Samuele Nicotra

Introduction Alveolar air leaks are common complications after thoracoscopic lung resections, increasing morbidity, hospital stay, and costs. Polymeric hydrogel matrix (PHM) has shown effectiveness in reducing air leaks and chest tube duration after lobectomy. This study aims to assess PHM’s impact on air leaks, chest drain duration, hospital stay, and its cost-effectiveness following thoracoscopic segmentectomies. Materials and Methods Patients with moderate intraoperative alveolar air leaks during thoracoscopic lung segmentectomy were randomized to receive either PHM (PHM Group) or standard care (SC Group). A cost-effectiveness analysis compared surgical materials between PHM and SC procedures. Results Out of 109 screened patients, 60 were randomized into the two groups. No differences were found in baseline characteristics, surgical procedures, or complications. However, the PHM group had significantly shorter durations for air leaks (p = 0.01), chest drain stay (p = 0.01), and hospital stay (p = 0.01). The PHM group had higher procedure expenses (p = 0.02), but a single day of early discharge offset this cost. Conclusion This prospective trial shows that PHM application in thoracoscopic lung segmentectomies with moderate intraoperative air leaks significantly reduces postoperative air leaks, chest tube duration, and hospital stay. Additionally, the cost-effectiveness analysis supports PHM’s potential to expand surgical capacity. Trial registration Clinical Trials, www.clinicaltrials.gov, NCT06544200.

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.

Minimally invasive segmentectomy/lobectomy is an alternative to traditional thoracotomy for the treating lung cancer, offering benefits such as reduced postoperative pain, shorter recovery times and improved cosmetic outcomes. However, its feasibility in patients with a history of prior thoracotomy remains debated due to potential pleuro-parenchymal adhesions, scarring and hilar fibrosis with altered anatomy, which may increase the complication rate. This paper addresses some technical considerations about redo video-assisted thoracoscopic surgery (VATS) major lung resection in patients with a history of thoracotomy. We describe the preoperative planning, anesthetic preparation for these cases, and a step-by-step description of the surgical strategy used in our center. Moreover, we discuss principles for postoperative care and follow-up, with specific attention to managing complications. The main concerns in redo cases are about the higher rates of postoperative bleeding and prolonged air-leaks, often associated with mobilizing dense adhesions and scar tissue during surgery. Redo VATS major lung resections following a prior thoracotomy offer substantial advantages in terms of reduced morbidity and faster recovery, but also present challenges related to adhesions, compromised anatomy and patient-specific factors. The decision to pursue this approach is made on a case-by-case basis, weighing the patient’s overall performance status, challenges posed by the prior surgery and the surgeon’s expertise.

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.

Background: Division of the pulmonary ligament is standard in lower lobectomies, but its application in upper lobectomies remains controversial due to potential complications like atelectasis and bronchial kinking. This retrospective matched cohort study aimed to evaluate the efficacy and safety of ligament resection in upper lobectomies for oncological purposes. Methods: From January 2015 to December 2020, 988 patients who underwent minimally invasive upper lobectomies across multiple centers were identified. They were categorized into ligament resection and no ligament resection groups, with propensity score matching (PSM) to minimize confounding factors. Endpoints included operative time, pleural effusion, complications (frequency and Clavien–Dindo scores), chest drainage removal, length of stay, pleural space, collapse rate, and bronchial kinking. Results: Following PSM, 276 patients were included in each group, with no significant differences in baseline characteristics. Ligament resection correlated with longer operative times, increased lymphadenectomy sampling at station #9 (p < 0.001), and a bigger change in the bronchial angle (p < 0.001). No statistically significant differences were observed for the other endpoints. Conclusions: Ligament resection during upper lobectomy may impact the bronchial angle without immediate postoperative outcome changes. Further research is necessary to comprehensively assess the risks and benefits of ligament resection in upper lobectomies for neoplastic disease.

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

Fibrolamellar hepatocellular carcinoma (FL-HCC) is a malignant primary hepatic cancer that affects mainly adolescents and young adults without underlying liver disease. Its biology remains unknown, but it is pathologically distinct from traditional HCC. Therapeutic strategies are not well defined and, as chemotherapies seem to have limited efficacy, surgical resection remains the only effective treatment. Here we report on a case of a metastatic FL-HCC in an 18-year-old man successfully treated with aggressive intra-thoracic bilateral lung metastasectomy following primary tumour resection and adjuvant chemotherapy. Survival time after initial hepatectomy is 39 months, with no recurrence of disease to date. Aggressive surgical resection and redo surgery should be considered until more effective multimodality therapies are identified. Multidisciplinary team discussion and involvement of medical and surgical specialties are essential in managing these rare entities.

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.