Ugo Cioffi

Oligometastatic non-small cell lung cancer (NSCLC) is defined anatomically by a threshold of five or fewer metastatic lesions across three or fewer organs. That definition is a proxy for a biological question it cannot answer: whether the metastatic process has been arrested at a stage where eradication of all detectable disease is curative. Randomized phase II trials of local consolidative therapy have shown median progression-free survival gains of 6.2 and 8.0 months and, in one trial, a median overall survival of 41.2 months vs. 17.0 months, yet median progression-free survival with local therapy did not exceed 14.2 months, and the phase II/III NRG-LU002 trial found no significant survival benefit from adding local therapy to maintenance therapy. Circulating tumor DNA (ctDNA) measures molecular disease burden. In resectable NSCLC, preoperative ctDNA detection is associated with a higher risk of relapse; in oligometastatic disease, the baseline sample is instead the quantitative reference for response. ctDNA kinetics during induction therapy track systemic response before any operation, although no response threshold has been validated, and postoperative molecular residual disease anticipates radiological relapse by a median of approximately 5 months. This review synthesizes the evidence linking liquid biopsy to surgical decision-making and proposes, as a hypothesis for prospective testing, a dynamic risk stratification framework anchored on five plasma sampling points. We separate established prognostic evidence from untested hypotheses, address oncogene-driven and other oligometastatic states, and define the assay requirements, confounders and trial designs needed before ctDNA can select patients for or against thoracic resection.

This unstructured narrative review appraises lymph node evaluation as an accountability measure in non-small cell lung cancer surgery. Commission on Cancer Operative Standard 5.8 requires assessment of at least three mediastinal and one hilar nodal station for every curative-intent resection, with accreditation consequences. We ask what the standard has been validated to measure, and at which level of attribution. Neither the count-based nor the station-based threshold was derived from interventional evidence. The reported value reflects surgeon technique, surgeon-led specimen process, pathologist effort, operative platform, and case mix together, which bears on attribution to individual surgeons rather than on the legitimacy of the measure. We separate two causal models linking nodal evaluation to survival and examine each against evidence identified by a reproducible search, including the biomarker-directed and neoadjuvant eras and sublobar resection. Anchored to the National Quality Forum and Donabedian criteria, we conclude that Standard 5.8 is well-supported as an institutional minimum standard for staging completeness, that the evidence identified does not yet support extension to individual-surgeon benchmarking, that compliance should be reported stratified by resection type, and that low sublobar compliance most plausibly identifies a real quality problem. Nothing here reduces the obligation to perform systematic nodal assessment.

Liver transplantation (LT) has evolved from a treatment for end-stage benign liver disease into a therapeutic strategy for selected oncological indications, including hepatocellular carcinoma (HCC), unresectable colorectal liver metastases (CRLM), hepatoblastoma, neuroendocrine tumor hepatic metastases, and hepatic epithelioid hemangioendothelioma. As the indications for LT expand and post-transplant survival improves, pulmonary recurrence has emerged as the predominant pattern of extrahepatic relapse across histologies. Yet no standardized surgical guidelines exist for managing lung metastases in the post-transplant patient. This narrative review synthesizes the available evidence on pulmonary metastasectomy following LT, addressing the incidence and tumor-specific patterns of pulmonary recurrence, the influence of immunosuppression on metastatic biology, surgical indications and contraindications, approach and timing considerations, and patient selection across primary histologies. We propose a practical decision-making framework integrating primary tumor biology, disease-free interval, lesion characteristics, immunosuppression regimen, and systemic therapy response. With the recent regulatory recognition of CRLM as a standard transplant indication and the ongoing SECA-III randomized trial, the downstream surgical management of pulmonary recurrence in LT recipients requires urgent evidence-based codification.

The adoption of neoadjuvant immune checkpoint inhibitor (ICI)-based chemoimmunotherapy has fundamentally transformed the operative landscape of resectable non-small cell lung cancer (NSCLC). Surgeons are now routinely confronted with ICI-altered tissue planes characterized by hilar fibrosis, vascular friability, and disrupted lymph node architecture. Simultaneously, robotic-assisted thoracic surgery (RATS) has consolidated its position as the dominant minimally invasive platform for pulmonary resection, accounting for the majority of lobectomies and segmentectomies performed at high-volume centers in 2023. Whether RATS confers specific technical advantages in this increasingly complex operative context remains incompletely characterized. We conducted a structured narrative review of published evidence, synthesizing data from randomized controlled trials, prospective cohorts, national registry analyses, and emerging technology reports addressing RATS in the setting of neoadjuvant ICI-based therapy for NSCLC. A systematic literature search was conducted across PubMed and EMBASE using predefined search terms. Available evidence, though largely retrospective and limited by small sample sizes, consistently demonstrates that RATS after neoadjuvant chemoimmunotherapy is technically feasible and oncologically sound, with R0 resection achievable in virtually all cases. The enhanced three-dimensional visualization, tremor filtration, and instrument degrees of freedom afforded by robotic platforms appear particularly advantageous in the setting of dense hilar adhesions and fragile pulmonary vasculature. Lymph node yield, a recognized robotic advantage, is preserved or enhanced despite post-ICI fibrosis. Pooled conversion rates to thoracotomy, derived from post hoc surgical analyses of ICI trial populations rather than trials designed to measure conversion, are higher than for upfront resection; available retrospective single-center data, including one direct RATS-versus-VATS comparison, suggest lower conversion rates with RATS in experienced hands, though this conclusion requires prospective validation. Emerging platform integrations, including combined robotic bronchoscopy and thoracoscopic surgery, single-port systems, and artificial intelligence-assisted anatomical navigation, are poised to further extend the reach of minimally invasive surgery in this challenging clinical scenario. In experienced centers, RATS appears to offer a technically favorable minimally invasive platform for pulmonary resection after neoadjuvant ICI-based therapy, with potential advantages over VATS in managing immunotherapy-altered anatomy; however, this conclusion is derived from retrospective series and should be interpreted cautiously pending prospective comparative data. Prospective multicenter trials with standardized surgical endpoints are urgently needed.

Near misses—clinical events that could have resulted in patient harm but did not—are increasingly recognized as critical yet underutilized sources of insight in surgical quality improvement. In thoracic surgery, where procedures are physiologically demanding and care pathways are highly interdependent, near misses frequently precede major complications and expose latent system vulnerabilities rather than isolated technical errors. A structured narrative review methodology was employed, including a targeted literature search of major biomedical databases and thematic synthesis of relevant studies. This narrative review synthesizes evidence from patient safety science, surgical quality literature, and thoracic surgery—specific outcomes research to examine how near misses can be systematically leveraged to improve care. We discuss the transition from individual-centered explanations of adverse events to system-based models that emphasize human factors, communication, escalation pathways, and organizational culture. Particular attention is given to contemporary quality frameworks such as failure to rescue and textbook outcome, which highlight the importance of early recognition, coordinated response, and recovery from complications rather than complication avoidance alone. We further explore the central role of psychological safety and leadership behaviors in enabling meaningful learning from near misses. By reframing near misses as actionable data rather than anecdotal “close calls,” quality improvement emerges as a core professional responsibility in thoracic surgery. We conclude that excellence in thoracic surgery should be defined not by the absence of complications, but by the capacity of surgical systems to learn, adapt, and prevent future harm.

Objectives: Central airway obstruction (CAO) caused by malignant tumors may necessitate combined and prompt treatment. The aim is to recanalize and stabilize the airways as palliation. We present our multicentric experience managing malignant CAO through the placement of Y-shaped self-expanding covered metallic or silicone trachea-bronchial stents. Methods: This retrospective study includes patients who underwent placement of Y-shaped stents from 2002 to 2024 across six different centers in Italy and Great Britain. We evaluated outcomes related to the feasibility and safety of the procedure, as well as the palliation of dyspnoea on the Modified Borg Scale of Dyspnoea. Results: Eighty patients (56.2% female) with a mean age of 64.8 ± 9.6 years were included in the study. Successful placement was achieved in 76 (95%) cases, with no cases of intraoperative mortality. The mean procedure time was 36.64 ± 15.7 min. The complications noted included: 7 (8.7%) cases of periprocedural clinical complications and 7 (8.7%) patients requiring intensive care unit admittance after the procedure. Fifty patients (78.1%) received cancer treatment following the procedure. The mean dyspnoea score on the Borg scale decreased from 7.78 ± 0.98 to 4.02 ± 2.2 (p < 0.05). Conclusions: The placement of metal or silicone Y-shaped stents is a feasible and safe procedure for the palliative treatment of dyspnoea in patients with malignant stenosis of the trachea and main bronchi. Stabilizing the airway also enables these patients to access cancer treatments.

Lymph node evaluation is a central determinant of oncologic quality in the surgical management of non-small-cell lung cancer (NSCLC). Accurate assessment of hilar and mediastinal lymph nodes underpins pathologic staging, informs postoperative treatment decisions, and remains essential for prognostic stratification and assessment of resection completeness. Although international guidelines provide clear recommendations, real-world data consistently demonstrate substantial variability in lymph node staging practices, with inadequate evaluation frequently observed across institutions and surgical settings. Insufficient nodal assessment, manifested as the omission of mediastinal staging, limited station sampling, or low lymph node yield, is associated with reduced nodal upstaging, inappropriate omission of adjuvant therapy, higher recurrence rates, and inferior long-term survival. Contemporary guidance from major societies, including the National Comprehensive Cancer Network, European Society of Thoracic Surgeons, International Association for the Study of Lung Cancer, and the Commission on Cancer, has increasingly converged on a station-based definition of adequacy, emphasizing systematic evaluation of both N1 and N2 nodal stations rather than reliance on absolute node counts alone. In parallel, preoperative mediastinal staging algorithms have evolved toward routine use of endobronchial and esophageal ultrasound as first-line invasive modalities, reserving surgical mediastinoscopy for selected high-risk or inconclusive cases. Evidence from randomized trials, population-level databases, and meta-analyses indicates that thorough nodal assessment improves staging accuracy and survival, while recent data support the selective use of lobe-specific or tailored lymphadenectomy in carefully staged, low-risk early disease. Finally, emerging quality improvement interventions, including standardized specimen handling, operative checklists, and multidisciplinary feedback mechanisms, have demonstrated measurable improvements in guideline adherence and patient outcomes. This narrative review integrates contemporary evidence and guideline recommendations to outline a practical framework for implementing reliable, high-quality lymph node staging in modern lung cancer surgery.

BACKGROUND Median sternotomy has been considered the gold standard approach for anterior mediastinal tumor resection. However, recent advances in video-assisted thoracoscopic surgery and robotic-assisted thoracoscopic surgery with carbon dioxide insufflation have allowed minimally invasive approaches even for large and locally invasive tumors of the upper-anterior mediastinum. The subxiphoid robotic optical approach is a recently developed technique for accessing the mediastinum. The trans-subxiphoid technique offers excellent exposure of the surgical field, reduces postoperative pain, facilitates specimen retrieval even for large tumors, and potentially improves early surgical outcomes. AIM To evaluate the safety, feasibility, and outcomes of a robotic subxiphoid approach for the resecting of large/invasive mediastinal tumors. METHODS Between July 2024 and September 2025, 12 patients underwent subxiphoid robotic mediastinal resection. The diameter of the operated lesions ranged from 30 mm to 70 mm. A 3 cm subxiphoid incision was made at the subxiphoid level for GelPort placement, allowing for optical port access. Two operating ports were placed at the sixth intercostal space bilaterally. Carbon dioxide insufflations (8-10 mmHg) enlarged the surgical field, improving visualization of critical anatomical landmarks, such as the internal mammary arteries and phrenic nerves. This approach allowed complete resection of large or invasive tumors, preserving thoracic stability and reducing the risk of postoperative myasthenic crisis. RESULTS The mean operating time was 170.2 minutes, and the median hospital stay was 3.5 days. No major postoperative complications occurred. Two conversions were necessary: One with a lateral robotic approach due to previous abdominal surgery, and one with a sternotomy for tumor invasion of the aortic arch. Histopathological analysis identified nine thymomas and one solitary fibrous tumor. CONCLUSION Subxiphoid robotic approach is a safe, effective technique for extended thymectomy, fulfilling both oncological and myasthenia gravis surgical objectives.

Background/Objectives: Primary palmar hyperhidrosis (PPH) is a socially debilitating condition that often begins in adolescence. Although sympathicotomy is a low-risk procedure, there are conflicting opinions about the optimal time for surgery: some recommend it at onset in adolescence, while others are cautious because of the risk of recurrence associated with juvenile neuroplasticity. The primary objective was to assess the recurrence rate; secondary objectives included the management of hyperhidrosis, compensatory sweating onset, and satisfaction. Methods: This retrospective cohort study included sympathicotomy procedures for palmar hyperhidrosis performed between 2004 and 2024 in patients younger than 18 years with a preoperative Hyperhidrosis Disease Severity Scale (HDSS) class of 4. Quantitative data are presented as medians and interquartile ranges, while categorical data are presented as numbers and percentages. Results: 28 patients were included, of whom 4 underwent single-stage surgery and 24 two-stage surgery. The median age was 17.30 years, with no gender predominance. At a median follow-up of 75 months, the recurrence rate was 10.71%. Twenty-two patients experienced compensatory sweating, with the majority (60.7%) reporting mild symptoms and the remainder reporting moderate. The median patient satisfaction score was 9.34 (range 9–10). Conclusions: Even though PPH typically begins during adolescence, there is no consensus on the appropriateness of sympathicotomy for younger patients, primarily due to concerns about recurrence. Our data, characterized by long-term follow-up and large numbers of minors, are consistent with those observed in adults’ cohorts in terms of hyperhidrosis management, compensatory sweating rates, and, particularly, recurrence rates, supporting the surgical approach even at a young age.

Objective: Textbook outcome (TO) is a multidimensional composite quality metric that integrates several desirable short-term outcomes into a single measure representing the “ideal” perioperative course. Unlike traditional indicators that focus narrowly on mortality or single complications, TO captures the complexity of cardiothoracic care, encompassing oncologic adequacy, absence of major complications, avoidance of reintervention and readmission, and timely discharge. Methods: In this systematic review, we synthesize evidence on the definition, incidence, determinants, prognostic impact, and limitations of TO across cardiothoracic surgery (lung and esophageal resections, lung transplantation, cardiac surgery, and adult heart transplantation) in accordance with the PRISMA guidelines. Results: Reported achievement rates range from 24% to 66% in thoracic series, 30% after Norwood palliation, 37–45% after adult heart transplantation, and 52% in a contemporary national cohort of lung transplantation, with wide between-center variability. Achieving TO is consistently associated with improved overall and disease-free survival, lower costs, and enhanced benchmarking. Determinants of failure include inadequate lymph node dissection, prolonged operative time, advanced comorbidity, pretransplant organ support, and socioeconomic disadvantage. Heterogeneity of definitions, limited incorporation of patient-reported outcomes, and equity concerns remain barriers to its successful use. Outside transplantation, benchmarking of TO in adult cardiac procedures (e.g., CABG/valve) remains limited and non-standardized. Conclusions: We argue for harmonized, procedure-specific core TO sets aligned with widely available registry fields, integration of equity-sensitive risk adjustment, and prospective validation. TO is poised to become a cornerstone metric of quality assessment and improvement in cardiothoracic surgery.