Marco Anile

Tumour-to-tumour metastasis (TTM) is a very rare condition in which a malignant tumour (donor) metastasizes into another primary neoplasm, either benign or malignant (recipient). We report the case of a 74-year-old man previously surgically treated for a clear cell renal cell carcinoma (ccRCC) who developed a new subsolid nodule in the right upper pulmonary lobe discovered at a 4-year follow-up CT scan. The patient underwent a right uniportal thoracoscopic S1 segmentectomy and mediastinal lymph node dissection. Histopathological examination revealed a lung adenocarcinoma (LUAD) containing a focus of metastatic ccRCC without lymph node involvement or evidence of additional metastatic disease. To date, the patient remains disease-free. Metastasis of renal tumour cells into a primary lung tumour is exceptionally rare. To our knowledge, this is the first reported case of ccRCC metastasizing into LUAD without evidence of systemic dissemination.

Objective: Recent guidelines suggest sublobar resection as a viable option for peripheral lung cancer smaller than 2 cm. However, the presence of Spread through Air Spaces (STAS) is a well-known poor prognostic factor in early-stage lung cancer treated with sublobar resections. The aim of this study is to analyze the potential correlation between STAS and maximum standardized uptake volume (SUVmax) in this subset of patients to help define the optimal resection. Methods: A retrospective monocentric study was performed including patients diagnosed with stage IA lung cancer undergoing surgical resection. Patients were divided into two groups according to the presence/absence of STAS. As further investigation, we also separately analyzed the subgroup of patients with a peripheral nodule smaller than 2 cm. A p-value ≤ 0.05 was considered statistically significant. Results: The study cohort consists of 121 patients, 76 (62.8%) male, with a mean age of 74.2 ± 8.8 years. STAS was observed in 67 (55.4%) cases. The STAS-positive group showed a higher SUVmax value compared to the STAS-negative one (mean 5.5 ± 4.4 vs. 3.9 ± 3.0; p-value 0.007) with an AUC of 0.65 and an optimum SUVmax cut-off value of 3.0. Moreover, patients with SUVmax ≥ 3 showed a 77% increase in risk of having STAS (RR = 1.77; 95%CI = 1.21–2.59, p-value 0.014). This association was confirmed also in the subgroup of patients with nodules ≤ 2 cm (mean SUVmax 5.3 ± 4.6 vs. 3.6 ± 2.7; p value = 0.014). Conclusions: In our study, an SUVmax ≥ 3 in preoperative 18-FDG-PET is associated with the presence of STAS in stage IA lung cancer and peripheral cancer smaller than 2 cm. These findings, integrated with other clinical and radiological data, may guide surgeons to optimize the surgical strategy.

Background: The role of thymectomy in ocular myasthenia gravis (OMG) remains controversial, particularly before secondary generalization. Methods: We conducted a multicenter retrospective study on 174 OMG patients who underwent thymectomy (112 OMG, 62 generalized OMG [g-OMG]). The primary endpoint was complete stable remission (CSR; MGFA-PIS criteria). Multivariable analyses identified predictors of CSR and generalization. Results: Mean age at surgery was 42.3 ± 13.0 years; 53.4% were male. Thymoma was present in 29.3%. CSR was achieved in 18.9% overall, significantly higher in OMG (23.2%) compared to g-OMG (11.3%, p = 0.036), with 5-year CSR probabilities of 43% vs. 22% (p = 0.017). In non-thymomatous patients, 5-year CSR remained higher in OMG (41% vs. 17%, p = 0.010). Postoperative myasthenic crisis occurred exclusively in g-OMG (8.1%, p = 0.004). Multivariable analysis identified preoperative cholinesterase inhibitor monotherapy as an independent predictor of CSR (HR = 31.776, 95% CI: 4.188–241.111, p = 0.001; non-thymomatous: HR = 19.746, 95% CI: 2.518–154.849, p = 0.005). Minimally invasive techniques (78.6%) were associated with low morbidity (5.2%). Conclusions: Thymectomy during the purely ocular stage is associated with higher CSR rates and lower perioperative neurological risk than after generalization, particularly in non-thymomatous disease. Use of cholinesterase inhibitors as sole therapy prior to thymectomy independently predicts CSR. These findings support earlier surgical consideration in selected OMG patients and highlight the safety of minimally invasive approaches.

Background: multilocular thymic cysts are uncommon acquired cysts in the anterior mediastinum caused by incomplete thymic involution. They may be associated with autoimmune diseases, such as rheumatoid arthritis and systemic sclerosis. Methods: a 61-year-old man with a history of rheumatoid arthritis for 8 years was referred to our unit because of a multiloculated mass in the anterior mediastinum with a high F¹⁸ fluorodeoxyglucose uptake at PET-CT scan. Histology showed a multilocular thymic cyst with lymphoid tissue, organized in germinal centers and internodal areas. Results: rheumatoid arthritis-related symptoms progressively disappeared after the excision of the mass. Conclusions: to our knowledge, this is the first report in the English language of rheumatoid arthritis symptoms improvement after multilocular thymic cyst surgical removal.

The general world population is aging and patients are often diagnosed with early-stage lung cancer at an advanced age. Several studies have shown that age is not itself a contraindication for lung cancer surgery, and therefore, more and more octogenarians with early-stage lung cancer are undergoing surgery with curative intent. However, octogenarians present some peculiarities that make surgical treatment more challenging, so an accurate preoperative selection is mandatory. In recent years, new artificial intelligence techniques have spread worldwide in the diagnosis, treatment, and therapy of lung cancer, with increasing clinical applications. However, there is still no evidence coming out from trials specifically designed to assess the potential of artificial intelligence in the preoperative evaluation of octogenarian patients. The aim of this narrative review is to investigate, through the analysis of the available international literature, the advantages and implications that these tools may have in the preoperative assessment of this particular category of frail patients. In fact, these tools could represent an important support in the decision-making process, especially in octogenarian patients in whom the diagnostic and therapeutic options are often questionable. However, these technologies are still developing, and a strict human-led process is mandatory.

Chest tubes are routinely inserted after thoracic surgery procedures in different sizes and numbers. The aim of this study is to assess the efficacy of Smart Drain Coaxial drainage compared with two standard chest tubes in patients undergoing thoracotomy for pulmonary lobectomy. Ninety-eight patients (57 males and 41 females, mean age 68.3 ± 7.4 years) with lung cancer undergoing open pulmonary lobectomy were randomized in two groups: 50 received one upper 28-Fr and one lower 32-Fr standard chest tube (ST group) and 48 received one 28-Fr Smart Drain Coaxial tube (SDC group). Hospitalization, quantity of fluid output, air leaks, radiograph findings, pain control and costs were assessed. SDC group showed shorter hospitalization (7.3 vs. 6.1 days, p = 0.02), lower pain in postoperative day-1 (p = 0.02) and a lower use of analgesic drugs (p = 0.04). Pleural effusion drainage was lower in SDC group in the first postoperative day (median 400.0 ± 200.0 mL vs. 450.0 ± 193.8 mL, p = 0.04) and as a mean of first three PODs (median 325.0 ± 137.5 mL vs. 362.5 ± 96.7 mL, p = 0.01). No difference in terms of fluid retention, residual pleural space, subcutaneous emphysema and complications after chest tubes removal was found. In conclusion, Smart Drain Coaxial chest tube seems a feasible option after thoracotomy for pulmonary lobectomy. The SDC group showed a shorter hospitalization and decreased analgesic drugs use and, thus, a reduction of costs.

Spread through air spaces (STAS) is a pattern of invasion present in some adenocarcinomas (ADC). The goal of this study was to assess the impact of STAS in patients treated with different types of surgical resections and on the clinical outcome in patients with ADC of different diameters and with different degrees of nodal involvement. A total of 109 patients were reviewed. Complete surgical resection with systematic nodal dissection was achieved in all patients. The median follow-up was 65 months (3–90 months). STAS was observed in 70 cases (64.2%); 13 patients (18.5%) had lymph node involvement (N1 and N2). Overall survival and progression-free survival were higher in patients without STAS (P = 0.042; P = 0.027). The presence of STAS in tumours ≤2 cm was a predictor of worse progression-free survival following sublobar resection compared to major resections (P = 0.011). Sublobar resection of N0 STAS-positive tumours was associated with worse long-term survival compared to a major resection (P = 0.04). Statistical analyses showed that age >70 years and recurrence were independent variables for survival; smoking pack-years >20, sublobar resection and nodal involvement were independent variables for recurrence; and smoking pack-years >20 were independent variables for a history of cancer and pleural invasion for local recurrence. STAS seems to play a role in long-term survival, particularly for patients with N0 and tumours smaller than 2 cm. Further studies are necessary to validate this hypothesis.