BACKGROUND:Technological advances and widely spread screening programs enabled the discovery of ever smaller lesions. As such, in the last years, the tendency has shifted towards lung-sparing procedures. The role of limited surgical excision for small peripheral nodules is currently a topic of heated debate. AIM:In our work, we try to answer whether the segmentectomy could adequately treat the peripheral NSCLC staged as Tis/1a-bN0M0. MATERIALS AND METHODS:Our analysis is a single-center retrospective study based on the 8-year experience of our department. We identified 73 lobectomy patients and 16 segmentectomy patients. However, the lack of similarity between the two groups made it inadequate to draw satisfactory conclusions, therefore we reduced the lobectomy group and selected only those patients who could be paired with corresponding patients in the segmentectomy group. The established parameters of similarity were age (weighted at 15%), size of the lesion (50%), and follow-up (35%), and the input values were normalized. With this method, we could compare two samples of the most similar patients. 32 cases were included in the final analysis. The inclusion criteria were: NSCLC histology, size up to 2 cm, no visceral pleura invasion, N0 disease, and performed segmentectomy or lobectomy between Jan/2015 and Dec/2022. We analyzed the disease-free time and relapse rate. RESULTS:Data refers to a total of 32 patients distributed in two groups: group A with 16 segmentectomies (S6, S1+2 or S1) and group B with 16 lobectomies. The mean time of follow-up was 30 months (1-85) for group A and 32 months (1-91) for group B. The disease-free survival was 27 months for group A and 31 months for group B. The relapse rate was 19% for segmentectomies and 12.5% for lobectomies. CONCLUSIONS:In conclusion, while this article presents our center's experience with segmentectomy, we believe further studies with larger sample sizes are needed to establish its non-inferiority. Nevertheless, our experience indicates that segmentectomy offers significant benefits, including lung preservation and the potential for future resections.

INTRODUCTION:Mesothelioma is a devastating, insidious disease with a long latency period. Its peak incidence occurs in the 5th and 6th decades of life, up to 40 years after asbestos exposure which is strongly related to the disease. The optimal treatment is the object of an intense discussion. AIMS:The established outcomes were disease-free survival (DFS) and 1-year survival analyzed in the context of neoadjuvant chemotherapy with subsequent surgery, surgical intervention without any systemic treatment, an upfront surgery and adjuvant chemotherapy and surgical intervention with both neo- and adjuvant therapy to establish the most advantageous treatment in terms of oncological results. MATERIALS AND METHODS:We analyzed our center's surgical experience with radical surgery for mesothelioma, evaluating the disease-free time and 1-year survival in relation to the treatment scheme. A search of the department's surgical database for mesothelioma cases between January 2016 and December 2020 revealed 16 cases, which were included in the final analysis. The established outcomes were disease-free survival and 1-year survival. RESULTS:The 3 patients treated with surgery without any systemic treatment had a median follow-up period (MFUP) of 7 months (3- 12), 67% of recurrence, DFS of 6 months (0-12), and 1-year survival of 33%. The 6 patients treated with neoadjuvant chemotherapy, surgical resection, and adjuvant therapy, had an MFUP of 45 months (8-82), 67% of recurrence, DFS of 32 months (2-82), and 1-year survival of 83%. The 1 patient, treated with neoadjuvant chemotherapy and subsequently, surgery had a follow-up of 29 months with DFS of 20 months and he was alive at the time of submission of this article. The 6 patients treated with an up-front surgery and adjuvant chemotherapy had an MFUP of 20 months (8-33), 67% of recurrence, DFS of 15 months (6-33), and 1-year survival of 67%. CONCLUSION:Despite the limitations of the study, the multimodal approach with both neoadjuvant and adjuvant chemotherapy demonstrated the longest MFUP, DFS, and 1-year survival. The worst results were observed in patients treated only with radical surgery, while the sequence of systemic treatment did not influence the rate of recurrence.

INTRODUCTION:Complete radical resection is crucial for successfully treating thymic carcinomas. However, when the invasion of the great vessels or the heart in Masaoka III and IV stages occurs, the management poses more challenges. The R0 resection often requires neoadjuvant treatment. We present an example of a debatable case in which a treatment decision was guided by an imminent risk to the patient's life. CASE DESCRIPTION:We report the case of a 74-year-old female with a mediastinal mass invading the superior vena cava (SVC) and the right atrium (RA), which was successfully treated with radical resection. The procedure under the femoro-femoral CardioPulmonary Bypass (CPB) included resection of the right intra-auricular mass and the SVC followed by the interposition of a Gore-Tex conduit between the left innominate vein and RA and also wedge resection of the upper left (LUL) and right lobes (RUL). A final histopathological examination confirmed the diagnosis of squamous cell carcinoma. CONCLUSIONS:Complete radical resection is essential for successful treatment and represents the most significant prognostic factor.

Aim: Lung cancer is the most common cause of cancer death in Portugal. The Dutch–Belgian lung cancer screening (LCS) study (NELSON), the biggest European LCS study, showed a lung cancer mortality reduction in a high-risk population when being screened. In this study, the cost–effectiveness of LCS, based on the NELSON study protocol and outcomes, was evaluated compared with no screening in Portugal. Methods: The present study modified an established decision tree by incorporating a state-transition Markov model to evaluate the health-related advantages and economic implications of low-dose computed tomography (LDCT) LCS from the healthcare standpoint in Portugal. The analysis compared screening versus no screening for a high-risk population aged 50–75 with a smoking history. Various metrics, including clinical outcomes, costs, quality-adjusted life years (QALYs), life-years (LYs) and the incremental cost–effectiveness ratio (ICER), were calculated to measure the impact of LDCT LCS. Furthermore, scenario and sensitivity analyses were executed to assess the robustness of the obtained results. Results: Annual LCS with volume-based LDCT resulted in €558 million additional costs and 86,678 additional QALYs resulting in an ICER of €6440 per QALY for one screening group and a lifetime horizon. In total, 13,217 premature lung cancer deaths could be averted, leading to 1.41 additional QALYs gained per individual diagnosed with lung cancer. Results are robust based on the sensitivity analyses. Conclusion: This study showed that annual LDCT LCS for a high-risk population could be cost-effective in Portugal based on a willingness to pay a threshold of one-time the GDP (€19,290 per QALY gained).

INTRODUCTION:Myasthenia gravis (MG) is an autoimmune, neurologic disease that causes a wide range of symptoms. While the transsternal, transcervical and thoracotomy approaches are accepted as effective, there is still debate regarding the VATS approach.MATERIALS AND METHODS:We analyzed our center's surgical experience with thymectomy for myasthenia gravis, comparing the results of patients operated on using VATS and more invasive approaches, over a period of 10 years. A search of the department's surgical database for myasthenia gravis cases between January 2010 and January 2021, revealed a total of 40 cases. Twenty-four patients were included in the final analysis and were distributed into two groups: the VATS procedure group (group A) and the open procedure group (group B). The latter included sternotomy, thoracotomy, transcervical and hemiclamshell approaches. Only radical thymectomies were included. The established outcomes were clinical improvement defined as asymptomatic remission, reduction, or discontinuation of the medication necessary to achieve optimal symptom control.RESULTS:The median follow-up time was 27 months (ranging from 4 to 75 months). Videothoracoscopy radical thymectomy was performed on 12 patients. Complete remission with no medication was achieved in 1 case (8.3%), while 2 patients (16.7%) became asymptomatic with reduced medication. An improvement (reduced symptoms or decreased medication) was observed in 8 cases (66.6%). No change in clinical outcome was noted in 1 patient (8.3%). None of the patients reported worsening symptoms. Open thymectomy was performed on 12 patients. Complete remission with no medication was achieved in 1 case (8.3%), while 2 patients (16.7%) became asymptomatic with reduced medication. An improvement was noted in 6 cases (50%). No change in clinical outcome was observed in 3 patients (25%) whereas 2 of them (16.7%) experienced slightly better symptom control but with a significant increase in medication. One patient (8.3%) described the clinical results as without any significant change. None of the patients reported worsening symptoms.CONCLUSION:The videotoracoscopic approach in the treatment of myasthenia gravis is non-inferior compared to the open approach and effective in a long-term follow-up, offering all the additional benefits of less invasive surgery.

Male, 71 year-old, asymptomatic, former smoker and previous history of lung tuberculosis. Referred to outpatient clinic due to left lower lobe consolidation diagnosed on non-contrasted CT scan, with increased uptake on PET-CT. Then, a contrast-enhanced CT scan revealed extralobar pulmonary sequestration with venous drainage to the left azygos vein (Blue arrow) and a double branch arterial supply from the thoracic aorta (Red arrow).

The need for complete resection of chest wall tumors creates a huge challenge in terms of reconstructing the complex dynamics of the thorax. We are reporting a case of a low-grade fibromyxoid sarcoma (LGFMS) diagnosed in a young male, where the complete resection of the mass, sternum and parcially the pericardium was performed. Subsequently, a composite porous high-density polyethylene StarPore® prosthesis of the sternum and costal arches was used and the latissimus dorsi muscle free flap with skin graft was implanted over the sternum.

Background and Objective: In thoracic surgery, different modalities of extracorporeal life support (ECLS) can be used for cardiorespiratory support in complex scenarios. Decades of learning in clinical practice and physiology associated with technological development led to a great variety of ECLS technologies available. Thoracic surgery procedures with difficult or impossible single lung ventilation may still be performed using different ECLS modalities. The aim of this review is to describe the use of ECLS, with its different modalities, as a solution to perform complex surgeries in a patient with difficult or impossible single lung ventilation.Methods: A literature review was conducted using the terms "extracorporeal life support pulmonary resection" and "extracorporeal life support thoracic surgery", and articles were selected according to defined criteria.Key Content and Findings: To support lung function during thoracic surgery, the most efficient and popular variety of ECLS is venovenous extracorporeal membrane oxygenation. Lung resection on a single lung after pneumonectomy, surgery in a patient with severe hypercapnia and/or low respiratory reserve, carinal and airway surgery, and severe thoracic trauma are the main examples of situations where ECLS may be the solution to provide a safe surgical environment in patients who cannot tolerate single lung ventilation. Multidisciplinarity, selection of patients and careful surgical planning are cornerstones in defining the situations that may benefit from ECLS support.Conclusions: Knowledge on techniques of ECLS are essential for every thoracic surgeon. Although rarely used, these techniques of cardiorespiratory support should be considered when planning complex cases with difficulties in ventilation and emergent situations.

We report a case of a 67-years old non-smoking female diagnosed with hypertension when 24-years-old and complicated with chronic kidney and hypertensive heart diseases. On CT-Chest an incidental discovery of a lesion (16x14x23mm) adjacent to the abdominal aorta was made. Initially suspected to be paraganglioma, a hypothesis which the subsequent MRI did not exclude. Urine analysis showed normal Metanephrine with slightly elevated Chromogranin-A levels. During VATs-procedure "bulging" below the adventitial layer of the descending aorta at the level of the diaphragmatic gutter was identified. By opening the adventitia, a lipomatous lesion with a nodular, consistent center was identified and excised. Final histopathological report confirmed the diagnosis of lymph node not suggestive of neoplasia. Currently, 12 months after the surgery, the patient's condition is good being under surveillance in the Thoracosurgical Outpatient Clinic. Despite not having identified any neuroendocrine component, the patient had clinical signs of clear improvement of arterial hypertension.

INTRODUCTION:Mediastinal staging is a hot topic in thoracic oncology. According to the guidelines, and besides other criteria, in the presence of a primary lung cancer with increased mediastinal lymph node uptake on PET-CT, a negative result after lymph node sampling by Endobronchial Ultrasound (EBUS) is not enough to rule out mediastinal lymph node involve- ment, demanding a cervical mediastinoscopy to vouch for the results.METHODS AND OBJECTIVES:In order to study the percentage of lymph node surgical upstaging in patients with neg- ative mediastinal node staging by EBUS and evaluate the role of mediastinoscopy in these patients, we conducted a search in our department's database using the key-word EBUS in the period concerned between January 2014 and August 2020. A total of 302 patients were found. After applying defined criteria, we obtained 42 cases.RESULTS:Lymph node surgical upstaging occurred in 11 (26%) patients, of which 8 were upstaged to N2 and 3 to N1. Most of the cases were single station. Only in 5 (12% of the total) of the 11 patients, the upstaging was related to lymph node stations previously sampled by EBUS. Upstaging was more frequent among males and lower lobe tumours.DISCUSSION AND CONCLUSIONS:Regarding the 8 upstage cases for N2, 5 were single station. Of these 8 cases, only 5 would be approachable by cervical mediastinoscopy. Furthermore, 2 of them were single station, eligible for upfront surgery. Then, only in 3 (7%) of the 42 cases cervical mediastinoscopy would be of foremost importance.

Background: Hemangioblastomas commonly occur in the posterior fossa and are typically attributed to sporadic or familial Von Hippel–Lindau disease. Spinal hemangioblastomas, found in 7–10% of patients, are usually located within the cord (i.e., intramedullary). Here, a 58-year-old male presented with a purely extradural hemangioblastoma involving a spinal root that was surgically excised. Case Description: A 58-year-old male was admitted with a progressive paraparesis and incomplete sensory deficit. The magnetic resonance imaging documented a solid dumbbell-shaped lesion that extended through the left T3-T4 foramen resulting in nerve root and spinal cord compression. Following arterial embolization and lesion excision by both neurosurgeons and thoracic surgeons, the patient’s deficits improved. The postoperative computed tomography scan documented complete tumor removal, and the neuropathology revealed a hemangioblastoma. Conclusion: Here, we describe a 58-year-old male with a purely extradural thoracic foraminal T3-T4 dumbbell-shaped hemangioblastoma successfully treated by both embolization and surgical excision.

An 18-year-old boy presented with a giant midline mass with 9 years of evolution. The tumor was excised, and reconstruction made with a customized sternum implant and a free latissimus dorsi muscle flap with skin graft. Histological analysis was compatible with low-grade fibromyxoid sarcoma (LGFMS).

OBJECTIVES:Identify risk factors for major perioperative complications (MPC) after anatomical lung resection for NonSmall-Cell Lung Cancer (NSCLC) and establish a scoring system. METHODS:Single center retrospective study of all consecutive patients diagnosed with NSCLC submitted to anatomical lung resection from 2015 to 2019 (N=564). EXCLUSION CRITERIA:previous lung surgery, concomitant non-lung cancer related procedures, urgency surgery. STUDY POPULATION:520 patients. PRIMARY END-POINT:MPC defined as a composite endpoint including at least one of the in-hospital complications. Univariable and Multivariable analyses were developed to identify predictors of perioperative complications and create a risk score. Discrimination was assessed using the C-statistic. Calibration was evaluated by Hosmer and Lemeshow test and internal validation was obtained by means of bootstrap replication. RESULTS:Mean age of 65 years and 327 (62.9%) were males. Mean hospital stay of 9 days after surgery. Overall MPC rate was 23.3%. Male gender, hypertension, FEV1<75%, thoracotomy, bilobectomy/pneumectomy and additional resection were independent predictors of MPC. A risk score based on the odds ratios was developed - Major Perioperative Complications of Lung Resection (MPCLR) scoring system - and ranged between 0 and 14 points. It was divided in 5 groups: 1-2 points (positive preditive value 15%); 3-4 (PPV 25%); 5-7 (PPV 35%); 8-9 (PPV 60%); >10 points (PPV 88%). The score showed rea- sonable discrimination (C-statistic=0.70), good calibration (P=.643) and it was internally validated (C-statistic=0,70 BCa95% CI,0.65-0.79). CONCLUSIONS:This study proposes a simple and daily-life risk score system that was able to predict the incidence of perioperative complications.

Solitary fibrous tumor of the pleura (SFTP) is a rare tumor. The prognosis is relatively good, but up to 20% of the cases are malignant. We presented a case of a large mass of the thorax, showing malignant poor prognosis features.A 73-year-old male, former smoker, presented with a history of dry cough. Chest CT revealed a left bronchopulmonary mass (11 cm × 14 cm) extending from the costal pleura to the left hilum. Histopathologic examination of the transbronchial lung biopsy was consistent with SFTP. A left pneumonectomy was performed due to invasive nature of the lesion.According to features associated to poor prognosis (lung tumor ≥ 10 cm, hipercellularity, abundant intratumor blood vessels and areas of necrosis), and in spite of proliferation index (Ki67+) <1%, the case was discussed in a multidisciplinary meeting, and was assumed to be malignant. At the present time, the patient is his fifth month after surgery, in tight follow up.This case highlights a rare SFTP presenting bad prognosis features, that although completely resected should have long-term follow-up due to the high risk of recurrence.

Chest wall tumours are challenging subjects. In the present article we describe a case of a 51 year old female who developed an angiosarcoma eight years after radiotherapy treatment due to left breast cancer at age 41. She had resection of the anterior segments of the 3rd to 5thribs followed by chest wall reconstruction, using MatrixRib fixation system®, Marlex® mesh and latissimus dorsi muscle flap. After two years the angiosarcoma relapsed. Considering the predicted extent of the chest wall resection, a reconstruction using titanium plates was not an option, so we opted to shape neo-ribs of Methyl Methacrylate using rubber drains as a mold. It affords very good anatomical contour of the chest wall and more physiological function than other options, although only long-term follow-up and future studies will determine the performance of this method.

OBJECTIVES:Compare the incidence of Postoperative atrial fibrillation (PAF) after anatomical lung resection for Non- Small-Cell Lung Cancer (NSCLC) following open surgery versus VATS.METHODS:Single center retrospective study of all consecutive patients diagnosed with NSCLC submitted to anatomical lung resection from 2015 to 2019 (N=564).EXCLUSION CRITERIA:prior atrial fibrillation, previous lung surgery, concomitant procedures, pneumectomy, non-pulmonary resections, urgency surgery. Study population of 439 patients.PRIMARY END-POINT:incidence of PAF. Univariable analysis was used to compare the baseline characteristics of the 2 groups. Inverse probability of treatment weighting (IPTW) multivariable logistic regression was used including 23 clinical variables to analyze the effect of the approach. The balance was assessed by standardized mean differences.RESULTS:Thoracotomy was performed in 280 patients (63.8%) and 159 (36.2%) were submitted to VATS. Patients submitted to VATS were more likely to be females, had a lower prevalence of non-adenocarcinoma cancer, stage TNM IIIIV, Diabetes Mellitus, respiratory disease, and chronic heart failure. They were submitted less often to neoadjuvant therapy, bilobectomy and they presented higher levels of diffusing capacity for carbon monoxide. After IPTW adjustment, all clinical covariates were well balanced. PAF occurred in 8.6% of the patients undergoing thoracotomy and 3,8% of the patients after VATS. After IPTW adjustment, VATS was not associated with a lower incidence of PAF (OR 0.40; CI95%:0.140-1.171; p=0.095).CONCLUSION:In this study, minimally invasive non-rib spreading VATS did not decrease the incidence of PAF when compared with standard thoracotomy regarding anatomical lung resection for NSCLC.

Pancoast tumours are defined as tumours arising from the upper lobe and invading the thoracic inlet,representing less than 5% of all lung cancers. Clinical features depend on the involved structures. For many years invasion of the spine was considered unresectable and fatal. Due to the progress in spine surgery, en bloc resection including the spine is nowadays possible. We report the first case of a successful en bloc vertebral resection of a Pancoast tumour in a 66 year-old male, with a squamous cell carcinoma, treated at our department in a multidisciplinary setting, after induction chemoradiotherapy. An en bloc resection including the left upper lobe, the first three ribs and the vertebral body of D2, was performed through a Paulson incision after posterior cervico-dorsal arthrodesis. A complete R0 resection was confirmed on the pathology specimen. Currently, one year after surgery, although no local recurrence has occurred, the patient is being treated with immunotherapy due to disease progression in the right acetabulum which was irradiated (20Gy) and then submitted to iliac resection and prothesis reconstruction.

Introduction Solitary fibrous tumors of the pleura (SFTP) are rare, slowly growing pleural neoplasms. Patients are usually diagnosed in their 5th to 8th decade, without associated symptoms. The best treatment consists of margin free surgical resection (R0). Objectives We analysed our center's surgical experience with SFTP, describing the demographic and individual patient/tumor characteristics, the surgical options and results over a period of 20 years. Materials and Methods The Department's database was searched for SFTP between January 2000 and July 2020, resulting in total of 58 cases. 51 patients were included in the final analysis. Results 31 were women (61%) and 20 men (39%). Most (88%) were diagnosed over age 50, the average age being 60.2 years (range 30 - 78). Symptoms were present in 43% of the patients (22 cases), most commonly coughing, dyspnea or unspecific symptoms (weight loss, tiredness, anorexia). Thoracalgia was present in 17.6% (9) and 7.8% (4) had finger clubbing and polyarthralgia. Doege-Potter syndrome was found in one case (1.9%) and completely resolved after surgery. The largest tumor diameter was 22 cm and the smallest one 2 cm, with an average size of 6,62 cm. Videothoracoscopy was performed in 35% (18 cases) and thoracotomy in the remaining 33 (65%). R0 ressection rate was 90.2%. Lung resection, along with the mass, was performed whenever the origin was the visceral pleura, to insure a safe margin: wedge resection in 49% (25 cases), lobectomy in 5.9% (3 cases) and bilobectomy and pneumonectomy each in 1.9% (one case). Other structural en-bloc resections were also necessary at times: ribs in one case (1.9%) and diaphragm in 2 (3.9%). Predictors of recurrency were present in 30 patients: pleural effusion (1 case, 1.9%), atypical localization (41.2%; 21 cases), histological criteria for malignancy (7 cases,13.7%) and border-line in 1 (1.9%). There were 4 recurrences (7.8%). 3 out of these 4 patients had an atypical localization of the tumor defined as parietal or costal/cisural pleura. In all cases the resection was deemed complete, none had histological criteria for malignancy, but necrosis was present in 3 cases and atypia in the other 2. Disease free survival was 49 months (range 13 - 105). Conclusions Solitary fibrous tumors of the pleura are characterized by uncertain behavior. They often present as large assymptomatic masses. En bloc complete resection is the most important prognostic factor. Relapse can occur more than a decade after the initial diagnosis.

A 19 years-old woman, on her 17th week of pregnancy presented to the emergency department with thoracic pain and vomiting. An empyema was diagnosed and she was transferred to a tertiary hospital for treatment. After drainage of the empyema a mediastinal mass was detected and a thoracic MRI revealed a multicystic lesion of the anterior mediastinum, causing cardiac and left lung compression, suggestive of a complicated teratoma. After a multidisciplinary discussion involving pulmonology, radiology, obstetrics and thoracic surgery, she was operated successfully by clamshell incision. A mature complicated teratoma was resected and a left pleurectomy/decortication performed. She was discharged on day 17 with no obstetrical or respiratory symptoms..