Claudia Bardoni

Background: The integration of neoadjuvant and perioperative chemo-immunotherapy (CT-IO) has significantly reshaped the treatment of resectable non-small-cell lung cancer (NSCLC), improving pathological response and survival outcomes. However, its impact on surgical management—particularly robotic-assisted thoracic surgery (RATS)—remains incompletely defined. This review provides a practical overview of current evidence and technical considerations for robotic lung resection following neoadjuvant chemo-immunotherapy. Methods: A narrative review of the literature was performed, focusing on phase III trials, meta-analyses, and surgical series reporting perioperative, oncological, and technical outcomes of minimally invasive—especially robotic—approaches after neoadjuvant or perioperative chemo-immunotherapy. Results: Randomized trials have established CT-IO as a standard treatment option for selected patients with resectable stage II–III NSCLC—although the specific standard varies according to stage, molecular and PD-L1 status, and regulatory approval—significantly improving pathological complete response and event-free survival. However, immune-related fibrosis, nodal scarring, and altered tissue planes increase surgical complexity and intra-postoperative complications. Available evidence, largely retrospective and derived from selected patient populations treated at experienced centers, suggest that RATS is feasible and safe, offering enhanced visualization and dexterity that may facilitate dissection in challenging post-induction settings. Vascular management and lymph node dissection remain critical technical aspects, and early conversion to open surgery, when required, should be regarded as an appropriate safety strategy rather than a complication. Conclusions: RATS after neoadjuvant chemo-immunotherapy appears feasible and promising in selected patients treated at experienced centers, but current evidence does not yet establish it as the preferred approach for all patients. Careful patient selection, adherence to oncological principles, and surgeon experience are essential. Prospective data are needed to define optimal surgical timing and standardize techniques.

Background. Robotic-assisted bronchoscopy with the ION™ Endoluminal System facilitates precise access to peripheral pulmonary lesions. However, procedural duration and diagnostic performance remain influenced by patient and lesion-specific factors. To investigate the impact of lesion diameter, radiological appearance, and presence of bronchial signs on procedural duration and diagnostic yield using conventional regression and gradient boosting machine learning models. Methods. In this single-center retrospective cohort study, 189 ION™ Endoluminal System procedures (November 2024–June 2025) were analyzed. Procedural duration and diagnostic yield served as primary outcomes. Predictive modeling included multivariable regression and gradient boosting. Feature importance metrics were extracted. Results. The median lesion diameter was 12.3 mm, with a “strict” diagnostic yield of 87.3%. Gradient boosting regression identified lesion diameter as the primary predictor of procedural time (89.2% importance; test MSE = 865.6). Diagnostic classification achieved an ROC-AUC of 0.68, with lesion diameter (85.8%) and bronchial sign (14.2%) as key predictors. Conclusions. Lesion diameter emerged as the most consistent predictor of procedural efficiency and was associated with diagnostic performance, albeit within the limitations of the dataset. Broader datasets are needed for external validation and generalizability.

Background. Chondrosarcomas of the manubrium are exceedingly rare, accounting for approximately 20% of all primary bone malignancies, and present unique challenges in surgical management and reconstruction. Reliable reconstructive strategies for medial clavicular stabilization remain limited. Case Presentation. We report the first documented use of STRATOS bars for unilateral clavicular stabilization following manubrial chondrosarcoma resection. A 19-year-old woman with a poorly differentiated (G3) chondrosarcoma of the manubrium underwent neoadjuvant chemotherapy followed by en bloc resection of the manubrium, medial clavicle, and first rib. Reconstruction and clavicular stabilization were achieved using STRATOS, which is traditionally employed for chest-wall reconstruction. This represents a novel use of the device for medial clavicular stabilization after SCJ resection. At the 6-month follow-up, the patient remained disease-free, with preserved shoulder function and stable reconstruction. STRATOS provided stable fixation, preserved shoulder function, and an excellent cosmetic outcome. A brief review of the literature on sternal chondrosarcoma and reconstruction techniques is also presented. Conclusion. This unique application expands the reconstructive possibilities of modular titanium systems. It may offer a more reliable biomechanical alternative to traditional fixation methods in cases requiring stability of the shoulder girdle after SCJ resection. Further validation through biomechanical studies and larger case series is warranted.

Introduction: Malignant pericardial effusion (MPE) represents a relatively rare complication in various types of solid tumors. Its management is often challenging. One solution can be represented by surgical approaches, including a pericardio-peritoneal window (PPW), which allows draining the fluid into the abdominal cavity. The aim of this study is to investigate the efficacy and long-term outcomes of the PPW procedure as a definitive therapeutic strategy for MPE. Materials and methods: We retrospectively and prospectively observed pre-, peri-, and postoperative data of patients undergoing pericardio-peritoneal window creation from 2010 to December 2023 at the European Institute of Oncology (IEO), including the surgical procedures needed, total and specific postoperative complications, 30-day mortality rate, relapse rate, and the treatment of possible relapses. Results: A total of 44 consecutive patients underwent a pericardio-peritoneal window. In 28 patients (63.8%) PPW was associated with mono or bilateral videothoracoscopy for pleural biopsies/talc poudrage. In 23 cases, pre-operative percutaneous pericardial drainage (usually 1–2 days before surgery) was performed. No intraoperative deaths were observed. The 30-day mortality was 9% (four patients). We observed pericardial effusion recurrence in three patients at two months and in five patients at six months. In only two cases we treated this condition because of a pre-tamponade condition, treated by percutaneous pericardial drainage. The success rate of the PPW regarding pericardial relapse requiring further procedures was 95.5%. Conclusions: Patients presenting with a favorable short-term prognosis benefit from the pericardio-peritoneal window as a safe and effective method for resolving malignant pericardial effusion. Conversely, pericardial drainage is recommended as the most appropriate therapy for those with a less favorable prognosis.

Objectives: Adenocarcinoma presenting as ground-glass opacities (GGOs) often corresponds to lepidic growth tumor and is associated with less invasive behavior and a good prognosis. The aim of this study is to investigate the correlation between radiological and pathological findings of GGO and their relationship with lung cancer-specific survival (LCSS) and incidence of relapses to better define their surgical management. Methods: One hundred seventy-two patients underwent lung resection for adenocarcinoma presenting as pure GGO or partial solid GGO at CT scan. Based on consolidation-to-tumor ratio (CTR) at CT scan, patients were categorized into two groups: pure GGO (CTR 0) and partial solid GGO (CTR ≤ 0.5, 0.5 < CTR ≤ 0.75, and 0.75 < CTR ≤ 1.0). Histological analysis confirmed diagnosis, invasiveness, and grading. Results: Comparing the group with pure GGO (n = 90; 52.3%) and the groups with partial solid GGO (n = 82; 47.7%), invasive adenocarcinoma was significantly more frequent in the last one (p = 0.0006). In the partial solid GGO group, the majority of tumors were G2, and the percentage of G3 tumors increased with the CTR increasing (p < 0.0001). Twenty-one (12.2%) patients experienced disease recurrence: 16 (9.3%) were invasive adenocarcinoma (IA), and 5 (2.9%) were minimally invasive adenocarcinomas (MIA); radiologically, 13 (7.5%) were pure GGO, and 8 (4.6%) had a solid component. At multivariate analysis, relapse was associated with age > 60 (p = 0.037), clinical stage ≥ cIB (p = 0.002), and sublobar resection (p = 0.005). Conclusions: Pure GGO was associated with minor invasiveness, with prognosis dependent on age, clinical stage, and type of surgery (sublobar vs. lobar resection). Sublobar resections had a higher recurrence risk.

Background: The optimal surgical approach for malignant pleural mesothelioma (PM) remains a topic of debate. While extrapleural pneumonectomy (EPP) offers radical resection, it is associated with significant morbidity. Pleurectomy/decortication (P/D) is less extensive but may offer comparable oncologic outcomes with reduced perioperative risk. This study aimed to conduct a comprehensive systematic review and meta-analysis to systematically evaluate and quantitatively compare survival outcomes, 30-day postoperative mortality, and baseline characteristics between patients undergoing P/D and EPP for PM. Methods: A systematic review was conducted in accordance with the PRISMA guidelines. MEDLINE, Embase, and Scopus were searched up to May 2025. Studies comparing EPP and P/D in PM that reported on survival, mortality, or baseline demographics were included. Data from 24 retrospective studies were extracted. Pooled estimates were calculated using random-effects models. Meta-regression and subgroup analyses were performed by geographic region and publication year. Results: P/D was associated with a significantly improved overall survival compared to EPP in the primary analysis (mean difference = 7.01 months; 95% CI: 1.15–12.86; p = 0.018), with substantial heterogeneity (I² = 98.5%). In a sensitivity analysis excluding one statistical outlier, the survival benefit remained significant (mean difference = 4.31 months; 95% CI: 1.69–6.93), and heterogeneity was markedly reduced. The 30-day mortality rate was also significantly lower for P/D (odds ratio = 0.34; 95% CI: 0.13–0.88; p = 0.027). Patients undergoing P/D were, on average, 3.78 years older than those undergoing EPP (p < 0.001), whereas no significant difference was observed in the sex distribution between groups. Subgroup analyses by region and publication year confirmed the robustness of the findings. Meta-regression did not reveal substantial modifiers of survival. Conclusions: P/D demonstrates superior overall survival and reduced perioperative mortality compared to EPP, without evidence of baseline demographic confounding. These findings, derived from retrospective comparative studies, support the preferential use of P/D in eligible patients, particularly in high-volume centers, given its favorable safety profile and superior median survival. However, the absence of randomized trials directly comparing P/D and EPP and the potential influence of patient selection warrant cautious interpretation, and surgical decisions should be tailored to individual patient factors within a multidisciplinary setting.

Objectives: Robotic-assisted segmentectomy (RAS) has proven to be safe and feasible for early-stage lung cancer; nonetheless, its oncologic efficacy and long-term outcomes are still debated. We aimed to explore whether RAS could be an alternative to robotic-assisted lobectomy (RAL) in early-stage NSCLC, focusing on long-term outcomes such as 10-year cancer-specific survival (CSS), cumulative rate of relapse (RR), and local recurrence (LR). Methods: Patients undergoing RAS for early-stage NSCLC (clinical stage I) were analyzed from August 2007 to August 2023. A 1:3 propensity score-matched analysis was performed among patients undergoing RAL, based on demographic characteristics and pathological stage. Primary endpoints were CSS, RR, and LR. Results: A total of 40 patients undergoing RAS were retrospectively enrolled. After matching 120 patients undergoing RAL, no significant differences were found in postoperative complications, median operative time, or length of hospital stay. Patients undergoing RAS had comparable 10-year CSS (p = 0.90) and RR (p = 0.99) to those undergoing RAL, whereas 10-year of cumulative incidence of local recurrence (LR) was 11.0% (95% CI: 3.4–23.7%) for RAS patients and 2.8% (95% CI: 0.5–8.9%) for RAL patients (p = 0.08). Additionally, RAL provided a significantly higher number of N1 and N2 lymph node retrievals (p < 0.0001 and 0.06, respectively), as well as a higher number of N2 stations (p = 0.0001). Conclusions: Based on our experiences, even though RAS can ensure excellent long-term outcomes in selected cases of early-stage NSCLC, comparable to RAL, the local recurrence rate was higher in the RAS group.

Objectives: Robotic-assisted segmentectomy (RAS) has proven to be safe and feasible for early-stage lung cancer; nonetheless, its oncologic efficacy and long-term outcomes are still debated. We aimed to explore whether RAS could be an alternative to robot-ic-assisted lobectomy (RAL) in early-stage NSCLC, focusing on long-term outcomes such as 10-year cancer-specific survival (CSS), cumulative rate of relapse (RR), and local recurrence (LR). Methods: Patients undergoing RAS for early-stage NSCLC (clinical stage I) were ana-lyzed from August 2007 to August 2023. A 1:3 propensity score-matched analysis was performed among patients undergoing RAL, based on demographic characteristics and pathological stage. Primary endpoints were CSS, RR, and LR. Results: A total of 40 patients undergoing RAS were retrospectively enrolled. After matching 120 patients undergoing RAL, no significant differences were found in post-operative complications, median operative time, or length of hospital stay. Patients undergoing RAS had comparable 10-year CSS (p=0.90) and RR (p=0.99) to those un-dergoing RAL, whereas 10-year of cumulative incidence of local recurrence (LR) was 11.0% (95% CI: 3.4% – 23.7%) for RAS patients, and 2.8% (95% CI: 0.5% – 8.9%) for RAL patients (p = 0.08). Additionally, RAL provided a significantly higher number of N1 and N2 lymph node retrievals (p < 0.0001 and 0.06, respectively), as well as a high-er number of N2 stations (p = 0.0001). Conclusion: Based on our experiences, even though RAS can ensure excellent long-term outcomes in selected cases of early-stage NSCLC, comparable to RAL, the local recurrence rate was higher in the RAS group.

Background. To comprehensively assess surgical safety, we conducted a meta-analysis on neoadjuvant chemo-immunotherapy for NSCLC. Methods. This systematic review and meta-analysis followed PRISMA guidelines (PROSPERO: CRD42023470682). A literature search and data extraction were performed independently by two reviewers. Primary outcomes included surgical feasibility and safety. Pooled prevalence proportions with 95% confidence intervals (CIs) were calculated. A random-effects model was applied if heterogeneity was significant (I² ≥ 50% or p ≥ 0.10). Sensitivity analysis assessed robustness and publication bias was examined using funnel plots and Egger’s test (p < 0.05 significant). Results. Fifteen studies were included, analyzing different immune checkpoint inhibitors with 2–3 cycles of neoadjuvant therapy. Surgery occurred 10–45 days post-treatment. The pooled surgical resection rate was 98.96% (95% CI: 98.93–98.98, I² = 0%). The conversion to thoracotomy rate was 16.49% (95% CI: 12.95–20.03, I² = 89.74%). Minimally invasive surgery was performed in 53.62% (95% CI: 49.53–57.72, I² = 95.92%). The median surgical delay was 28.53 days (95% CI: 23.66–33.41, I² = 0%). Surgical time averaged 165.27 min (95% CI: 112.32–218.22, I² = 0%), with mean blood loss of 182.0 mL (95% CI: 134.0–230.0, I² = 0%). Conclusions. Surgical intervention following neoadjuvant chemo-immunotherapy for NSCLC is feasible and safe, with a high resection rate (98.96%). Variability in minimally invasive surgery and conversion rates suggests differences in surgical approaches, while surgical time, blood loss, and delay showed consistency. These findings highlight the need for a multidisciplinary approach to optimize patient outcomes.