Background
The role of video-assisted thoracoscopic surgery for the treatment of non-small-cell lung cancer after neoadjuvant chemotherapy remains controversial. The aim of this study is to ...demonstrate the reliability of video-assisted lobectomy compared to the open approach by evaluating perioperative and long-term outcomes.
Methods
In this retrospective, multicentric study from January 2010 to December 2018, we included all patients with non-small-cell lung cancer who underwent lobectomy through the video-assisted or open approach after neoadjuvant chemotherapy. The perioperative outcomes, including data concerning the feasibility of the surgical procedure, the occurrence of any medical and surgical complications and long-term oncological evidence, were collected and compared between the two groups. To minimize selection bias, propensity score matching was performed.
Results
A total of 286 patients were enrolled: 193 underwent thoracotomy lobectomy, and 93 underwent VATS lobectomy. The statistical analysis showed that surgical time (
P
< 0.001), drainage time (
P
< 0.001), days of hospitalization (
P
< 0.001) and VAS at discharge (
P
= 0.042) were lower in the VATS group. The overall survival and disease-free survival were equivalent for the two techniques on long-term follow-up.
Conclusions
VATS lobectomy represents a valid therapeutic option in patients affected by non-small-cell lung cancer after neoadjuvant chemotherapy. The VATS approach in our experience seems to be superior in terms of the perioperative outcomes, while maintaining oncological efficacy.
The hypothesis to use microRNAs (miRNAs) circulating in the blood as cancer biomarkers was formulated some years ago based on promising initial results. After some exciting discoveries, however, it ...became evident that the accurate quantification of cell-free miRNAs was more challenging than expected. Difficulties were linked to the strong impact that many, if not all, pre- and post- analytical variables have on the final results. In this study, we used currently available high-throughput technologies to identify miRNAs present in plasma and serum of patients with breast, colorectal, lung, thyroid and melanoma tumors, and healthy controls. Then, we assessed the absolute level of nine different miRNAs (miR-320a, miR-21-5p, miR-378a-3p, miR-181a-5p, miR-3156-5p, miR-2110, miR-125a-5p, miR-425-5p, miR-766-3p) in 207 samples from healthy controls and cancer patients using droplet digital PCR (ddPCR) technology. We identified miRNAs specifically modulated in one or more cancer types, according to tissue source. The significant reduction of miR-181a-5p levels in breast cancer patients serum was further validated using two independent cohorts, one from Italy (n = 70) and one from US (n = 90), with AUC 0.66 and 0.73 respectively. This study finally powers the use of cell-free miRNAs as cancer biomarkers and propose miR-181a-5p as a diagnostic breast cancer biomarker.
During one-lung ventilation (OLV), titrating the positive end-expiratory pressure (PEEP) to target a low driving pressure (∆P) could reduce postoperative pulmonary complications. However, it is ...unclear how to conduct PEEP titration: by stepwise increase starting from zero PEEP (PEEP
INCREMENTAL
) or by stepwise decrease after a lung recruiting manoeuvre (PEEP
DECREMENTAL
). In this randomized trial, we compared the physiological effects of these two PEEP titration strategies on respiratory mechanics, ventilation/perfusion mismatch and gas exchange. Patients undergoing video-assisted thoracoscopic surgery in OLV were randomly assigned to a PEEP
INCREMENTAL
or PEEP
DECREMENTAL
strategy to match the lowest ∆P. In the PEEP
INCREMENTAL
group, PEEP was stepwise titrated from ZEEP up to 16 cm H
2
O, whereas in the PEEP
DECREMENTAL
group PEEP was decrementally titrated, starting from 16 cm H
2
O, immediately after a lung recruiting manoeuvre. Respiratory mechanics, ventilation/perfusion mismatch and blood gas analyses were recorded at baseline, after PEEP titration and at the end of surgery. Sixty patients were included in the study. After PEEP titration, shunt decreased similarly in both groups, from 50 39–55% to 35 28–42% in the PEEP
INCREMENTAL
and from 45 37–58% to 33 25–45% in the PEEP
DECREMENTAL
group (both p < 0.001 vs baseline). The resulting ∆P, however, was lower in the PEEP
DECREMENTAL
than in the PEEP
INCREMENTAL
group (8 7–11 vs 10 9–11 cm H
2
O; p = 0.03). In the PEEP
DECREMENTAL
group the PaO
2
/ FIO
2
ratio increased significantly after intervention (from 140 99–176 to 186 152–243, p < 0.001). Both the PEEP
INCREMENTAL
and the PEEP
DECREMENTAL
strategies were able to decrease intraoperative shunt, but only PEEP
DECREMENTAL
improved oxygenation and lowered intraoperative ΔP.
Clinical trial number
NCT03635281; August 2018; “retrospectively registered”
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.
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.
AIM：To study the short-term outcome of patients treated with laparoscopic right colectomy and how intracorporeal anastomosis has improved the outcome.METHODS：We retrospectively examined all patients ...affected by colorectal cancer who underwent a laparoscopic right colectomy between January 2006 and December 2010 in our department.Our evaluation criteria were：diagnosis of colorectal carcinoma at presurgical biopsy,elective surgery,and the same surgeon.We excluded：emergency surgery,conversions from laparotomic colectomy,and other surgeons.The endpoints we examined were：surgical time,number of lymph nodes removed,length of stay（removal of nasogastric tube,bowel movements,gas evacuation,solid and liquid feeding,hospitalization）,and major complications.Seventy-two patients were divided into two groups：intracorporeal anastomosis（39 patients）and extracorporeal anastomosis（33 patients）.RESULTS：Significant differences were observed between intracorporeal vs extracorporeal anastomosis,respectively,for surgical times（186.8 min vs 184.1 min,P 〈 0.001）,time to resumption of gas evacuation（3 d vs 3.5 d,P 〈 0.001）,days until resumption of bowel movements（3.8 d vs 4.9 d,P 〈 0.001）,days until resumption of liquid diet（3.5 d vs 4.5 d,P 〈 0.001）,days until resuming a solid diet（4.6 d vs 5.7 d,P 〈 0.001）,and total hospitalization duration（7.4 d vs 8.5 d,P 〈 0.001）.In the intracorporeal group,on average,19 positive lymph nodes were removed;in the extracorporeal group,on average,14 were removed P 〈 0.001）.Thus,intracorporeal anastomosis for right laparoscopic colectomy improved patient outcome by providing faster recovery of nutrition,faster recovery of intestinal function,and shorter hospitalization than extracorporeal anastomosis.CONCLUSION：Short-term outcomes favor intracorporeal anastomosis,confirming that a less traumatic surgical approach improves patient outcome.
Despite recent technological innovations and the development of minimally invasive surgery, esophagectomy remains an operation burdened with severe postoperative complications. Fluorescence imaging, ...particularly using indocyanine green (ICG), offers the ability to address a number of issues faced during esophagectomy. The three main indications for the intraoperative use of ICG during esophagectomy are visualization of conduit vascular supply, allow identification of sentinel nodes and visualization of the thoracic duct. The purpose of this mini review is to present an overview of current practice in fluorescence imaging utilizing ICG during esophagectomy, as well as to demonstrate how this technology can guide lymphadenectomy and reduce surgical morbidity such as anastomotic leaking and chylothorax.
Objective. There are limited data for estimating the risk of early discharge following thoracoscopic lobectomy. The objective was to identify the factors associated with a short length of stay and ...verify the influence of these variables in uncomplicated patients. Methods. We reviewed all lobectomies reported to the Italian VATS Group between January 2014 and January 2020. Patients and perioperative characteristics were divided into two subgroups based on whether or not they met the target duration of stay (≤ or >4 days). The association between preoperative and intraoperative variables and postoperative length of stay (LOS) ≤4 days was assessed using a stepwise multivariable logistic regression analysis to identify factors independently associated with LOS and factors related to LOS in uncomplicated cases. Results. Among 10,240 cases who underwent thoracoscopic lobectomy, 37.6% had a hospital stay ≤4 days. Variables associated with LOS included age, hospital surgical volume, Diffusion Lung CO % (81 69−94 vs. 85 73−98), Forced Expiratory Volume (FEV1) % (92 79−106 vs. 96 82−109), operative time (180 141−230 vs. 160 125−195), uniportal approach (571 9% vs. 713 18.5%), bioenergy sealer use, and pain control through intercostal block or opioids (p < 0.001). Except for FEV1 and blood loss, all other factors emerged significantly associated with LOS when the analysis was limited to uncomplicated patients. Conclusions. Demographic, clinical, and surgical variables are associated with early discharge after thoracoscopic lobectomy. This study indicates that these characteristics are associated with early discharge. This result can be used in association with clinical judgment to identify appropriate patients for fast-track protocols.
Bronchial carcinoids (BCs) are rare tumors originating from endocrine cells dispersed in the respiratory epithelium. It has been previously demonstrated that everolimus, or RAD001, an mTOR inhibitor, ...has potent antiproliferative effects in human endocrine tumors. Our aim was to evaluate the possible antiproliferative effects of everolimus in human BCs in primary culture. We collected 24 BCs that were dispersed in primary cultures, treated without or with 1 nM–1 μM everolimus, 10 nM SOM230 (pasireotide, a somatostatin receptor multiligand), and/or 50 nM IGF1. Cell viability was evaluated after 48 h, and chromogranin A (CgA) as well as vascular endothelial growth factor (VEGF) secretion was assessed after 8 h incubation. Somatostatin receptors, mTOR, and AKT expression were investigated by quantitative PCR. We found that in 15 cultures (67.5%), everolimus significantly reduced cell viability (by ∼30%; P<0.05 versus control), inhibited p70S6K activity (−30%), and blocked IGF1 proliferative effects. Everolimus also significantly reduced CgA (by ∼20%) and VEGF (by ∼15%) secretion. Cotreatment with SOM230 did not exert additive effects on cell viability and secretory activity. AKT expression was similar in responder and nonresponder tissues, while mTOR expression was significantly higher in the responder group, which was characterized by higher CgA plasma levels and bigger tumors with higher mitotic index and angiogenesis. Our data demonstrate that everolimus reduces VEGF secretion and cell viability in BCs with a mechanism likely involving IGF1 signaling, suggesting that it might represent a possible medical treatment for BCs.
Aims: Mucus expectoration is a common feature of chronic obstructive pulmonary disease (COPD). MUC5AC and MUC5B, the major mucins, are released predominantly from submucosal glands in the central ...airways. The aim was to investigate gland size and MUC5AC and MUC5B expression in bronchial rings from smokers with COPD compared with control groups.
Methods and results: Bronchial rings from 10 non‐smoking subjects, 20 smokers with normal lung function and 20 smokers with COPD were studied. Periodic acid–Schiff (PAS) and Alcian blue histochemistry and MUC5AC and MUC5B immunohistochemistry followed by quantification of the immunoreactive area was performed. The area occupied by MUC5AC+ cells in bronchial submucosal glands was increased in COPD 20% (5.5–31.7%) gland area compared with smokers with normal lung function 9.5% (2.5–17.5%); P < 0.05 and non‐smoking subjects 2% (0.4–6.2%); P < 0.05. The area occupied by MUC5AC+ cells in the bronchial surface epithelium was also increased in smokers (with/without COPD) 73.5% (25–92%) epithelial area compared with non‐smoking subjects 15% (2.7–32%); P < 0.01. Gland size, PAS, Alcian blue staining and MUC5B expression were not significantly different among groups. MUC5AC expression correlated with the degree of airflow obstruction. MUC5AC and MUC5B expression correlated with pack‐years.
Conclusions: COPD is associated with increased MUC5AC expression in submucosal glands, indicating that MUC5AC may be involved in the pathophysiology of the disease.
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