Purpose
This study aimed to evaluate the effectiveness of radio-guided localization for thoracoscopic resection of small nonpalpable lung nodules.
Methods
Nineteen patients with a solitary nodule ...were enrolled. Inclusion criteria were maximum nodule diameter <15 mm, distance from nearest pleural surface of 20–40 mm, nonsolid or partly solid nodule, and/or posterior location. Under computed tomography (CT) guidance, the nodule was identified and a needle was inserted to reach lesional or perilesional tissue. A solution of
99m
Tc macro-aggregates albumin diluted with iodized contrast medium was injected. After injection, CT and gamma scintigraphy were performed to confirm precise staining. Localization complications were minimal.
Results
At thoracoscopy, the gamma detector probe allowed localization of nodules in all patients, with the radioactive signal being converted by the system into audio and visual numeric signals. Resection was performed, and suture margins were checked with the probe to search for residual hyperabsorption. All specimens underwent frozen section. Mean time to detect nodules with the gamma probe was 6 min (range 3–9 min). Frozen section revealed primary pulmonary tumors in eight cases, secondary lesions in four cases, and a benign nodule in the remaining seven cases.
Conclusion
Radio-guided localization is a simple, safe procedure for localizing nonpalpable solitary pulmonary nodules.
IgG4-related disease (IgG4-RD) is a progressive inflammatory disease that might rarely involve only the lungs. We retrospectively reviewed the preoperative, clinical and surgical features of patients ...with a pathology highly suggestive or probable diagnosis of IgG4-RD without extra-thoracic involvement. Five patients were selected, 2 were operated on the right side. Positron emission tomography-computed tomography (PET-CT) showed an uptake in all the patients (median 5.5), and 2 patients had an uptake at the thoracic lymph nodes. Two diagnoses were made through a CT-guided needle biopsy, while 3 were determined based on a lung wedge resection. The levels of serum IgG4 were elevated (>1.35 g/dl) in all the patients. Two patients had a highly suggestive diagnosis of IgG4-RD, and 3 patients had a probable diagnosis of IgG4-RD. The differential diagnosis between IgG4-RD and lung malignancies based only on radiological features is challenging and often requires histological confirmation. A careful preoperative workup and a multidisciplinary approach to PET-positive nodules might help to avoid unnecessary major lung resections.
Thyroid transcription factor-1 (TTF-1) is a nuclear protein regulating the transcriptional activity of lung-specific genes in the normal and neoplastic bronchioloalveolar cells. It has been ...implicated in the normal growth and development of the lung, and the disruption of the TTF-1 locus leads to neonatal death with pulmonary hypoplasia. We evaluated retrospectively the prevalence and clinical significance of TTF-1 immunoreactivity in 222 patients with stage I non-small cell lung carcinoma (NSCLC) with a follow-up time of at least 5 years, and we investigated its relationship with other markers of tumor growth, namely cell proliferation and angiogenesis. TTF-1 immunoreactivity was documented by using the commercially available monoclonal antibody 8G7G3/1 in 72% of 97 adenocarcinomas, 5% of 119 squamous cell carcinomas, and in the glandular component of two adenosquamous carcinomas. Four large cell carcinomas were completely unreactive. In adenocarcinomas, but not squamous cell carcinomas, TTF-1 immunoreactivity correlated significantly with microvessel density (p = 0.04) and inversely with the tumor proliferation fraction assessed by Ki-67 immunostaining (p = 0.03). Also, TTF-1-immunoreactive adenocarcinomas showed a trend for a size less than 3 cm (p = 0.08). TTF-1 expression was not related to specific growth patterns, tumor grade, or tumor cell typing. TTF-1 immunoreactivity did not significantly affect patient survival, although patients with more than 75% immunoreactive neoplastic cells showed a trend for longer overall and disease-free survival. Our findings suggest that TTF-1 could be involved in the development of small pulmonary adenocarcinomas, but it has not prognostic implications in patients with stage I NSCLC.
Background
Single-port access video-assisted thoracic surgery (VATS), a technique progressively developed from the standard three-port approach in minimally invasive surgery, offers ergonomic ...advantages but also new challenges for the surgeon. We compared the ergonomics of three-port versus single-port VATS.
Methods
Posture analysis of surgeons was evaluated during 100 consecutive VATS wedge resections (50 triportal vs. 50 uniportal). Technically demanding procedures (major lung resection) were excluded. Operating table height, monitor height, distance and inclination were adjusted according to operator preference. Body posture was assessed by measuring head–trunk axial rotation and head flexion. Perceived physical strain was self-evaluated on the Borg Category Ratio (CR-10) scale. Mental workload was assessed with the National Aeronautics Space Administration–Task Load indeX (NASA–TLX), a multidimensional tool that rates workloads on six scales (mental, physical and temporal demand; effort; performance; frustration).
Results
All procedures were completed without complications. Head–trunk axial rotation was significantly reduced and neck flexion significantly improved in uniportal VATS. Viewing direction significantly declined (
p
= 0.01), body posture as measured on the Borg CR–10 scale was perceived as more stressful and the NASA–TLX score for overall workload was higher (
p
= 0.04) during triportal VATS. The NASA–TLX score for frustration was higher with uniportal VATS (
p
= 0.02), but the score for physical demand was higher in triportal VATS (
p
= 0.006).
Conclusions
The surgeon can maintain a more neutral body posture during uniportal VATS by standing straight and facing the monitor with only minimal neck extension/rotation; however, frustration is greater than with triportal VATS.
Introduction
18
Fluorine-fluorodeoxyglucose positron emission tomography/computed tomography is not yet accepted as a standard pretreatment evaluation of thymic epithelial neoplasm (TEN). Statistical ...correlation between standardized uptake value of tumor/mediastinum ratio and patients’ WHO risk class has been reported. PET metabolic tumor volume (MTV) and total glycolytic volume (TGV) have been reported as additional prognostic imaging biomarkers in several human tumors. Purpose of study was to establish whether MTV and TGV add prognostic information in TEN.
Materials and methods
A retrospective dynamic cohort study of prospectively collected data (2006–2012) on 23 consecutive patients with pathologically proven TEN (no thymic carcinoma) was conducted. All patients underwent chest CT, and PET for staging. SUV T/M ratio, semi-quantitative and volumetric analyses of TEN were calculated. Patients were categorized according to WHO classification (low-risk and high-risk thymomas). Statistical analysis was performed with bootstrap method. Multi-collinearity was established using Pearson correlation coefficient. Cut-off point for TGV was compared using Mantel Cox log rank test.
Results
SUV T/M ratio, MTV, and TGV correlate with low- and high-risk TEN. However, the statistical correlation between TGV and WHO classification (
ρ
= 0.897) was higher than SUV T/M ratio (
ρ
= 0.873). Since sample distributions were not uniformly smooth, only one cut-off value was identified: a TGV of 383 served as a cut-off value between low-risk and high-risk TEN.
Conclusion
TGV is a PET reproducible imaging marker in patients with TEN, provides prognostic information, and could be useful in pretreatment stratification of patients. Nevertheless, it needs validation in larger cohort studies.
Consistent branching of the thoracodorsal vessels to the latissimus dorsi makes it possible to split the muscle into independent branched units. The use of the lateral split latissimus dorsi muscle ...flap to protect the bronchial stump in case of bronchus at risk of insufficiency is described.
Determination of programmed death ligand 1 (PD-L1) expression defines eligibility for treatment with pembrolizumab in patients with advanced NSCLC. This study was designed to better define which ...value across core biopsy specimens from the same case more closely reflects the PD-L1 expression status on whole sections and how many core biopsy specimens are needed for confident classification of tumors in terms of PD-L1 expression.
We built tissue microarrays as surrogates of biopsies collecting five cores per case from 268 cases and compared PD-L1 staining results obtained by using the validated clone SP263 with the results obtained by using whole tumor sections.
We found an overall positivity in 39% of cases at a cutoff of 1% and in 10% of cases at a cutoff of 50%. The maximum value across cores was associated with high concordance between cores and whole sections and the lowest number of false-negative cases overall. To reach high concordance with whole sections, four and three cores are necessary at cutoffs of 1% and 50%, respectively. Importantly, with 20% as the cutoff for core biopsy specimens, fewer than three cores showed high sensitivity and specificity in identifying cases with 50% or more of tumor cells positive for PD-L1 on whole sections. Specifically, for PD-L1 expression values of 20% to 49% on cores, the probabilities of a tumor specimen expressing PD-L1 in at least 50% of cells on a whole section were 46% and 24% with one and two biopsy specimens, respectively.
An accurate definition of the criteria to determine the PD-L1 status of a given tumor may greatly help in selecting those patients who could benefit from anti–programmed cell death 1/PD-L1 treatment.
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