cancer (IASLC) resulted in the TNM classification of thymic tumors, which have been included in the eighth edition of the American Joint Committee on Cancer's (AJCC) Cancer Staging Manual. Herein, we report a narrative review of the evolution of the thymic epithelial tumors (TET) staging system and present a critical appraisal of the actual TNM classification compared with the historical Masaoka-Koga classification, with special focus on the proposal for the ninth edition of the TNM, expected in 2024.

Surgical treatment of tracheal stenosis during Covid-19 era: a single-center experience and lessons learnt on the field

SARS-CoV2 outbreak led to several healthcare system challenges, especially concerning respiratory support to Covid-19 patients. In the first 2 years of pandemic (2020-2021), we assisted to a marked increase of post-invasive mechanical ventilation (IMV) tracheal stenosis incidence, many of them requiring surgical treatment, namely resection and primary end-to-end anastomosis. Our aim is to describe our experience during the abovementioned biennium, focusing on postoperative outcomes of patients who have had Covid-19 ("post-Covid"). We retrospectively collected pre-, intra- and postoperative data on all patients who underwent tracheal surgery for benign stenosis in our Unit from May 2020 to October 2021, including previous Covid-19. Comparison between "post-Covid-19" and "non-Covid-19" groups' outcomes was then performed. Patients were 9 males and 6 females, and mean age was 57.4 ± 13.21 years. Nine patients had previous Covid-19 (60%). All patients underwent multidisciplinary preoperative evaluation. Almost every operation was conducted by cervicotomy, and the mean length of the resected specimen was 23.9 ± 6.5 mm. Postoperative complications were: dysphonia (3 cases), wound infection (1), bleeding (1), ab-ingestis pneumonia (1), anastomosis dehiscence (2), and stenosis recurrence (1). Thirty-day mortality rate was 6.7% (1 patient). No significant differences between "post-Covid-19" and "non-Covid-19" groups were identified. Pathology revealed, in 5 "post-Covid-19" patients, signs of vasculitis or perivascular inflammatory infiltrate. Tracheal stenosis' surgical treatment has always been known as a challenging procedure because of high perioperative morbidity and mortality rates. Our experience shows that previous Covid-19 and ongoing pandemic did not significantly affect perioperative outcomes of patients who underwent tracheal resection and primary end-to-end anastomosis in a high-volume Center and after multidisciplinary workup.

Unradical Surgery for Locally-Advanced Thymoma: Is it time to evolve Perspectives?

OBJECTIVES

Nearly-one-third of thymomas are locally-advanced at diagnosis. The traditional dogma that surgery is justified in case a complete resection can be achieved has remained unmovable until today. This study aimed to investigate feasibility and oncologic efficacy of incomplete resection for locally-advanced thymomas in a contest of multimodality therapy.

MATERIALS AND METHODS

A retrospective analysis was conducted using data of prospectively maintained thymomas database in a single high-volume centre. Data on 285 consecutive patients undergoing surgery for stage III and IVa thymomas between 1995 and 2019 were reviewed. Patients who underwent incomplete resection with curative-intent (removal of at least 90% of tumour burden) were included. Long-term outcomes and predictors of cancer-specific survival (CSS) and progression-free survival (PFS) were analyzed. Secondary endpoint was to assess adjuvant therapy efficacy.

RESULTS

The study included 79 patients, 60 with microscopic residual tumour (76%, R1) and 19 with macroscopic residual disease (24%, R2). Masaoka-Koga stage was: III in 41 patients (52%) and IVa in 38 (48%). Histology was B2-thymomas (n = 31, 39.2%) followed by B3 (n = 27, 34.2%). Five- and 10-years CSS was 88% and 80%. Seventy patients (90%) underwent adjuvant treatment; they showed CSS comparable to radical resected patients (5-years: 89.1% vs 98.9%, respectively; 10-years: 81.8% vs 92.7%, respectively, p = 0.43). The site of residual disease, Masaoka-Koga stage and WHO histology did not affect prognosis. Stepwise multivariable analysis confirmed adjuvant therapy as a favourable CSS prognostic factor (HR, 0.51; 95% CI, 0.33-0.79, p = 0.003). Stratifying by subgroups, R2-patients who received postoperative chemo(radio)therapy (pCRT) showed a significantly better prognosis than R2-patients treated by consolidation radiotherapy alone (10-years CSS: 60%, p < 0.001).

CONCLUSION

In locally-advanced thymomas, whenever a radical surgery cannot be achieved, incomplete resection has proved to be effective in a contest of multimodality strategy, independently of WHO histology, Masaoka-Koga stage and site of residual disease.

Intraoperative prevention and conservative management of postoperative prolonged air leak after lung resection: a systematic review

Background

Prolonged air leak (PAL) due to an alveolar-pleural fistula (APF) is the most common complication after lung surgery. PAL is associated with an increased risk of morbidity and mortality, a longer chest tube duration, hence a prolonged hospitalization. Management of PAL may be challenging, and the thoracic surgeon should be aware of the possible therapeutic strategies.

Methods

A systematic literature review was performed in PubMed, Cochrane Library, EMBASE, Ovid and Google Scholar. Title, abstract and full-text screening was performed, followed by structured data extraction, methodological quality assessment and Cochrane risk of bias assessment. Inclusion criteria were: case-control studies/randomized controlled trials (RCTs) comparing the new tested method with the standard of care to manage PAL after lung surgery; PAL due to APF; at least 10 patients; English-written papers.

Results

A total of 942 initial papers from literature search, resulted in 43 papers after the selection. This systematic review found that the use of intraoperative measures as surgical sealants or pleural tenting, as well as a proper management of the chest drain and the use of blood patch or sclerosant agents seem to reduce postoperative air leaks incidence and/or duration and length of chest drain stay and hospitalization.

Conclusions

Different measures have been described in literature to manage or prevent postoperative PAL. Most of them seem to be safe and efficient if compared to the "wait and see" strategy, even if large comparative studies that standardize the intra- and post-operative management of APF after lung resection are lacking and, actually, hard to conceptualize. However, there is a large consensus on the value of a preoperative PAL-risk stratification and on the necessity of tailoring PAL management or prevention's strategy and its timing on each patient's features.

Cold coagulation in thoracoscopic treatment of primary pneumothorax: a comparison with apicectomy

OBJECTIVES

Primary spontaneous pneumothorax is a common disease, whose surgical treatment is still enigmatic in terms of timing and technique. Herein, we reported our experience with the parenchymal-sparing technique via cold coagulation (CC), in comparison to stapler apicectomy (SA).

METHODS

We retrospectively collected data of all patients with apical blebs or <2 cm bullae treated with minimally invasive surgery for recurrent or persistent spontaneous pneumothorax, from 2010 to 2020. Two different surgical techniques were used: SA and the parenchymal-sparing CC of the apex. Perioperative and long-term results were analysed and compared.

RESULTS

Out of 177 patients enrolled, 77 patients (CC group) underwent cold-coagulation of the apex while 100 patients (SA group) were treated with SA. Two groups were comparable in terms of age, surgical indication, intraoperative findings and affected side. CC group had a mean operative time of 43.2 min (standard deviation ± 19.5), shorter than SA group with 49.3 min (standard deviation ± 20.1, P-value: 0.050). Complication rate was significantly different between 2 groups, 5 (7%) and 16 (16%), for the CC and SA groups, respectively (P: 0.048), even if not in terms of prolonged postoperative air leak (P: 0.16). During the follow-up, 13 homolateral recurrences were reported: 2 (3%) in group CC and 11 (11%) in group SA; with a significant difference (P: 0.044). All reinterventions (postoperative prolonged air leak and recurrences) required an SA.

CONCLUSIONS

Parenchymal-sparing technique through CC of apical blebs and bullae is an effective treatment for primary spontaneous pneumothorax and guarantees a good immediate lung sealing, despite stapling still represents the choice treatment in complex cases.

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 radical surgery.

Thymectomy in Myasthenic Patients With Thymoma: Killing Two Birds With One Stone

BACKGROUND

Thymoma and myasthenia gravis share several pathogenetic aspects including the role of surgery as a therapeutic option. Extended thymectomy is associated with excellent survival and good local control, especially in early stages, and its role for the neurologic disease has been recently validated. The aim of this study is evaluating oncologic and neurologic outcomes of myasthenic patients with thymoma who underwent extended thymectomy.

METHODS

We retrospectively collected surgical, oncologic, and neurologic data of all myasthenic patients with thymoma who underwent extended thymectomy at our department from January 1994 to December 2016. Clinical and pathologic data, neurologic remission rate, and overall survival and disease-free interval were analyzed.

RESULTS

In all, 219 patients underwent extended thymectomy. The B2 histotype was the most represented thymoma (24.2%), and the most prevalent pathologic Masaoka stage was IIB (37.9%). The overall survival and disease-free survival were statistically different between early stage and advanced stage. During the surveillance, 33 patients (15.1%) had recurrences, treated in 21 cases with iterative surgery. Regarding neurologic outcomes, 75 patients (34.2%) reached a complete stable remission, 84 (38.4%) a pharmacologic remission, 51 (23.3%) had an improvement of their symptoms, and in 9 patients (4.1%) myasthenia was unchanged or worsened.

CONCLUSIONS

Surgery is a cornerstone in the treatment of patients with both thymoma and myasthenia gravis. Extended thymectomy, as proposed by Masaoka, offers considerable oncologic outcomes with an excellent survival and low recurrence rate of thymoma; moreover, surgery leads to remarkable neurologic results.

Prognostic factors for survival in advanced thymomas: The role of the number of involved structures

BACKGROUND AND OBJECTIVES

The Masoka-Koga and tumor node metastases staging systems for thymoma are based on structures involved, but the prognostic role of the number of infiltrated/involved structures is still debated. We analyzed the prognostic role of involved structures and their combinations in locally advanced thymomas patients.

METHODS

Data on 174 surgically treated locally advanced thymoma patients from 1/01/1990 to 31/12/2015 were reviewed. Clinical and pathological characteristic, involved structures, number of involved structures and different combinations were correlated to cancer specific survival (CSS) using Kaplan-Meier product-limit method.

RESULTS

Five and 10-year CSS was 92% and 87%. Masaoka Stage 3 (p < 0.001), absence of pericardial involvement (p = 0.001), number of involved structures (p = 0.018), R0 (p < 0.001) and adjuvant radiotherapy (p = 0.008) were favorable prognostic CSS factors. A significant better prognosis was present in ≤2 involved structures vs >2 involved structures (5- and 10-year CSS: 95% and 93% vs. 80% and 51%). Multivariable analysis confirmed as independent prognostic factor R0 (p = 0.033, hazard ratio [HR]: 0.093, 95% confidence interval [CI] 0.010-0.827) and number of involved structures (p = 0.046, HR: 0.187, 95% CI: 0.036-0.968). In Masaoka Stage 3, patients with ≤2 involved structures had a significant better CSS than patients with >2 (10-year CSS: 98% vs. 73%, p = 0.008).

CONCLUSIONS

The number of involved structures and the concomitant involvement of the pericardium seems to be associated with a poor prognosis in surgically treated advanced thymoma patients.

The International Thymic Malignancy Interest Group Classification of Thymoma Recurrence: Survival Analysis and Perspectives

INTRODUCTION

The International Thymic Malignancy Interest Group (ITMIG) classifies thymoma recurrences on the basis of the topographic location, but its effectiveness in prognosis prediction has not been well investigated yet. Aims of this study are to analyze survival outcome of patients surgically treated for thymoma recurrence according to the ITMIG recurrence classification and to investigate possible alternatives.

METHODS

From January 1, 1990, to January 7, 2017, data on 135 surgically treated patients for thymoma recurrence from three high-volume centers were collected and retrospectively analyzed. Patients were classified according to the ITMIG classification as local, regional, and distant. The ITMIG classification and alternative classifications were correlated to overall survival (OS).

RESULTS

According to the ITMIG classification, recurrence was local in 17 (12.5%), regional in 97 (71.8%), and distant in 21 (15.7%) patients, with single localization in 38 (28.2%) and multiple localizations in 97 (71.8%). The 5- and 10-year OS were 79.9% and 49.7% in local, 68.3% and 52.6% in regional, and 66.3% and 35.4% in distant recurrences, respectively, but differences were not statistically significant (p = 0.625). A significant difference in survival was present considering single versus multiple localizations: 5- and 10-year OS of 86.2% and 81.2% versus 61.3% and 31.5% (p = 0.005, hazard ratio = 7.22, 95% confidence interval: 0.147-0.740), respectively. Combining the localization number with the recurrence site, ITMIG locoregional single recurrence had a statistically significant better survival compared with patients with ITMIG locoregional multiple recurrence or ITMIG distant recurrence (p = 0.028). Similarly, a significant difference was present considering intrathoracic single versus intrathoracic multiple versus distant recurrence (p = 0.024).

CONCLUSIONS

The ITMIG classification for thymoma recurrence did not have significant survival differences comparing local, regional, and distant recurrences. Integrating this classification with the number of the localizations may improve its effectiveness in prognosis prediction.

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

Surgical treatment of pleural recurrence of thymoma: is hyperthermic intrathoracic chemotherapy worthwhile?

OBJECTIVES

Recurrence of thymoma is described in 10-30% of cases after surgical resection. Iterative surgery for thymoma pleural relapses (TPRs) is often part of a multimodal treatment. Hyperthermic intrathoracic chemotherapy (HITHOC) following macroscopic radical surgery is an option that combines the effects of mild hyperthermia with those of chemotherapeutic agents. We evaluated the effectiveness of surgery + HITHOC, compared with surgery alone, in the treatment of TPR.

METHODS

We retrospectively collected data of all patients who underwent surgery for TPR in our centre from 2005 to 2017. Relapses were treated by partial pleurectomy with radical intent, followed by HITHOC when not contraindicated. Patients were divided into 2 groups: surgery + HITHOC and surgery alone. We collected demographic and clinical data and analysed postoperative results together with oncological outcomes.

RESULTS

Forty patients (27: surgery + HITHOC, 13: surgery alone), mean age 49.8 (±13.7) years, were included in this study. There were no perioperative deaths. We experienced 33.3% perioperative morbidity in the surgery + HITHOC group compared with 23.1% in the surgery alone group (P = 0.71). The overall survival rate was comparable between the 2 groups (P = 0.139), whereas the local disease-free interval was 88.0 ± 15 months in the surgery + HITHOC group and 57 ± 19.5 months in the surgery alone group (P = 0.046). The analysis of factors affecting the outcomes revealed that radical surgery is related with a better survival rate whereas the local disease-free interval was significantly influenced by HITHOC.

CONCLUSIONS

The safety and feasibility of HITHOC in the treatment of TPR are already known, even if it should be reserved for selected patients. Surgery + HITHOC seems to be associated with a longer local disease-free time compared to surgery alone.

Chest wall reconstruction with a novel titanium mesh after partial sternectomy for chondrosarcoma

Primitive malignant sternal tumours are extremely rare and represent less than 1% of all chest wall tumours. A combination of radical surgery and accurate reconstruction is mandatory to ensure adequate stability and to reduce paradoxical movement. To date, this is one of the few reports on a successful sternal reconstruction using a rigid titanium mesh to restore the skeletal integrity, which was then covered by bilateral muscular flaps.

Diaphragm and lung-preserving surgery with hyperthermic chemotherapy for malignant pleural mesothelioma: A 10-year experience

BACKGROUND

The best surgical treatment for malignant pleural mesothelioma is still under a debate, but recent evidence points toward a less-invasive approach to reduce morbidity and mortality. We reported our 10-year experience of a limited surgical approach associated with hyperthermic intrathoracic chemotherapy (HITHOC).

MATERIAL AND METHODS

Between 2005 and 2014, patients with epithelioid or biphasic malignant pleural mesothelioma were treated with lung-diaphragm-pericardium-sparing pleurectomy associated with double-drug HITHOC; at least 3 cycles of adjuvant chemotherapy were then administered. The primary outcome examined was the feasibility of the procedure, whereas secondary outcomes were overall survival and disease-free interval.

RESULTS

Among 49 patients, 41 were male. Median age was 68 years (35-76 years). Histology was epithelioid in 43 cases. Pathologic stage I, II, III, and IV occurred in 12, 14, 20, and 3 cases, respectively. No intraoperative complications or postoperative mortality occurred, whereas morbidity rate was 46.9%. Median hospital stay was 8 days (5-45 days). Actuarial median overall survival was 22 months and a 1-, 2-, and 5-year survival accounted for 79.6%, 45.7%, and 9.9%, respectively. Disease-free survival after surgery was 62%, 37.5%, and 18.5% at 1, 2, and 5 years, respectively. Risk factors analysis for overall survival confirmed a significant role for early stages, epithelioid histology, and fibrinogen serum levels.

CONCLUSIONS

Cytoreductive surgery associated with HITHOC and adjuvant chemotherapy appears feasible and safe, with no mortality and low morbidity. Preserving lung and diaphragmatic function might warrant an acceptable long-term outcome.

Is less also better? A single-institution experience on treatment of early stage Malignant Pleural Mesothelioma

OBJECTIVES

No clear evidence of which surgical procedure should be performed for early stage mesothelioma is available to date. We analyzed our 10-year experience in the treatment of early stage mesothelioma with surgery and Hyperthermic IntraTHOracic Chemotherapy.

METHODS

We retrospectively analyzed all cases of histologically proven epithelioid or biphasic IMIG stage I and II mesothelioma that we operated between 2005 and 2014. We performed an open pleurectomy and partial decortication of any visible lesion on the visceral pleura in all cases and both diaphragm and pericardium were always spared; Hyperthermic IntraTHOracic Chemotherapy was ran using Cisplatin 80 mg/m² and Doxorubicin 25 mg/m² at a target temperature of 42.5 °C for 60 min.

RESULTS

We operated on 26 patients (23 male and 3 female); epithelioid tumor was diagnosed in 23 cases. Twelve patients were in IMIG stage I and 14 in IMIG stage II; median overall survival for all patients, stage I and II were 35.6, 46 and 23 months respectively and disease free survival was 18, 18 and 16 months respectively. Our results for stage I were better than those reported in literature and were similar for stage II. We observe no 30- and 90- mortality and the rate of severe complication (all CTCAE stage 3) were 30%; the median postoperative stay was 7.5 days.

CONCLUSIONS

Our lung sparing approach for the treatment of pleural mesothelioma in early stages allows promising long term outcomes with a complete sparing of pulmonary and diaphragmatic function. Larger studies are needed to confirm our good results.

Lymph node dissection after pulmonary resection for lung cancer: a mini review

An accurate staging of a malignant disease is imperative in order to plan pre- and post-operative therapy, define prognosis and compare studies. According to the European Society of Thoracic Surgeons (ESTS) guidelines a systematic lymph node (LN) dissection is recommended in all cases of pulmonary resection for non-small cell lung cancer (NSCLC). The current lung cancer staging system considers the lymphatic stations involved but not the number of LNs. Up to date, published scientific studies on hilar and mediastinal lymphadenectomy mainly have been regarded the type of LN dissection procedure after pulmonary resection (selected LN biopsy, LN sampling, systematic nodal dissection, lobe specific nodal dissection and extended LN dissection) focusing particularly on the comparison between mediastinal LN dissection (MLND) and mediastinal LN sampling (MLNS). Recently, further investigations have been concentrated on surgical approach (videothoracoscopic vs. thoracotomic approach) used to perform pulmonary resection and following LN dissection in order to achieve a complete mediastinal lymphadenectomy. This short synthesis aims to present the current experiences in this setting.

Pleural recurrence of thymoma: surgical resection followed by hyperthermic intrathoracic perfusion chemotherapy†

OBJECTIVES

Recurrences of thymoma are described in 10-30% of cases up to 10 years after surgical resection. Herein we report our experience with surgical removal of pleural recurrences followed by hyperthermic intrathoracic perfusion chemotherapy (HITHOC).

METHODS

We prospectively collected data of patients with pleural recurrence of thymoma who underwent surgery followed by HITHOC. After thoracotomy had been closed, drainages were connected to a dedicated perfusion machine, pleural space was filled with saline solution, progressively heated up to 42.5°C. At this time, chemotherapeutic agents (Doxorubicin and Cisplatin) were injected and perfusion lasted 60 min.

RESULTS

In the period 2005-2012, 13 consecutive patients have been treated (8 males, 5 females, mean age 46 years). Initial Masaoka-Koga stage was 2 IIa, 5 IIb, 5 III, 1 IVa. Disease-free interval was 47.2 months on average [standard deviation (SD): 25.5]. Nine patients presented paraneoplastic syndromes (8 myasthenia gravis and 1 red cell aplasia). Complete resection was achieved in all cases except one. HITHOC was successfully performed in all cases and no signs or symptoms of toxicity were recorded in the perioperative period. With a mean follow-up period of 64.6 months (SD: 32.5), 1 patient died for toxicity following systemic chemotherapy, another one died disease-free, 4 patients developed pleural relapses (2 ipsilateral, 2 contralateral) and 1 mediastinal and abdominal nodal metastases. Mean survival was 58 months [SD: 34.4), median survival by the Kaplan-Meier method was not reached while 5-year actuarial survival was 92%.

CONCLUSIONS

HITHOC was shown to be feasible and safe. In terms of efficacy, it seems promising but multicentre studies and a longer follow-up period are required to ascertain its effectiveness.