BACKGROUND:Sarcomas are rare and heterogeneous malignancies arising from mesenchymal tissue, often requiring wide surgical resection that may result in large and complex soft and bony tissue defects needing complex reconstruction. Growing evidence indicates the added value of plastic surgery participation in multidisciplinary sarcoma care, yet evidence remains limited. METHODS:This retrospective single-center study included patients who underwent resection for soft-tissue or bone sarcoma at Ghent University Hospital between 2010 and 2022. The patients were categorized according to closure strategy during the index procedure (oncologic-only closure vs combined oncologic-plastic closure). Three multivariable logistic regression models were fitted. One model identified preoperative predictors of combined oncologic-plastic surgery, and two models assessed postoperative outcomes (seroma formation and R0 margin status by closure strategy). RESULTS:Of the 530 patients included, 409 (77.2 %) underwent primary tumor resection by the oncologic surgeon only, whereas 121 (22.8 %) had primary surgery performed by a combined oncologic-plastic team. Closure by the oncologic surgeon was independently predicted by upper leg location, whereas the combined oncologic-plastic operation was associated with myxofibrosarcoma histology, trunk location, high-grade tumors, and location superficial to the fascia. The combined oncologic-plastic approach reduced the formation of seroma. The R0 resection rates did not differ significantly between groups. CONCLUSION:This study may help define clearer indications for early reconstructive input during sarcoma surgery. Early integration of plastic surgery within a multidisciplinary sarcoma team enables more comprehensive surgical planning and may both facilitate radical resections and improve postoperative wound outcomes.

BACKGROUND:The role of surgery in pleural mesothelioma remains controversial. It may be appropriate in highly selected patients as part of a multimodality treatment including chemotherapy. Recent years have seen a shift from extrapleural pleuropneumonectomy toward extended pleurectomy/decortication. The most optimal sequence of surgery and chemotherapy remains unknown. METHODS:EORTC-1205-LCG was a multicentric, noncomparative phase 2 trial, 1:1 randomising between immediate (arm A) and deferred surgery (arm B), followed or preceded by chemotherapy. Eligible patients (Eastern Cooperative Oncology Group 0-1) had treatment-naïve, borderline resectable T1-3 N0-1 M0 mesothelioma of any histology. Primary outcome was rate of success at 20 weeks, a composite end-point including 1) successfully completing both treatments within 20 weeks; 2) being alive with no signs of progressive disease; and 3) no residual grade 3-4 toxicity. Secondary end-points were toxicity, overall survival, progression-free survival and process indicators of surgical quality. FINDINGS:69 patients were included in this trial. 56 (81%) patients completed three cycles of chemotherapy and 58 (84%) patients underwent surgery. Of the 64 patients in the primary analysis, 21 out of 30 patients in arm A (70.0%; 80% CI 56.8-81.0%) and 17 out of 34 patients (50.0%; 80% CI 37.8-62.2%) in arm B reached the statistical end-point for rate of success. Median progression-free survival and overall survival were 10.8 (95% CI 8.5-17.2) months and 27.1 (95% CI 22.6-64.3) months in arm A, and 8.0 (95% CI 7.2-21.9) months and 33.8 (95% CI 23.8-44.6) months in arm B. Macroscopic complete resection was obtained in 82.8% of patients. 30- and 90-day mortality were both 1.7%. No new safety signals were found, but treatment-related morbidity was high. INTERPRETATION:EORTC 1205 did not succeed in selecting a preferred sequence of pre- or post-operative chemotherapy. Either procedure is feasible with a low mortality, albeit consistent morbidity. A shared informed decision between surgeon and patient remains essential.

Non-small cell lung cancer (NSCLC) is known for high relapse rates despite resection in early stages. present the results of a phase I clinical trial in which a dendritic cell (DC) vaccine targeting patient neoantigens is evaluated in patients with resected NSCLC. Vaccine manufacturing is feasible enrolled patients. Toxicity is limited to grade 1-2 adverse events. Systemic T cell responses in five out of six vaccinated patients, with T cell responses remaining detectable up to 19 months nation. Single-cell analysis indicates that the responsive T cell population is polyclonal and exhibits entire spectrum of T cell differentiation states, including a naive-like state, but excluding exhausted states. Three of six vaccinated patients experience disease recurrence during the follow-up period Collectively, these data support the feasibility, safety, and immunogenicity of this treatment NSCLC.

A woman in her 30s, non-smoker, presented at the emergency department two times because of spontaneous pneumothorax. The first episode was treated with small bore catheter drainage, while during the second episode—occurring only 1 week later—thoracoscopic talcage was attempted. The postoperative course was characterised by slow clinical and radiological resolution, and recurrence 3 days after discharge. Eventually, multiportal video-assisted thoracoscopic exploration identified an interfissural solid mass. Resection and further work-up revealed the diagnosis of ‘low-risk’ solitary fibrous tumour (SFT) stage pT1N0M0. The interdisciplinary tumour board advised no adjuvant therapy. A CT thorax was scheduled in 1 year for follow-up. The patient was discharged without complications and has had no recurrences of pneumothorax at 6 months of follow-up. This report shows that SFT can easily be missed on initial presentation and should be considered in the differential diagnosis of pneumothorax, especially when frequently recurring.

Introduction Coronavirus disease 2019 (COVID-19) leads to thoracic complications requiring surgery. This is challenging, particularly in patients supported with venovenous extracorporeal membrane oxygenation (VV-ECMO) due to the need for continuous therapeutic anticoagulation. We aim to share our experience regarding the safety and perioperative management of video-assisted thoracic surgery for this specific population. Methods Retrospective, single-center study between November 2020 and January 2022 at the ICU department of a 1.061-bed tertiary care and VV-ECMO referral center during the COVID-19 pandemic. Results 48 COVID-19 patients were supported with VV-ECMO. A total of 14 video-assisted thoracic surgery (VATS) procedures were performed in seven patients. Indications were mostly hemothorax (85.7%). In eight procedures heparin was stopped at least 1 h before incision. A total of 10 circuit changes due to clot formation or oxygen transfer failure were required in six patients (85.7%). One circuit replacement seemed related to the preceding VATS procedure, although polytransfusion might be a contributing factor. None of the mechanical complications was fatal. Four VATS-patients (57.1%) died, of which two (50%) immediately perioperatively due to uncontrollable bleeding. All three survivors were treated with additional transarterial embolization. Conclusion (1) Thoracic complications in COVID-19 patients on VV-ECMO are common. (2) Indication for VATS is mostly hemothorax (3) Perioperative mortality is high, mostly due to uncontrollable bleeding. (4) Preoperative withdrawal of anticoagulation is not directly related to a higher rate of ECMO circuit-related complications, but a prolonged duration of VV-ECMO support and polytransfusion might be. (5) Additional transarterial embolization to control postoperative bleeding may further improve outcomes.

INTRODUCTION:To report a case of radiation necrosis after reirradiation for breast cancer and the difficulties encountered when treating these complex cases.PATIENTS AND METHODS:We present an 86-year-old woman with a history of right-sided intraductal breast cancer treated with a right mastectomy followed by local adjuvant radiotherapy (50 Gray). Twelve years later, she was diagnosed with a local recurrence in the mastectomy scar which was treated with local resection (including resection of rib four) and adjuvant radiotherapy up to 32 Gray. In July 2020 she presents at the Department of Plastic and Reconstructive Surgery with a chronic ulcer on the right-sided hemithorax.RESULTS:A multi-staged, multidisciplinary approach was necessary to secure lasting coverage of the extensive defect.CONCLUSION:Thoracic radiation necrosis should be subject to a multidisciplinary approach (plastic and thoracic surgeons) pre-, per-, and post-operatively. Each case may require a different surgical approach depending on the size and depth of the defect, patients' age, comorbidities, and previous medical treatment.

Background Research grade Fresh Frozen (FF) DNA material is not yet routinely collected in clinical practice. Many hospitals, however, collect and store Formalin Fixed Paraffin Embedded (FFPE) tumor samples. Consequently, the sample size of whole genome cancer cohort studies could be increased tremendously by including FFPE samples, although the presence of artefacts might obfuscate the variant calling. To assess whether FFPE material can be used for cohort studies, we performed an in-depth comparison of somatic SNVs called on matching FF and FFPE Whole Genome Sequence (WGS) samples extracted from the same tumor. Methods Four variant callers (i.e. Strelka2, Mutect2, VarScan2 and Shimmer) were used to call somatic variants on matching FF and FFPE WGS samples from a metastatic prostate tumor. Using the variants identified by these callers, we developed a heuristic to maximize the overlap between the FF and its FFPE counterpart in terms of sensitivity and precision. The proposed variant calling approach was then validated on nine matched primary samples . Finally, we assessed what fraction of the discrepancy could be attributed to intra-tumor heterogeneity (ITH), by comparing the overlap in clonal and subclonal somatic variants. Results We first compared variants between an FF and an FFPE sample from a metastatic prostate tumor, showing that on average 50% of the calls in the FF are recovered in the FFPE sample, with notable differences between callers. Combining the variants of the different callers using a simple heuristic, increases both the precision and the sensitivity of the variant calling. Validating the heuristic on nine additional matched FF-FFPE samples, resulted in an average F1-score of 0.58 and an outperformance of any of the individual callers. In addition, we could show that part of the discrepancy between the FF and the FFPE samples can be attributed to ITH. Conclusion This study illustrates that when using the correct variant calling strategy, the majority of clonal SNVs can be recovered in an FFPE sample with high precision and sensitivity. These results suggest that somatic variants derived from WGS of FFPE material can be used in cohort studies.

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery III (MP76)1 Apr 2019MP76-15 ROBOT-ASSISTED KIDNEY AUTOTRANSPLANTATION (RAKAT): UPDATE FROM THE FIRST SERIES IN EUROPE Benjamin Van Parys*, Jeroen Van Besien, Nicolas Doumerc, Liesbeth Desender, Caren Randon, Frederic De Ryck, Thomas Tailly, Matthias Beysens, Carl Van Haute, Diederik Ponette, Kathia De Man, Piet Hoebeke, Frank Vermassen, and Karel Decaestecker Benjamin Van Parys*Benjamin Van Parys* More articles by this author , Jeroen Van BesienJeroen Van Besien More articles by this author , Nicolas DoumercNicolas Doumerc More articles by this author , Liesbeth DesenderLiesbeth Desender More articles by this author , Caren RandonCaren Randon More articles by this author , Frederic De RyckFrederic De Ryck More articles by this author , Thomas TaillyThomas Tailly More articles by this author , Matthias BeysensMatthias Beysens More articles by this author , Carl Van HauteCarl Van Haute More articles by this author , Diederik PonetteDiederik Ponette More articles by this author , Kathia De ManKathia De Man More articles by this author , Piet HoebekePiet Hoebeke More articles by this author , Frank VermassenFrank Vermassen More articles by this author , and Karel DecaesteckerKarel Decaestecker More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000557307.93315.ccAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: Kidney autotransplantation (KAT) is the ultimate way to salvage kidneys with complex renovascular, ureteral or malignant pathologies that are not amendable to in situ reconstruction. Minimal invasive approach could broaden its adoption, due to the lower morbidity and high quality of anastomosis. We give an update of perioperative parameters and early (3 months) functional outcomes of the first robot-assisted kidney autotransplantation (RAKAT) series. METHODS: 10 patients underwent RAKAT (male/female 3/7; left/right 8/2), for complex ureteral strictures (8), severe left renal vein nutcracker (1) and loin-pain hematuria syndrome (1), between March 2017 and September 2018. Alternatives discussed with the patients were laparoscopic nephrectomy, Boari flap and ileal interposition. All patients gave written informed consent. In 9 patients the kidney was exteriorised for preparation on the bench; 2 patients underwent table top vascular reconstruction and 1 ex vivo flexible ureteroscopy to extract a 6 mm lower pole lithiasis. The technique is presented in the enclosed figure. RESULTS: RAKAT was successful in all patients. Mean operative and console time was 405 and 304 min with median vascular and ureteral anastomosis time 25 and 23 min. Median warm, cold and rewarming ischemia time was 3, 175 and 48 min respectively. No patient needed open conversion. 3 patients had a major 90d postoperative complication (grade 3b): wound dehiscence needing wound revision, stent dislodgment needing repositioning and left calf compartment syndrome needing fasciotomy without lasting disability. Median hospital stay was 6 days. At 3 months, all patients were free of indwelling stents, pain or hematuria and showed good vascularisation and absence of hydronephrosis of the autograft on ultrasound. Nuclear DMSA and Cr-EDTA scans 3 months postop showed no transplant kidney function loss in 5, a significant GFR drop in 2 and a significant GFR increase in 3 autotransplants. CONCLUSIONS: We describe the first series of a minimal invasive technique for KAT. RAKAT is a promising approach to salvage kidneys in selected patients with complex and disabling ureteral or renal pathology. RAKAT resolves the disabling symptoms and results in good function of the autotransplant at 3 months. Source of Funding: none Ghent, Belgium; Toulouse, France; Ghent, Belgium; Ostend, Belgium; Ghent, Belgium© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e1128-e1129 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Benjamin Van Parys* More articles by this author Jeroen Van Besien More articles by this author Nicolas Doumerc More articles by this author Liesbeth Desender More articles by this author Caren Randon More articles by this author Frederic De Ryck More articles by this author Thomas Tailly More articles by this author Matthias Beysens More articles by this author Carl Van Haute More articles by this author Diederik Ponette More articles by this author Kathia De Man More articles by this author Piet Hoebeke More articles by this author Frank Vermassen More articles by this author Karel Decaestecker More articles by this author Expand All Advertisement PDF downloadLoading ...

Problems: A 48-year-old female patient presented with a left cervical thoracic duct cyst. Most previous reports on thoracic duct cysts have described open surgery' with excision and ligation. However, less invasive treatment methods have proven effective. Methodology: Here, we describe a thoracic duct cyst that was refractory to aspiration or upstream clipping of the thoracic duct via video-assisted thoracoscopic surgery (VATS). Eventually, we performed percutaneous sclerotherapy with OK-432 (Picibanil). Analysis of a fine-needle aspirate of the cystic mass confirmed the diagnosis. Results: Minimally invasive management with sclerotherapy completely resolved the cyst. Conclusions: Thoracic duct cysts can be treated successfully with a non-surgical sclerotherapy approach. Clipping the thoracic duct via VATS can prevent chyle accumulation in the thoracic duct cyst and resolve chyle leakage. Consequently, an open surgical approach can be avoided, but remains optional, in case minimally invasive management is unsuccessful.

The authors declare no conflicts of interest.

Background Kidney autotransplantation (KAT) is the ultimate way to salvage kidneys with complex renovascular, ureteral, or malignant pathologies that are not amenable to in situ reconstruction. A minimally invasive approach could broaden its adoption. Objective To describe operative technique, perioperative complications, and early functional outcomes of robot-assisted kidney autotransplantation (RAKAT). Design, setting, and participants Retrospective review of prospectively collected data regarding consecutive patients undergoing RAKAT between March 2017 and February 2018 at two university hospitals. Intervention RAKAT. Outcome measurements and statistical analysis Technical feasibility, perioperative complications, and early functional results. Results and limitations Seven patients underwent RAKAT (three male and four female; five left and two right; one totally intracorporeal) for complex ureteral strictures (n = 5), severe left renal vein nutcracker (n = 1), and loin pain hematuria syndrome (n = 1). Two patients underwent bench vascular reconstruction and one patient underwent ex vivo flexible ureterorenoscopy. No patient needed open conversion. Median operative and console time was 370 and 255 min, respectively, with median vascular and ureteral anastomosis time of 28 and 23 min, respectively. Median warm, cold, and rewarming ischemia time was 2, 178, and 44 min, respectively. One major postoperative complication occurred—wound dehiscence needing wound revision (grade 3b). Median hospital stay was 5 d. At 3 mo, all patients were free of indwelling stents, pain, or hematuria. Median serum creatinine at 3 mo was 0.80 mg/dl and median calculated autotransplant glomerular filtration rate did not drop significantly. Conclusions RAKAT is feasible, safe, and results in good functioning of the autotransplant in selected patients with complex ureteral strictures, loin pain hematuria, or severe nutcracker syndrome. Larger studies with longer follow-up are needed to confirm these findings and to test whether RAKAT is feasible for other KAT indications. Patient summary We describe the first series worldwide of a minimally invasive technique for kidney autotransplantation. Robot-assisted kidney autotransplantation is a safe and feasible approach to prevent nephrectomy for intractable symptoms in selected patients with complex ureteral or renal pathology.

BACKGROUND Patients with clinical N1 (cN1) lung cancer based on imaging are at risk for malignant mediastinal nodal involvement (N2 disease). Endosonography with a needle technique is suggested over surgical staging as a best first test for preoperative invasive mediastinal staging. The addition of a confirmatory mediastinoscopy seems questionable in patients with a normal mediastinum on imaging. This prospective multicenter trial investigated the sensitivity of preoperative linear endosonography and mediastinoscopy for mediastinal nodal staging of cN1 lung cancer. METHODS Consecutive patients with operable and resectable cN1 non-small cell lung cancer underwent a lobe-specific mediastinal nodal staging by endosonography. The primary study outcome was sensitivity to detect N2 disease. The secondary end points were the prevalence of N2 disease, the negative predictive value (NPV) of both endosonography and endosonography with confirmatory mediastinoscopy, and the number of patients needed to detect one additional N2 disease with mediastinoscopy. RESULTS Of the 100 patients with cN1 on imaging, 24 patients were diagnosed with N2 disease. Invasive mediastinal nodal staging with endosonography alone has a sensitivity of 38%, which can be increased to 73% by adding a mediastinoscopy. NPV was 81% and 91%, respectively. Ten mediastinoscopies are needed to detect one additional N2 disease missed by endosonography. CONCLUSIONS Endosonography alone has an unsatisfactory sensitivity to detect mediastinal nodal metastasis in cN1 lung cancer, and the addition of a confirmatory mediastinoscopy is of added value. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01456429; URL: www.clinicaltrials.gov.

OBJECTIVE:Omnidirectional articulated instruments enhance dexterity. In neurosurgery, for example, the simultaneous use of 2 instruments through the same endoscopic shaft remains a difficult feat. It is, however, very challenging to manufacture steerable instruments of the requisite small diameter. We present a new technique to produce such instruments by means of laser cutting. Only 3 coaxial tubes are used. The middle tube has a cutting pattern that allows the steering forces to be transmitted from the proximal to the distal end. In this way the steering part is concealed in the wall of the tube. Large diameter articulated instruments such as for laparoscopy might benefit from the excellent tip stability provided by the same economical technology.METHOD:Coaxial nitinol tubes are laser-cut with a Rofin Stent Cutter in a specific pattern. The 3 tubes are assembled by sliding them over one another, forming a single composite tube. In a surgical simulator, the neurosurgical microinstruments and laparoscopic needle drivers were evaluated on surgical convenience.RESULTS:Simultaneous use of 2 neurosurgical instruments (1.5 mm diameter) through the same endoscopic shaft proved to be very intuitive. The tip of the steerable laparoscopic instruments (10 mm diameter) could resist a lateral force of more than 20 N. The angle of motion for either instrument was at least 70° in any direction.CONCLUSIONS:A new design for steerable endoscopic instruments is presented. It allows the construction in a range from microinstruments to 10-mm laparoscopic devices with excellent tip stability.

The aneurysms-osteoarthritis syndrome (AOS) was recently described and encompasses multiple aneurysms and tortuosity of the great arteries. Most patients have early-onset osteoarthritis. We report the diagnosis, treatment, and follow-up of a patient presenting with bilateral aneurysms of the common iliac arteries and an ascending aortic aneurysm. After proper surgical treatment, genetic studies revealed a causal mutation in the SMAD3 gene. (Ann Thorac Surg 2013;95:332-5) (C) 2013 by The Society of Thoracic Surgeons