Alessandro Rebusso

Purpose: Ground‐glass opacities (GGOs) are increasingly detected due to widespread low‐dose CT screening for lung cancer. Among them, malignant GGOs (mGGOs) are a clinical challenge. This study aimed to compare the radiological and anatomopathological characteristics of pure and semi‐solid mGGOs and to identify radiological predictive factors for consolidation. Methods: A retrospective study was conducted on patients resected due to mGGOs between 2016 and 2023. Patients were classified based on whether initially pure mGGOs remained pure or developed a solid component before surgery. Radiological, pathological, and molecular characteristics were analyzed. Results: Of 135 patients, 61 (46%) mGGOs became partially solid during surveillance. Semi‐solid mGGOs had a higher acinar component ( p = 0.038) and larger pathological diameter (20 vs. 18 mm, p = 0.047), while pure mGGOs had a higher lepidic percentage (20% vs. 10%, p = 0.026). STAS and LVI were observed in 25% and 15% of cases. Logistic regression showed pleural contact was protective against consolidation ( p = 0.033), while arterial vascularization was predictive of consolidation ( p = 0.028). Five‐year survival was comparable and satisfactory for both groups (81.7% for pures and 85.5% for semi‐solids). Overall, LVI but no STAS was cause of a lower survival expectancy in the entire sample, regardless of consolidation ( p = 0.004). Conclusions: Both pure and semi‐solid mGGOs showed precocious pathological and molecular features. Surgical intervention with curative intent, even in pure GGOs, is accompanied by long expected survivals. Vascular features on imaging may help inform surgical decision‐making, whereas pathological LVI may have prognostic significance in patients with mGGOs.

Background: In patients with non-small cell lung cancer (NSCLC) treated with neoadjuvant chemo-immunotherapy, pulmonary resection can be technically demanding because of hilar/mediastinal inflammation and fibrosis, potentially limiting the use of minimally invasive surgery (MIS). We report our single-center experience with MIS anatomical lung resections after neoadjuvant chemo-immunotherapy. Methods: We retrospectively collected consecutive NSCLC patients who underwent neoadjuvant chemo-immunotherapy followed by anatomical lung resection with an intended MIS approach at our institution between May 2018 and October 2025. Primary endpoints were feasibility and safety (conversion rate, intraoperative and postoperative complications, need for reoperation, and 30-day mortality). Results: Fifty-two patients were included. Mean age was 65.9 ± 8.6 years; 27 (51.9%) were male. Median Charlson Comorbidity Index was 3 (IQR 2–4). Most patients had clinical stage III disease (IIIA 40.4%, IIIB 30.8%). Conversion to open surgery occurred in 7 cases (13.5%). One intraoperative complication was recorded (1.9%). Anatomical resections were predominantly lobectomies (including combined/extended lobectomies) (88.4%); sleeve resections accounted for 11.5%, and bilobectomy for 7.7%. Postoperative complications occurred in 13 patients (25.0%); reoperation for complications was required in 1 case (1.9%). No deaths were recorded in the dataset. Pathological response showed pCR in 22 patients (42.3%) and MPR in 10 (19.2%). Conclusions: In our experience, minimally invasive anatomical lung resection after neoadjuvant chemo-immunotherapy for NSCLC is feasible, with an acceptable conversion rate and manageable morbidity, and is associated with a substantial rate of pathological response. Careful patient selection and surgical expertise remain essential.

Malignant Triton Tumors (MTTs) are rare, high-grade malignant peripheral nerve sheath tumors (MPNSTs) frequently associated with Type 1 Neurofibromatosis (NF1). NF1, an autosomal dominant disorder, predisposes approximately 10% of affected individuals to developing MPNSTs, with 50% of these tumors occurring in NF1 patients, while others arise sporadically or in association with radiation exposure. MTTs predominantly affect anatomical regions rich in large nerves, such as the limbs, spinal root, and cranial nerves. Mediastinal presentations are exceedingly rare, posing significant diagnostic and therapeutic challenges. Current treatment strategies include surgical resection, chemotherapy, radiotherapy, and lung-sparing procedures for metastatic disease. Molecular studies of MPNSTs have revealed that NF1 mutations lead to dysregulation of the RAS signalling pathway, while epigenetic alterations (e.g., SUZ12/EED mutations) further contribute to tumor progression. Dysregulated phylogenetically conserved pathways, including Wnt/beta-catenin and non-canonical SHH signalling, play a role in sarcoma progression and Schwann cell transformation. Recent advances in miRNA research highlight their involvement in tumor invasion and progression, with dysregulated miRNA expression and chromatin remodeling contributing to the pathogenesis of these neoplasms. However, the distinct molecular profiles for MTTs remain incompletely understood. Further investigation of the genetic and epigenetic landscape is essential for improving our understanding and identifying potential therapies. Herein, we present a single-center retrospective case series of three patients with an intrathoracic triton tumor treated at our University Hospital between 2000 and 2024, serving as a starting point for future insights into MPNST pathobiology.

Background: Pancoast tumors are a rare subset of lung cancers that require a multimodal approach (induction chemoradiotherapy and surgery), best performed in highly specialized centers. This study analyzes the outcomes and prognostic factors in patients treated at a high-volume center over an extended period. Methods: We retrospectively reviewed 43 patients who underwent surgery for Pancoast tumors, following induction treatment between 2005 and 2023. Survival was estimated using the Kaplan–Meier method, and a Cox proportional hazards model was applied to identify prognostic factors (significance level p = 0.05). Results: The median patient age was 63 years, with over 90% having a disease at stage III or higher. Induction chemoradiotherapy was administered to 79% of the patients, achieving a pathological complete response (PCR) in 23% of the patients. The median overall survival (OS) was 37 months, with 1–3 and 5-year OS rates of 71%, 52%, and 41%, respectively. The median disease-free survival (DFS) was 38 months, with 1-, 3-, and 5-year DFS rates of 72%, 62%, and 35%, respectively. A pathological complete response (PCR) and vertebral and/or vascular infiltration significantly influenced recurrence and mortality risk. Conclusions: Trimodal therapy still offers the best short- and long-term outcomes in patients with Pancoast tumors. Future strategies incorporating tyrosine kinase inhibitors and anti-PD1/PD-L1 may improve outcomes for patients by increasing PCR rates and improving disease control.

Background: The tumour inflammatory microenvironment (TIME) reflects a selective activation of the central immune system (IS), particularly T-cells expansion, which leads to immune cells migrating to the target, such as lung cancer, via the bloodstream and lymphatic vessels. In this study, the aim is to investigate whether the distribution of peripheral blood cells varies based on the immune status of patients with lung adenocarcinoma. Methods: This is a single-center retrospective study conducted in the Thoracic Surgery Unit of the University of Padua (Italy) between 1 January 2016 and 1 April 2024. It included patients (>18 years old) with lung adenocarcinoma deemed resectable (cT2bN0M0 or lower) who experienced pathological upstaging (IIB or higher). Patients were classified as TIME-active (with tumour-infiltrating lymphocytes—TILs and/or PD-L1 expression) or TIME-silent (without TILs or PD-L1). According to the TIME status, peripheral blood cell counts with clinical and pathological data were compared between groups using the Fisher’s, Pearson’s or Wilcoxon’s test when appropriate. A Kaplan–Meier estimator investigated overall survival (OS) and recurrence-free survival (RFS) adopting the log-rank test. Results: Preoperatively, the TIME-a group demonstrated a significantly higher lymphocyte count (p = 0.02) and a lower absolute neutrophil rate (p = 0.01) than TIME-s. These differences persisted after resection (p = 0.06 and p = 0.02) while they became similar one month after surgery (p = 1 and p = 0.32). The neutrophil-to-lymphocyte ratio—NLR showed similar trends (p = 0.01 and p = 1). Better OS and RFS were shown in the TIME-a group (p = 0.02 and 0.03, respectively). Conclusions: Resected upstaged lung adenocarcinomas show distinct peripheral blood cell profiles based on immune status. TIME-active patients had a significantly lower NLR, which normalized post-surgery. Surgical resection may help restore native immune surveillance.

Chylothorax is a rare complication occurring after cardio-thoracic surgical procedures. This condition presents challenges for diagnosis and treatment. Operative ductal ligation is the method of choice for relapsing or refractory cases, and it can be performed through the aid of IGC injection for the identification of chylous leakage. Our report presents the use of ICG fluorescence during VATS to successfully identify and treat a left-sided post-surgical chylothorax. The patient underwent a pulmonary wedge resection for a suspect malignant lesion and developed chylous leakage in the early postoperative period. On postoperative day 7, the patient underwent a revision thoracoscopy for hemostasis and thoracic duct ligation. ICG injections were performed through bilateral inguinal lymph nodes and approximately 15 min after we performed the re-thoracoscopy with effective identification and ligation of the chyle leakage. ICG fluorescence-guided VATS is a valuable and effective method for managing postoperative chylothorax, especially for left-sided leaks.

Chylothorax is a rare complication occurring after cardio-thoracic surgical procedures. This condition presents challenges about diagnosis and treatment. Operative ductal ligation is the method of choice for relapsing or refractory cases, and it can be performed through the aid of IGC injection for the identification of chylous leakage. Our report presents the use of ICG fluorescence during VATS to successfully identify and treat a left-sided post-surgical chylothorax. The patient underwent a pulmonary wedge resection for a suspect malignant lesion and developed chylous leakage in the early postoperative period. On postoperative day 7 the patient underwent a revision thoracoscopy for hemostasis and thoracic duct ligation. ICG injections have been performed through bilateral inguinal lymph nodes and approximately 15 minutes after we performed the re-thoracoscopy with effective identification and ligation of the chyle leakage. ICG fluorescence-guided VATS is a valuable and effective method for managing postoperative chylothorax, especially for left-sided leaks. The video of the procedure can be found at: https://zenodo.org/records/13786288

Background/Objectives: Chest X-ray (CXR) is currently the most used investigation for clinical follow-up after major noncardiac thoracic surgery. This study explores the use of lung ultrasound (LUS) as an alternative to CXR in the postoperative management of patients who undergo major thoracic procedures. Methods: The patients in our cohort were monitored with both a CXR and a lung ultrasonography after surgery and the day after chest drain removal. The LUS was performed by a member of the medical staff of our unit who was blinded to both the images and the radiologist’s report of the CXR. Findings were compared between the two methods. Results: In the immediate postoperative evaluation, 280 patients were compared, finding general agreement between the two procedures at 84% (kappa statistic, 0.603). The LUS showed a sensibility of 84.1%, a specificity of 84.3%, a positive predictive value (PPV) of 60.9%, and a negative predictive value (NPV) of 94.8%. We evaluated 219 out of 280 patients in the postdrainage-removal setting due to technical issues. Concordance between the methods in the postdrainage-removal setting was 89% (kappa statistic, 0.761) with the LUS demonstrating an 82.2% sensibility, a 93.2% specificity, a PPV of 85.7%, and an NPV of 91.3%. Conclusions: The results of this study showed a substantial agreement between LUS and CXR, suggesting that the LUS could reduce the number of X rays in certain conditions. The high NPV allows for the exclusion of PNX and pleural effusion without the need to expose patients to radiation. Discrepancies were noted in cases of mild pneumothorax or modest pleural effusion, without altering the clinical approach.

Background and objectives: VATS segmentectomy has been proven to be effective in the treatment of stage I NSCLC, but its technical complexity remains one of the most challenging aspects for thoracic surgeons. Furthermore, 3D-CT reconstruction images can help in planning and performing surgical procedures. In this paper, we present our personal experience of 11 VATS anatomical resections performed after accurate pre-operative planning with 3D reconstructions. Materials and methods: A 3D virtual model of the lungs, airways, and vasculature was obtained, starting from a 1.25 mm 3-phase contrast CT scan, and the original images were used for the semi-automatic segmentation of the lung parenchyma, airways, and tumor. Results: Six males and five females were included in this study. The median diameter of the pulmonary lesion at the pre-operative chest CT scan was 20 mm. The surgical indication was confirmed in seven patients: in three cases, a lobectomy, instead of a segmentectomy, was needed due to intraoperative findings of nodal metastasis. Meanwhile, only in one case, we performed a lobectomy because of inadequate surgical resection margins. Skin-to-skin operative average time was 142 (IQR 1-3 105–182.5) min. The median post-operative stay was 6 (IQR 1-3 3.5–7) days. The mean value of the closest surgical margin was 13.7 mm. Conclusion: Image-guided reconstructions are a useful tool for surgeons to perform complex resections in order to spare healthy parenchyma and to ensure disease-free margins. Nevertheless, human skill and surgeon experience still remain fundamental for the final decisions regarding the proper resection to perform.

Background: The use of smoking donors (SD) is one strategy to increase the organ pool for lung transplantation (LT), but the benefit-to-risk ratio has not been demonstrated. This study aimed to evaluate the impact of SD history on recipient outcomes and graft alterations. Methods: LTs in 293 patients were retrospectively reviewed and divided into non-SD (n = 225, group I), SD < 20 pack-years (n = 45, group II), and SD ≥ 20 pack-years (n = 23, group III) groups. Moreover, several lung donor biopsies before implantation (equally divided between groups) were evaluated, focusing on smoking-related lesions. Correlations were analyzed between all pathological data and smoking exposure, along with other clinical parameters. Results: Among the three groups, donor and recipient characteristics were comparable, except for higher Oto scores and age in group III. Group III showed a longer intensive care unit (ICU) and hospital stay compared with the other two groups. This finding was confirmed when SD history was considered as a continuous variable. However, survival and other mid- and long-term major outcomes were not affected by smoking history. Finally, morphological lesions did not differ between the three groups. Conclusions: In our study, SDs were associated with a longer post-operative course, without affecting graft aspects or mid- and long-term outcomes. A definition of pack-years cut-off for organ refusal should be balanced with the other extended criteria donor factors.