BackgroundCurrently there is major lack of agreement on the diagnostic and therapeutic management... more BackgroundCurrently there is major lack of agreement on the diagnostic and therapeutic management of patients with idiopathic pulmonary fibrosis (IPF) and lung cancer. Our aim was to identify variations in diagnostic and management strategies across different institutions and provide rationale for a consensus statement on this issue.MethodsThis was a joint-survey by European Respiratory Society (ERS) Assemblies 8, 11 and 12. The survey consisted of 25 questions.ResultsFour hundred and ninety-four (n=494) physicians from 68 different countries and five continents responded to the survey. Ninety-four per cent of participants were pulmonologists, 1.8% thoracic surgeons and 1.9% oncologists; 97.7% were involved in multidisciplinary team approaches on diagnosis and management. Regular low-dose high-resolution computed tomography (HRCT) scan was used by 49.5% of the respondents to screen for lung cancer in IPF. Positron emission tomography (PET) scan and endobronchial ultrasound (EBUS) is...
Background: A minority of European countries have participated in international comparisons with ... more Background: A minority of European countries have participated in international comparisons with high level data on lung cancer. However, the nature and extent of data collection across the continent is simply unknown, and without accurate data collection it is not possible to compare practice and set benchmarks to which lung cancer services can aspire. Methods: Using an established network of lung cancer specialists in 37 European countries, a survey was distributed in December 2014. The results relate to current practice in each country at the time, early 2015. The results were compiled and then verified with co-authors over the following months. Results: Thirty-five completed surveys were received which describe a range of current practice for lung cancer data collection. Thirty countries have data collection at the national level, but this is not so in Albania, Bosnia-Herzegovina, Italy, Spain and Switzerland. Data collection varied from paper records with no survival analysis, to well-established electronic databases with links to census data and survival analyses. Conclusion: Using a network of committed clinicians, we have gathered validated comparative data reporting an observed difference in data collection mechanisms across Europe. We have identified the need to develop a welldesigned dataset, whilst acknowledging what is feasible within each country, and aspiring to collect high quality data for clinical research.
The persistence of anti-HBs protective levels in groups of children who had been immunized agains... more The persistence of anti-HBs protective levels in groups of children who had been immunized against Hepatitis B 5 and 10 years earlier, in their first year of life, has been studied. The results were analyzed according to the type of vaccine (both plasma-derived and DNA recombinant) and the number of doses administered (three or four doses). In addition, the protective e#ect of the vaccine in vaccinated subjects was studied in relation to the anti-HBc presence. The serologic results suggest that, in cohorts of children vaccinated 5 years earlier, a higher prevalence of subjects with anti-HBs protective levels was found, when the DNA recombinant vaccines were administered (97.6% for A4SD Recombivax and 97.1% for SKF Engerix B); a lower one when the plasma-derived vaccine was used (80.4% Pasteur Merieux, Hevac B). Moreover, in cohorts of children vaccinated with plasma derived vaccine (Hevac B) 10 years earlier, a higher prevalence of subjects with anti-HBs protective levels was demonstrated when four doses were administered (76.9?/0); a lower one when three doses were inoculated (57.5%). The absence of core antibody (anti-HBc) in responders to the vaccination shows the protective e#icacy of both the DNA recombinant and plasma derived vaccines. On the other hand the presence of anti-HBc in some anti-HBs negative non-responders subjects shows the susceptibility of these people to infection. In anti-HBs negative vaccinated subjects the appearance of levels of anti-HBs in 95.9!% of subjects, 1 week after the administration of a booster dose, demonstrates the presence of a solid immunologic memory.
International Journal of Surgery Case Reports, 2015
INTRODUCTION: Catamenial pneumothorax (CP) is a spontaneous recurrent pneumothorax occurring in w... more INTRODUCTION: Catamenial pneumothorax (CP) is a spontaneous recurrent pneumothorax occurring in women in reproductive age. The etiology of CP has been associated with thoracic endometriosis and is its most common presentation. PRESENTATION OF CASE: A case of right catamenial pneumothorax in a 38 year old woman is presented in which three episodes of CP occurred within 72 h of menses in a 6 month period. The patient underwent videothoracoscopy that revealed a solitary localization of diaphragmatic endometriosis. After surgical pleurodesis and based on final pathology of resected lesion, hormonal treatment was started. The outcome was uneventful and the patients is symptom-free at 6 months. DISCUSSION: Catamenial pneumothorax (CP) is a rare clinical entity characterized by lung collapse during menstruation, believed to be secondary to pleural endometriosis. Nearly all catamenial pneumothorax occur on the right side as pleural lesions are almost exclusively right-sided. Diagnostic imaging is based on high resolution computed tomography (HRCT) and, preferably, magnetic resonance imaging (MRI) since it is able to detect the blood products in the endometrial deposits. However the lack of macroscopic findings at surgery makes this condition still under-diagnosed. Based on the solitary diaphragmatic localization of endometriosis in our case we preferred to limit surgery to videothoracoscopic pleurodesis and start hormonal treatment with successful outcome. CONCLUSION: Catamenial pneumothorax is the most common presentation of thoracic endometriosis syndrome and should always be suspected in women in childbearing age. Treatment option are still debated but best results are achieved by videothoracoscopic pleurodesis combined with hormonal therapy.
International Journal of Surgery Case Reports, 2015
INTRODUCTION: Thoracic outlet syndrome (TOS) includes a group of disorders caused by extrinsic co... more INTRODUCTION: Thoracic outlet syndrome (TOS) includes a group of disorders caused by extrinsic compression of neurovascular structures between the 1st rib and clavicle. It usually presents as an enlarging neck mass, with shoulder or upper limb pain, weakness, paresthesias and impalpable radial pulse (Raynaud's phenomenon). PRESENTATION OF CASE: We report a rare case of TOS caused by an infraclavicular subpectoral lipoma that, although challenging because of limited access and proximity of vital neurovascular structures, was successfully removed through a simple transaxillary incision with an excellent esthetic result. The patients is symptom-free 6 months after surgery. DISCUSSION: Multiplicity of symptoms makes causes, diagnosis, and treatment of TOS controversial. Accurate diagnosis of TOS can be a substantial challenge in practice, because of a lack of physician awareness, overlapping of clinical features, and an absence of clearly defined diagnostic criteria. TOS may be associated with the presence of a benign subpectoral mass like lipomas, that seldom have an irregular distribution that involve neurovascular structures. CONCLUSION: Although benign soft tissue tumors infraclavicular subpectoral lipomas may exert pressure on neurovascular surrounding structures during their progressive expansion and cause TOS. Therefore, a thorough preoperative study by radiological imaging such as MRI or neurophysiological test should always be performed in order to prevent unintentional lesions of the involved axillo-subclavicular plexus and plan correct surgical procedure.
Interactive cardiovascular and thoracic surgery, 2010
Lymph node involvement in adenocarcinoma of the esophagogastric junction (EGJ) is similar to that... more Lymph node involvement in adenocarcinoma of the esophagogastric junction (EGJ) is similar to that of gastric cancer. The impact on survival of the number and site of lymph nodes involved in a subgroup of patients undergone surgery for adenocarcinoma of EGJ is reported. Sixty-four patients undergone transthoracic esophagectomy with two-field lymphadenectomy for adenocarcinoma of the EGJ were retrospectively assessed. Five-year survival according to AJCC gastric cancer nodal classification and central node invasion was evaluated. In N0 patients survival was assessed in relation to the number of lymph nodes removed. Five-year survival was 72% in N0, 46% in N1 and 0% in N2 and N3 group. Intergroup differences were statistically significant (P<0.05) except between N2 and N3 groups. Overall survival was different depending on the infiltration of distal or proximal site nodes, 23% vs. 58% (P<0.05); in N0 patients it was related to the number of lymph nodes removed (83%…
Gemcitabine and paclitaxel are among the most active new agents in non-small cell lung cancer (NS... more Gemcitabine and paclitaxel are among the most active new agents in non-small cell lung cancer (NSCLC) and are worth considering for second-line chemotherapy. In this phase I-II study, we combined gemcitabine and paclitaxel for second-line treatment of advanced NSCLC. Gemcitabine doses were kept fixed at 1000 mg/m 2 on day 1 and 8, and paclitaxel doses were escalated from 90 mg/m 2 on day 1 of the 21-day cycle. Thirty-seven patients were treated at six different dose levels. Grade 4 neutropenia was dose-limiting toxicity (DLT), since it occurred in two out of six patients treated at paclitaxel 240 mg/m 2 ; the paclitaxel dose level just below (210 mg/m 2) was selected for phase II evaluation. Non-hematologic toxicity was mild. One complete response (CR) (3%) and 13 partial responses (PR) (36%) were observed in 36 evaluable patients for an overall response rate of 39% (95% C.I., 23-57%). Median duration of response was 35 weeks (range, 8-102). All of the observed objective responses occurred in the 19 patients who had previously responded to the first-line therapy. Median survival was 40 weeks (range, 8-108 weeks). The combination of gemcitabine and paclitaxel is a feasible, well-tolerated, and active scheme for second-line treatment of advanced NSCLC; further evaluation, at least in selected patients, such as those previously responding to first-line chemotherapy, is definitely warranted.
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and its prevalence is 1-... more Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and its prevalence is 1-2% of the general population, but higher with increasing age and in patients with concomitant heart disease. The Cox-maze III procedure was a groundbreaking development and remains the surgical intervention with the highest cure rate, but due to its technical difficulty alternative techniques have been developed to create the lesions sets. The field is fast moving and there are now multiple energy sources, multiple potential lesion sets and even multiple guidelines addressing the issues surrounding the surgical treatment of AF both for patients undergoing this concomitantly with other cardiac surgical procedures and also as stand-alone procedures either via sternotomy or via videothoracoscopic techniques. The aim of this document is to bring together all major guidelines in this area into one resource for clinicians interested in surgery for AF. Where we felt that guidance was lacking, we also reviewed the evidence and provided summaries in those areas. We conclude that AF surgery is an effective intervention for patients with all types of AF undergoing concomitant cardiac surgery to reduce the incidence of AF, as demonstrated in multiple randomized studies. There is some evidence that this translates into reduced stroke risk, reduced heart failure risk and longer survival. In addition, symptomatic patients with AF may be considered for surgery after failed catheter intervention or even as an alternative to catheter intervention where either catheter ablation is contraindicated or by patient choice.
The association between lung malignancy and cardiovascular disease has been frequently reported t... more The association between lung malignancy and cardiovascular disease has been frequently reported though its therapeutic and prognostic implications not thoroughly analyzed. This study aims at assessing the possible impact of coexisting cardiovascular disease on the outcome of surgical treatment of non small cell lung cancer (NSCLC). Methods: Among 247 consecutive patients undergone surgery for stage I and II NSCLC between 1990 and 1997, 34 (13.7%) had a cardiovascular comorbidity going to be treated by surgery, namely coronary artery disease (n ¼ 14), carotid stenosis (n ¼ 21), abdominal aortic aneurysm (n ¼ 9) and lower limbs arteriopathy (n ¼ 7). Among 22 patients (64.7%) who underwent cardiac/vascular surgery first, operation was performed after a median interval of 4.5 weeks. In five of this subset lung cancer was incidentally detected. In the other patients the cardiovascular disease was diagnosed and treated after the lung cancer had been detected and operated with a median interval of 3.5 months from thoracic procedure. Surgical procedures for lung cancer were three pneumonectomies, 12 lobectomies, 19 wedge resections. Uni and multivariate analysis for risk factors was carried out. Results: In the group with cardiovascular comorbidity overall postoperative mortality was 9%, while morbidity rate was 58.8%, both of them primarily caused by cardiovascular disease and significantly higher for major resections. The 3-and 5-year survival rates were 54.8% and 35.5% compared to 69.2% and 56.4% among patients without cardiovascular comorbidity (P ¼ 0:01) while the timing of vascular surgery (before or after thoracic procedure) did not significantly affect survival. Multifocal vascular disease resulted the only positive factor at multivariate analysis (P ¼ 0:005, Odd Ratio ¼ 3.51, 95% Confidence Interval ¼ 1.4-8.4). Conclusions: Cardiovascular disease seems to have significant impact on survival and morbidity in patients undergone surgery for lung cancer, especially in presence of multifocal vascular disease and following major resections. The timing of vascular surgery and the extension of resection should rely on the severity of vascular disease, anaesthesiologist's and surgeon's final evaluation.
Background: This study was designed to determine whether bronchoplastic resection could be an alt... more Background: This study was designed to determine whether bronchoplastic resection could be an alternative to pneumonectomy in patients with operable primary lung cancer. Methods: From 1980 to 1996, 63 patients (59 males and four females; mean age 62^7 years) underwent a bronchoplastic lobectomy for non-small cell lung cancer, indicated because of a disabled respiratory function in 34 patients, and performed electively in 29 patients. There were 38 right upper lobectomies, four bilobectomies, one middle lobectomy combined with lower lobe apical segmentectomy, ten left upper and ten left lower lobectomies. The bronchoplasty was a full sleeve in 24 patients, and a bronchial wedge resection in 39. Results: A single patient died post-operatively (1.6%). Speci®c procedure-related complications are summarized as follows: six anastomotic complications managed conservatively (9.5%), 15 space problems (23.8%), nine sputum retentions (14.2%). Pathologic staging classi®ed 30 patients in stage I, 21 patients in stage II, and 12 in stage IIIA. Estimated 5-year survival was 69:79 :8% in stage I, 37:1^12:1% in stage II, and 8:3^8:0% in stage IIIA. Fourteen patients (22.2%) developed locoregional recurrence. Three of them died with local recurrence alone, whereas 10 developed metastatic progression; a single patient is alive following completion pneumonectomy. According to stage, three recurrences occurred in stage I (10%), six in stage II (28%), and ®ve in stage IIIA (38%). Actuarial freedom from local recurrence was signi®cantly higher after elective procedures (P 0:019); there was a trend towards improved outcome following right-sided procedures (P 0:079) and following wedge bronchoplasty (P 0:055). Five patients experienced a second primary cancer (7.9%), which was resected in four. Conclusion: Bronchoplastic resections achieve local control and long-term survival comparable to standard resections in patients with stage I or II disease, and may be considered as a valuable alternative to pneumonectomy.
The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration... more The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and where appropriate and necessary the patient's guardian or carer. It is also the health professional's responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.
Indeterminate solitary pulmonary nodules (SPNs), measuring up to 3 cm in diameter, are incidental... more Indeterminate solitary pulmonary nodules (SPNs), measuring up to 3 cm in diameter, are incidental radiological findings. The ever-growing use of modern imaging has increased their detection. The majority of those nodules are benign; however, the possibility of diagnosing early-stage lung cancer still stands. Guidelines for the management of SPNs have never been validated in prospective comparative studies.Positron emission tomography (PET) is a useful tool to provide functional information on SPNs. However, overall sensitivity and specificity of PET in detecting malignant SPNs of at least 10 mm in diameter are about 90% and false-negative results are reported.The development of video-assisted thoracic surgery has provided minimally invasive diagnosis and treatment of SPNs. In our series, 105 patients underwent surgery based on combined increased18F-labelled 2-fluoro-2-deoxy-d-glucose (FDG) uptake on PET computed tomography and radiological features (morphology and density) without p...
MPEs are a common and important cause of cancer-related mortality and morbidity. Prompt diagnosis... more MPEs are a common and important cause of cancer-related mortality and morbidity. Prompt diagnosis using minimally invasive procedures is a key point in the evolution of disease since the overall median survival after diagnosis is only 4-9 months. Tumour markers analysis has been proposed as a less invasive alternative for categorizing malignant and non-malignant pleural effusions. This multi-centre study aimed at establishing diagnostic cut-offs for a panel of markers in pleural fluid and serum to identify patients with malignancy. Methods Pleural fluid specimens and serum samples from 162 patients (102 malignant, 60 non-malignant) consecutively admitted in three Italian university hospitals were analyzed for Ca15.3, Ca 19.9, Ca72, Ca 125, Cyfra 21.1, NSE, CEA, M2PK and ADA. The diagnosis of malignant or non-malignant effusion was based on cytology, pleural biopsy, thoracoscopy, video-assisted thoracic surgery (VATS). Statistical evaluation included Kolmogorov-Smirnov, Mann-Whitney, Chi-square and Fisher’s exact tests. Non parametric (Spearman) correlations were determined. ROC curve analysis was performed to determine analyte cut-offs, sensitivity, specificity and AUC values of each marker. A p-value <0,05 was considered statistically significant. Results Cytological negative samples were analyzed to ensure that they truly represented non-malignant effusions related to other diseases such as congestive heart failure (CHF), renal imbalance, pneumonia, tuberculosis or post-traumatic. Patients with a history of malignancy or subsequent diagnosis of malignancy with a cytological negative pleural sample were excluded from the study. All examined concentrations were significantly higher in malignant effusions compared to non-malignant effusions. The value of AUC of pleural samples was always higher than in serum for all malignant cases. The best AUC value in pleural samples (Fig.1) was detected for Ca72 (0,800), Cyfra 21.1 (0,776) and CEA (0,773) while in serum samples Ca72 (0,761), Ca15.3 (0,653) and CEA (0,648) were the best performers (Fig.2). Conclusions Tumour markers assay in pleural fluid complements cytology and other classifying tests. Our study shows a significant performance of pleural fluid vs serum samples when comparing AUC values. A few tumour markers over-expressed in pleural fluid of patients with known malignancy have been identified. Therefore the use of a panel including the best performing markers may prevent patients with suspected malignancy from undergoing invasive procedures such as thoracoscopy or VATS. While routine analysis of markers is not recommended in all pleural effusions, tailoring a specific marker assay in pleural fluid for a specific malignancy is highly advisable especially in patients with relevant comorbidity.
Background Aims of this study were to assess the results of anti-COVID19 measures applied to main... more Background Aims of this study were to assess the results of anti-COVID19 measures applied to maintain thoracic surgery activity at an Italian University institution through a 12-month period and to assess the results as compared with an equivalent non-pandemic time span. Methods Data and results of 646 patients operated on at the department of Thoracic Surgery of the Tor Vergata University Policlinic in Rome between February 2019 and March 2021 were retrospectively analyzed. Patients were divided in 2 groups: one operated on during the COVID-19 pandemic (pandemic group) and another during the previous non-pandemic 12 months (non-pandemic group). Primary outcome measure was COVID-19 infection-free rate. Results Three patients developed mild COVID-19 infection early after surgery resulting in an estimated COVID-19 infection-free rate of 98%. At intergroup comparisons (non-pandemic vs. pandemic group), a greater number of patients was operated before the pandemic (352 vs. 294, p = 0.00...
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, Jan 24, 2018
Training of European thoracic surgeons is subject to huge variations in terms of length of traini... more Training of European thoracic surgeons is subject to huge variations in terms of length of training, content of training and operative experience during training. Harmonization of training outcomes has been approached by creating the European Board of Thoracic Surgery, which has been accredited by the European Union of Medical Specialists (UEMS); however, a clear description of the content of training is lacking. Building on their recognized experience with curriculum building, task forces of the European Respiratory Society and the European Society of Thoracic Surgery agreed on a joint task force on training in thoracic surgery. The goal of this study is to report on the mission statement developed from the UEMS-driven survey, describe the Delphi method and the observed results and present the first large consensus-based syllabus. The working group is currently working on a description of the curriculum and assessment of learning outcomes.
Authors report their experience concerning surgical treatment of thoracic recurrence from previou... more Authors report their experience concerning surgical treatment of thoracic recurrence from previously operated breast cancer. 96 patients were treated: 9 with loco-regional chest wall recurrence, 84 with malignant pleural effusion, 3 with solitary lung metastasis. Eight of 9 cases with chest wall recurrence underwent skin and soft tissue "en bloc" resection while in one case a thoracectomy was performed. Malignant pleural effusions were treated by thoracentesis in 21 cases (25%), tube thoracostomy in 8 (4.76%), tube thoracostomy plus chemical pleurodesis in 54 (64.2%) and pleurectomy in one case (1.19%). In all the cases with solitary lung metastasis a wedge resection was performed. Two out of 9 patients with chest wall recurrence are not evaluable as they did not enter the minimum follow-up period (15 months), 6 died after a mean period of 18.6 months (range 15-25) following surgery and one is alive at the end of the follow-up (39 months). Among the 3 patients with solitar...
Hydrogels are an important class of highly hydrated polymers that are widely investigated for pot... more Hydrogels are an important class of highly hydrated polymers that are widely investigated for potential use in soft tissue engineering. Generally, however, hydrogels lack the ability to mineralize, preventing the formation of chemical bonds with hard tissues such as bone. A recent trend in tissue engineering involves the development of hydrogels that possess the capacity to mineralize. The strategy that has attracted most interest has been the incorporation of inorganic phases such as calcium phosphate ceramics and bioglasses into hydrogel matrices. These inorganic particles act as nucleation sites that enable further mineralization, thus improving the mechanical properties of the composite material. A second route to create nucleation sites for calcification of hydrogels involves the use of features from the physiological mineralization process. Examples of these biomimetic mineralization strategies include (1) soaking of hydrogels in solutions that are saturated with respect to calcium phosphate, (2) incorporation of enzymes that catalyze deposition of bone mineral, and (3) incorporation of synthetic analogues to matrix vesicles that are the initial sites of biomineralization. Functionalization of the polymeric hydrogel backbone with negatively charged groups is a third mechanism to promote mineralization in otherwise inert hydrogels. This review summarizes the main strategies that have been developed in the past decade to calcify hydrogel matrices and render these hydrogels suitable for applications in bone regeneration.
Pleural effusion is a common diagnostic problem and a challenge to the thoracic surgeon. The anal... more Pleural effusion is a common diagnostic problem and a challenge to the thoracic surgeon. The analysis of serum and body fluids for tumor markers is an established diagnostic procedure. Among various markers, tumors are linked to the overexpression of a glycolytic isoenzyme, M2-pyruvate-kinase (M2-PK). This preliminary study evaluated this enzyme as a tumor marker to differentiate malignant from benign pleural effusion. Methods: The tumor M2-PK concentration was measured in the EDTA-plasma and pleural fluid of 34 patients with an established diagnosis of cancer, either primary of the chest (18) or secondary to chest (16) and in 34 controls with benign effusion. The concentration was quantitatively determined by an enzyme-linked immunosorbent assay. The cutoff level between negative and positive values of the tumor M2-PK was defined as the benign group's mean + 2SD (95% percentile). True-positives, false-positives, true-negatives, and false-negatives, were determined with 'positive' referring to histologically proven malignant effusion and 'negative' referred to as nonmalignant effusions. Sensitivity, specificity, positive predictive value, and negative predictive value were assessed. Results: The cutoff value was established at 7.61 U/ml for plasma and 32.9 U/ml for pleural fluid. Both plasma and pleural fluid levels of tumor M2-PK were significantly higher in patients with known chest malignancy, either primary or metastatic, compared to nonmalignant effusions (p < 0.001). Sensitivity in pleural fluid was significantly higher compared to plasma (85.7% vs 76.2%; p < 0.01). Moreover, negative predictive value was higher for pleural fluid compared to plasma (79.4% vs 70.8; p < 0.01) Conclusions: Tumor M2-PK marker is useful in differentiating malignant from benign pleural effusions. Moreover, its sensitivity and NPV in pleural fluid are significantly higher compared to plasma. The usefulness of such a test is not strictly diagnostic but aims at excluding poorly performing patients from further invasive procedures. Thus, the inclusion of M2-PK within a panel of well-known tumor markers such as CEA, MCA, Ca 125 and Ca 19-9, may help in increasing the overall sensitivity and specificity.
BackgroundCurrently there is major lack of agreement on the diagnostic and therapeutic management... more BackgroundCurrently there is major lack of agreement on the diagnostic and therapeutic management of patients with idiopathic pulmonary fibrosis (IPF) and lung cancer. Our aim was to identify variations in diagnostic and management strategies across different institutions and provide rationale for a consensus statement on this issue.MethodsThis was a joint-survey by European Respiratory Society (ERS) Assemblies 8, 11 and 12. The survey consisted of 25 questions.ResultsFour hundred and ninety-four (n=494) physicians from 68 different countries and five continents responded to the survey. Ninety-four per cent of participants were pulmonologists, 1.8% thoracic surgeons and 1.9% oncologists; 97.7% were involved in multidisciplinary team approaches on diagnosis and management. Regular low-dose high-resolution computed tomography (HRCT) scan was used by 49.5% of the respondents to screen for lung cancer in IPF. Positron emission tomography (PET) scan and endobronchial ultrasound (EBUS) is...
Background: A minority of European countries have participated in international comparisons with ... more Background: A minority of European countries have participated in international comparisons with high level data on lung cancer. However, the nature and extent of data collection across the continent is simply unknown, and without accurate data collection it is not possible to compare practice and set benchmarks to which lung cancer services can aspire. Methods: Using an established network of lung cancer specialists in 37 European countries, a survey was distributed in December 2014. The results relate to current practice in each country at the time, early 2015. The results were compiled and then verified with co-authors over the following months. Results: Thirty-five completed surveys were received which describe a range of current practice for lung cancer data collection. Thirty countries have data collection at the national level, but this is not so in Albania, Bosnia-Herzegovina, Italy, Spain and Switzerland. Data collection varied from paper records with no survival analysis, to well-established electronic databases with links to census data and survival analyses. Conclusion: Using a network of committed clinicians, we have gathered validated comparative data reporting an observed difference in data collection mechanisms across Europe. We have identified the need to develop a welldesigned dataset, whilst acknowledging what is feasible within each country, and aspiring to collect high quality data for clinical research.
The persistence of anti-HBs protective levels in groups of children who had been immunized agains... more The persistence of anti-HBs protective levels in groups of children who had been immunized against Hepatitis B 5 and 10 years earlier, in their first year of life, has been studied. The results were analyzed according to the type of vaccine (both plasma-derived and DNA recombinant) and the number of doses administered (three or four doses). In addition, the protective e#ect of the vaccine in vaccinated subjects was studied in relation to the anti-HBc presence. The serologic results suggest that, in cohorts of children vaccinated 5 years earlier, a higher prevalence of subjects with anti-HBs protective levels was found, when the DNA recombinant vaccines were administered (97.6% for A4SD Recombivax and 97.1% for SKF Engerix B); a lower one when the plasma-derived vaccine was used (80.4% Pasteur Merieux, Hevac B). Moreover, in cohorts of children vaccinated with plasma derived vaccine (Hevac B) 10 years earlier, a higher prevalence of subjects with anti-HBs protective levels was demonstrated when four doses were administered (76.9?/0); a lower one when three doses were inoculated (57.5%). The absence of core antibody (anti-HBc) in responders to the vaccination shows the protective e#icacy of both the DNA recombinant and plasma derived vaccines. On the other hand the presence of anti-HBc in some anti-HBs negative non-responders subjects shows the susceptibility of these people to infection. In anti-HBs negative vaccinated subjects the appearance of levels of anti-HBs in 95.9!% of subjects, 1 week after the administration of a booster dose, demonstrates the presence of a solid immunologic memory.
International Journal of Surgery Case Reports, 2015
INTRODUCTION: Catamenial pneumothorax (CP) is a spontaneous recurrent pneumothorax occurring in w... more INTRODUCTION: Catamenial pneumothorax (CP) is a spontaneous recurrent pneumothorax occurring in women in reproductive age. The etiology of CP has been associated with thoracic endometriosis and is its most common presentation. PRESENTATION OF CASE: A case of right catamenial pneumothorax in a 38 year old woman is presented in which three episodes of CP occurred within 72 h of menses in a 6 month period. The patient underwent videothoracoscopy that revealed a solitary localization of diaphragmatic endometriosis. After surgical pleurodesis and based on final pathology of resected lesion, hormonal treatment was started. The outcome was uneventful and the patients is symptom-free at 6 months. DISCUSSION: Catamenial pneumothorax (CP) is a rare clinical entity characterized by lung collapse during menstruation, believed to be secondary to pleural endometriosis. Nearly all catamenial pneumothorax occur on the right side as pleural lesions are almost exclusively right-sided. Diagnostic imaging is based on high resolution computed tomography (HRCT) and, preferably, magnetic resonance imaging (MRI) since it is able to detect the blood products in the endometrial deposits. However the lack of macroscopic findings at surgery makes this condition still under-diagnosed. Based on the solitary diaphragmatic localization of endometriosis in our case we preferred to limit surgery to videothoracoscopic pleurodesis and start hormonal treatment with successful outcome. CONCLUSION: Catamenial pneumothorax is the most common presentation of thoracic endometriosis syndrome and should always be suspected in women in childbearing age. Treatment option are still debated but best results are achieved by videothoracoscopic pleurodesis combined with hormonal therapy.
International Journal of Surgery Case Reports, 2015
INTRODUCTION: Thoracic outlet syndrome (TOS) includes a group of disorders caused by extrinsic co... more INTRODUCTION: Thoracic outlet syndrome (TOS) includes a group of disorders caused by extrinsic compression of neurovascular structures between the 1st rib and clavicle. It usually presents as an enlarging neck mass, with shoulder or upper limb pain, weakness, paresthesias and impalpable radial pulse (Raynaud's phenomenon). PRESENTATION OF CASE: We report a rare case of TOS caused by an infraclavicular subpectoral lipoma that, although challenging because of limited access and proximity of vital neurovascular structures, was successfully removed through a simple transaxillary incision with an excellent esthetic result. The patients is symptom-free 6 months after surgery. DISCUSSION: Multiplicity of symptoms makes causes, diagnosis, and treatment of TOS controversial. Accurate diagnosis of TOS can be a substantial challenge in practice, because of a lack of physician awareness, overlapping of clinical features, and an absence of clearly defined diagnostic criteria. TOS may be associated with the presence of a benign subpectoral mass like lipomas, that seldom have an irregular distribution that involve neurovascular structures. CONCLUSION: Although benign soft tissue tumors infraclavicular subpectoral lipomas may exert pressure on neurovascular surrounding structures during their progressive expansion and cause TOS. Therefore, a thorough preoperative study by radiological imaging such as MRI or neurophysiological test should always be performed in order to prevent unintentional lesions of the involved axillo-subclavicular plexus and plan correct surgical procedure.
Interactive cardiovascular and thoracic surgery, 2010
Lymph node involvement in adenocarcinoma of the esophagogastric junction (EGJ) is similar to that... more Lymph node involvement in adenocarcinoma of the esophagogastric junction (EGJ) is similar to that of gastric cancer. The impact on survival of the number and site of lymph nodes involved in a subgroup of patients undergone surgery for adenocarcinoma of EGJ is reported. Sixty-four patients undergone transthoracic esophagectomy with two-field lymphadenectomy for adenocarcinoma of the EGJ were retrospectively assessed. Five-year survival according to AJCC gastric cancer nodal classification and central node invasion was evaluated. In N0 patients survival was assessed in relation to the number of lymph nodes removed. Five-year survival was 72% in N0, 46% in N1 and 0% in N2 and N3 group. Intergroup differences were statistically significant (P<0.05) except between N2 and N3 groups. Overall survival was different depending on the infiltration of distal or proximal site nodes, 23% vs. 58% (P<0.05); in N0 patients it was related to the number of lymph nodes removed (83%…
Gemcitabine and paclitaxel are among the most active new agents in non-small cell lung cancer (NS... more Gemcitabine and paclitaxel are among the most active new agents in non-small cell lung cancer (NSCLC) and are worth considering for second-line chemotherapy. In this phase I-II study, we combined gemcitabine and paclitaxel for second-line treatment of advanced NSCLC. Gemcitabine doses were kept fixed at 1000 mg/m 2 on day 1 and 8, and paclitaxel doses were escalated from 90 mg/m 2 on day 1 of the 21-day cycle. Thirty-seven patients were treated at six different dose levels. Grade 4 neutropenia was dose-limiting toxicity (DLT), since it occurred in two out of six patients treated at paclitaxel 240 mg/m 2 ; the paclitaxel dose level just below (210 mg/m 2) was selected for phase II evaluation. Non-hematologic toxicity was mild. One complete response (CR) (3%) and 13 partial responses (PR) (36%) were observed in 36 evaluable patients for an overall response rate of 39% (95% C.I., 23-57%). Median duration of response was 35 weeks (range, 8-102). All of the observed objective responses occurred in the 19 patients who had previously responded to the first-line therapy. Median survival was 40 weeks (range, 8-108 weeks). The combination of gemcitabine and paclitaxel is a feasible, well-tolerated, and active scheme for second-line treatment of advanced NSCLC; further evaluation, at least in selected patients, such as those previously responding to first-line chemotherapy, is definitely warranted.
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and its prevalence is 1-... more Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and its prevalence is 1-2% of the general population, but higher with increasing age and in patients with concomitant heart disease. The Cox-maze III procedure was a groundbreaking development and remains the surgical intervention with the highest cure rate, but due to its technical difficulty alternative techniques have been developed to create the lesions sets. The field is fast moving and there are now multiple energy sources, multiple potential lesion sets and even multiple guidelines addressing the issues surrounding the surgical treatment of AF both for patients undergoing this concomitantly with other cardiac surgical procedures and also as stand-alone procedures either via sternotomy or via videothoracoscopic techniques. The aim of this document is to bring together all major guidelines in this area into one resource for clinicians interested in surgery for AF. Where we felt that guidance was lacking, we also reviewed the evidence and provided summaries in those areas. We conclude that AF surgery is an effective intervention for patients with all types of AF undergoing concomitant cardiac surgery to reduce the incidence of AF, as demonstrated in multiple randomized studies. There is some evidence that this translates into reduced stroke risk, reduced heart failure risk and longer survival. In addition, symptomatic patients with AF may be considered for surgery after failed catheter intervention or even as an alternative to catheter intervention where either catheter ablation is contraindicated or by patient choice.
The association between lung malignancy and cardiovascular disease has been frequently reported t... more The association between lung malignancy and cardiovascular disease has been frequently reported though its therapeutic and prognostic implications not thoroughly analyzed. This study aims at assessing the possible impact of coexisting cardiovascular disease on the outcome of surgical treatment of non small cell lung cancer (NSCLC). Methods: Among 247 consecutive patients undergone surgery for stage I and II NSCLC between 1990 and 1997, 34 (13.7%) had a cardiovascular comorbidity going to be treated by surgery, namely coronary artery disease (n ¼ 14), carotid stenosis (n ¼ 21), abdominal aortic aneurysm (n ¼ 9) and lower limbs arteriopathy (n ¼ 7). Among 22 patients (64.7%) who underwent cardiac/vascular surgery first, operation was performed after a median interval of 4.5 weeks. In five of this subset lung cancer was incidentally detected. In the other patients the cardiovascular disease was diagnosed and treated after the lung cancer had been detected and operated with a median interval of 3.5 months from thoracic procedure. Surgical procedures for lung cancer were three pneumonectomies, 12 lobectomies, 19 wedge resections. Uni and multivariate analysis for risk factors was carried out. Results: In the group with cardiovascular comorbidity overall postoperative mortality was 9%, while morbidity rate was 58.8%, both of them primarily caused by cardiovascular disease and significantly higher for major resections. The 3-and 5-year survival rates were 54.8% and 35.5% compared to 69.2% and 56.4% among patients without cardiovascular comorbidity (P ¼ 0:01) while the timing of vascular surgery (before or after thoracic procedure) did not significantly affect survival. Multifocal vascular disease resulted the only positive factor at multivariate analysis (P ¼ 0:005, Odd Ratio ¼ 3.51, 95% Confidence Interval ¼ 1.4-8.4). Conclusions: Cardiovascular disease seems to have significant impact on survival and morbidity in patients undergone surgery for lung cancer, especially in presence of multifocal vascular disease and following major resections. The timing of vascular surgery and the extension of resection should rely on the severity of vascular disease, anaesthesiologist's and surgeon's final evaluation.
Background: This study was designed to determine whether bronchoplastic resection could be an alt... more Background: This study was designed to determine whether bronchoplastic resection could be an alternative to pneumonectomy in patients with operable primary lung cancer. Methods: From 1980 to 1996, 63 patients (59 males and four females; mean age 62^7 years) underwent a bronchoplastic lobectomy for non-small cell lung cancer, indicated because of a disabled respiratory function in 34 patients, and performed electively in 29 patients. There were 38 right upper lobectomies, four bilobectomies, one middle lobectomy combined with lower lobe apical segmentectomy, ten left upper and ten left lower lobectomies. The bronchoplasty was a full sleeve in 24 patients, and a bronchial wedge resection in 39. Results: A single patient died post-operatively (1.6%). Speci®c procedure-related complications are summarized as follows: six anastomotic complications managed conservatively (9.5%), 15 space problems (23.8%), nine sputum retentions (14.2%). Pathologic staging classi®ed 30 patients in stage I, 21 patients in stage II, and 12 in stage IIIA. Estimated 5-year survival was 69:79 :8% in stage I, 37:1^12:1% in stage II, and 8:3^8:0% in stage IIIA. Fourteen patients (22.2%) developed locoregional recurrence. Three of them died with local recurrence alone, whereas 10 developed metastatic progression; a single patient is alive following completion pneumonectomy. According to stage, three recurrences occurred in stage I (10%), six in stage II (28%), and ®ve in stage IIIA (38%). Actuarial freedom from local recurrence was signi®cantly higher after elective procedures (P 0:019); there was a trend towards improved outcome following right-sided procedures (P 0:079) and following wedge bronchoplasty (P 0:055). Five patients experienced a second primary cancer (7.9%), which was resected in four. Conclusion: Bronchoplastic resections achieve local control and long-term survival comparable to standard resections in patients with stage I or II disease, and may be considered as a valuable alternative to pneumonectomy.
The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration... more The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and where appropriate and necessary the patient's guardian or carer. It is also the health professional's responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.
Indeterminate solitary pulmonary nodules (SPNs), measuring up to 3 cm in diameter, are incidental... more Indeterminate solitary pulmonary nodules (SPNs), measuring up to 3 cm in diameter, are incidental radiological findings. The ever-growing use of modern imaging has increased their detection. The majority of those nodules are benign; however, the possibility of diagnosing early-stage lung cancer still stands. Guidelines for the management of SPNs have never been validated in prospective comparative studies.Positron emission tomography (PET) is a useful tool to provide functional information on SPNs. However, overall sensitivity and specificity of PET in detecting malignant SPNs of at least 10 mm in diameter are about 90% and false-negative results are reported.The development of video-assisted thoracic surgery has provided minimally invasive diagnosis and treatment of SPNs. In our series, 105 patients underwent surgery based on combined increased18F-labelled 2-fluoro-2-deoxy-d-glucose (FDG) uptake on PET computed tomography and radiological features (morphology and density) without p...
MPEs are a common and important cause of cancer-related mortality and morbidity. Prompt diagnosis... more MPEs are a common and important cause of cancer-related mortality and morbidity. Prompt diagnosis using minimally invasive procedures is a key point in the evolution of disease since the overall median survival after diagnosis is only 4-9 months. Tumour markers analysis has been proposed as a less invasive alternative for categorizing malignant and non-malignant pleural effusions. This multi-centre study aimed at establishing diagnostic cut-offs for a panel of markers in pleural fluid and serum to identify patients with malignancy. Methods Pleural fluid specimens and serum samples from 162 patients (102 malignant, 60 non-malignant) consecutively admitted in three Italian university hospitals were analyzed for Ca15.3, Ca 19.9, Ca72, Ca 125, Cyfra 21.1, NSE, CEA, M2PK and ADA. The diagnosis of malignant or non-malignant effusion was based on cytology, pleural biopsy, thoracoscopy, video-assisted thoracic surgery (VATS). Statistical evaluation included Kolmogorov-Smirnov, Mann-Whitney, Chi-square and Fisher’s exact tests. Non parametric (Spearman) correlations were determined. ROC curve analysis was performed to determine analyte cut-offs, sensitivity, specificity and AUC values of each marker. A p-value <0,05 was considered statistically significant. Results Cytological negative samples were analyzed to ensure that they truly represented non-malignant effusions related to other diseases such as congestive heart failure (CHF), renal imbalance, pneumonia, tuberculosis or post-traumatic. Patients with a history of malignancy or subsequent diagnosis of malignancy with a cytological negative pleural sample were excluded from the study. All examined concentrations were significantly higher in malignant effusions compared to non-malignant effusions. The value of AUC of pleural samples was always higher than in serum for all malignant cases. The best AUC value in pleural samples (Fig.1) was detected for Ca72 (0,800), Cyfra 21.1 (0,776) and CEA (0,773) while in serum samples Ca72 (0,761), Ca15.3 (0,653) and CEA (0,648) were the best performers (Fig.2). Conclusions Tumour markers assay in pleural fluid complements cytology and other classifying tests. Our study shows a significant performance of pleural fluid vs serum samples when comparing AUC values. A few tumour markers over-expressed in pleural fluid of patients with known malignancy have been identified. Therefore the use of a panel including the best performing markers may prevent patients with suspected malignancy from undergoing invasive procedures such as thoracoscopy or VATS. While routine analysis of markers is not recommended in all pleural effusions, tailoring a specific marker assay in pleural fluid for a specific malignancy is highly advisable especially in patients with relevant comorbidity.
Background Aims of this study were to assess the results of anti-COVID19 measures applied to main... more Background Aims of this study were to assess the results of anti-COVID19 measures applied to maintain thoracic surgery activity at an Italian University institution through a 12-month period and to assess the results as compared with an equivalent non-pandemic time span. Methods Data and results of 646 patients operated on at the department of Thoracic Surgery of the Tor Vergata University Policlinic in Rome between February 2019 and March 2021 were retrospectively analyzed. Patients were divided in 2 groups: one operated on during the COVID-19 pandemic (pandemic group) and another during the previous non-pandemic 12 months (non-pandemic group). Primary outcome measure was COVID-19 infection-free rate. Results Three patients developed mild COVID-19 infection early after surgery resulting in an estimated COVID-19 infection-free rate of 98%. At intergroup comparisons (non-pandemic vs. pandemic group), a greater number of patients was operated before the pandemic (352 vs. 294, p = 0.00...
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, Jan 24, 2018
Training of European thoracic surgeons is subject to huge variations in terms of length of traini... more Training of European thoracic surgeons is subject to huge variations in terms of length of training, content of training and operative experience during training. Harmonization of training outcomes has been approached by creating the European Board of Thoracic Surgery, which has been accredited by the European Union of Medical Specialists (UEMS); however, a clear description of the content of training is lacking. Building on their recognized experience with curriculum building, task forces of the European Respiratory Society and the European Society of Thoracic Surgery agreed on a joint task force on training in thoracic surgery. The goal of this study is to report on the mission statement developed from the UEMS-driven survey, describe the Delphi method and the observed results and present the first large consensus-based syllabus. The working group is currently working on a description of the curriculum and assessment of learning outcomes.
Authors report their experience concerning surgical treatment of thoracic recurrence from previou... more Authors report their experience concerning surgical treatment of thoracic recurrence from previously operated breast cancer. 96 patients were treated: 9 with loco-regional chest wall recurrence, 84 with malignant pleural effusion, 3 with solitary lung metastasis. Eight of 9 cases with chest wall recurrence underwent skin and soft tissue "en bloc" resection while in one case a thoracectomy was performed. Malignant pleural effusions were treated by thoracentesis in 21 cases (25%), tube thoracostomy in 8 (4.76%), tube thoracostomy plus chemical pleurodesis in 54 (64.2%) and pleurectomy in one case (1.19%). In all the cases with solitary lung metastasis a wedge resection was performed. Two out of 9 patients with chest wall recurrence are not evaluable as they did not enter the minimum follow-up period (15 months), 6 died after a mean period of 18.6 months (range 15-25) following surgery and one is alive at the end of the follow-up (39 months). Among the 3 patients with solitar...
Hydrogels are an important class of highly hydrated polymers that are widely investigated for pot... more Hydrogels are an important class of highly hydrated polymers that are widely investigated for potential use in soft tissue engineering. Generally, however, hydrogels lack the ability to mineralize, preventing the formation of chemical bonds with hard tissues such as bone. A recent trend in tissue engineering involves the development of hydrogels that possess the capacity to mineralize. The strategy that has attracted most interest has been the incorporation of inorganic phases such as calcium phosphate ceramics and bioglasses into hydrogel matrices. These inorganic particles act as nucleation sites that enable further mineralization, thus improving the mechanical properties of the composite material. A second route to create nucleation sites for calcification of hydrogels involves the use of features from the physiological mineralization process. Examples of these biomimetic mineralization strategies include (1) soaking of hydrogels in solutions that are saturated with respect to calcium phosphate, (2) incorporation of enzymes that catalyze deposition of bone mineral, and (3) incorporation of synthetic analogues to matrix vesicles that are the initial sites of biomineralization. Functionalization of the polymeric hydrogel backbone with negatively charged groups is a third mechanism to promote mineralization in otherwise inert hydrogels. This review summarizes the main strategies that have been developed in the past decade to calcify hydrogel matrices and render these hydrogels suitable for applications in bone regeneration.
Pleural effusion is a common diagnostic problem and a challenge to the thoracic surgeon. The anal... more Pleural effusion is a common diagnostic problem and a challenge to the thoracic surgeon. The analysis of serum and body fluids for tumor markers is an established diagnostic procedure. Among various markers, tumors are linked to the overexpression of a glycolytic isoenzyme, M2-pyruvate-kinase (M2-PK). This preliminary study evaluated this enzyme as a tumor marker to differentiate malignant from benign pleural effusion. Methods: The tumor M2-PK concentration was measured in the EDTA-plasma and pleural fluid of 34 patients with an established diagnosis of cancer, either primary of the chest (18) or secondary to chest (16) and in 34 controls with benign effusion. The concentration was quantitatively determined by an enzyme-linked immunosorbent assay. The cutoff level between negative and positive values of the tumor M2-PK was defined as the benign group's mean + 2SD (95% percentile). True-positives, false-positives, true-negatives, and false-negatives, were determined with 'positive' referring to histologically proven malignant effusion and 'negative' referred to as nonmalignant effusions. Sensitivity, specificity, positive predictive value, and negative predictive value were assessed. Results: The cutoff value was established at 7.61 U/ml for plasma and 32.9 U/ml for pleural fluid. Both plasma and pleural fluid levels of tumor M2-PK were significantly higher in patients with known chest malignancy, either primary or metastatic, compared to nonmalignant effusions (p < 0.001). Sensitivity in pleural fluid was significantly higher compared to plasma (85.7% vs 76.2%; p < 0.01). Moreover, negative predictive value was higher for pleural fluid compared to plasma (79.4% vs 70.8; p < 0.01) Conclusions: Tumor M2-PK marker is useful in differentiating malignant from benign pleural effusions. Moreover, its sensitivity and NPV in pleural fluid are significantly higher compared to plasma. The usefulness of such a test is not strictly diagnostic but aims at excluding poorly performing patients from further invasive procedures. Thus, the inclusion of M2-PK within a panel of well-known tumor markers such as CEA, MCA, Ca 125 and Ca 19-9, may help in increasing the overall sensitivity and specificity.
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Papers by Stefano Elia