OBJECTIVES:The surgical treatment of multiple synchronous bilateral primary lung cancer (mSBPLC) showed promising results and the aims of this retrospective study were to assess the oncologic outcomes and the presence of risk factors of worse survival. METHODS:Patients underwent radical (all lesions removed) lung resection for mSBPLC from 2017 to 2024 were included. Exclusion criteria: patients unfit for bilateral surgery, pneumonectomy, multifocal ground-glass opacities, clinical stage IIIA or more, and preoperative treatment. Overall and disease-free survival (DFS) analyses were conducted with the Kaplan-Meier method and log-rank test, Cox-regression analysis was used to identify the predictors of worse survival. RESULTS:During the study period, 64 patients were screened for the presence of bilateral lung nodules, 45 patients (median age 69 years) were operated for mSBPLC and during the follow-up (median 34 months) we observed 11 deaths and 15 cancer recurrence. In the 80% of patients the main cancer was solid, contralateral was a part-solid in 20%, or pure ground-glass opacity in 20%. Adenocarcinoma was present in 77.8% at first surgery and in 80% at the second. Spread Through the Air Spaces (STAS) was present in 17.8%. The 5-year overall and DFS rate were 77% (median 86 months, 95% CI 72.4-99.5-) and 57% (median 69 months, 95% 32-105.9), respectively. Comparing survivals among patients with and without STAS, we had an overall survival of 0% vs 85% (86 vs 29 months, P < .01) and a DFS of 0% vs 63% (69 vs 9 months, P < .01). The multivariable analysis demonstrated STAS as significant predictor of worse overall (HR 7.08, P = .02) and DFS (HR 5.63, P = .017). CONCLUSIONS:Taking into account the small and highly selected study population, staged bilateral surgery could be considered safe and oncologically adequate, showing the association between the presence of STAS and unfavourable long-term outcomes.

BACKGROUND:Tumor size was recently proposed as a prognosticator in thymic tumors. The aim of this study is to investigate the prognostic role of tumor size in the different thymic tumor histologies. METHODS:Clinical and pathologic data of patients from the European Society of Thoracic Surgeons thymic database who underwent surgery for thymic epithelial tumors from January 2000 to December 2022 were reviewed, analyzed, and correlated to overall survival and disease-free survival using Kaplan-Meier curves. The log-rank test was used to assess differences between subgroups. RESULTS:The final analysis was conducted on 2,556 patients. Histology results showed thymoma in 2,231 (87.3%), thymic carcinoma in 271 (10.6%), and neuroendocrine tumors in 54 (2.1%) cases. In 1,518 (59.4%) cases, size was >5 cm. The survival difference was significant considering thymoma and thymic carcinoma/neuroendocrine tumor. The 5-and 10-year disease-free survival rates were 85.4% and 78.1% vs 77.6% and 62.4% in ≤5 cm vs >5 cm thymomas (P < .001), and 5- and 10-year overall survival rates were 92.4% and 79.4% vs 88% and 74.5% in ≤5 cm vs >5 cm thymomas (P = .002). For thymic carcinoma/neuroendocrine tumor, the disease-free survival rate in the ≤5 cm group was 61.3% at both 5 and 10 years, compared with 53.3% and 46.9% in the >5 cm group, respectively (P = .042), whereas 5- and 10-year overall survival rates were 84.9% and 79.4% vs 74.9% and 64.9% in ≤5 cm vs >5 cm groups (P = .002). CONCLUSION:Tumor size was a significant prognosticator in thymic epithelial tumor, thymoma, and thymic carcinoma/neuroendocrine tumor, confirming its validity in prognosis prediction of these tumors.

[This corrects the article DOI: 10.1016/j.cjco.2025.04.008.].

Background Tumor size is recently proposed as prognosticator in thymic tumors. The aim of this study is to investigate the prognostic role of tumor size in the different thymic tumor histologies. Methods Clinical and pathological data of patients from ESTS thymic database underwent surgery for TETs from 1/2000 to 12/2022 were reviewed, analyzed and correlated to overall survival (OS) and Disease free Survival (DFS) using Kaplan Meier curves. The log-rank test was used to assess differences between subgroups. Results The final analysis was conducted on 2.556 patients. Histology results showed thymoma in 2.231(87.3%), thymic carcinoma in 271(10.6%) and neuroendocrine tumors (NET) in 54 (2.1%) cases. In 1.518 (59.4%) size resulted > 5 cm.The survival difference was significant considering thymoma and thymic carcinoma/NET. The 5-and 10-year DFS of 85.4% and 78.1% versus 77.6% and 62.4% in ≤ 5 cm vs > 5 cm thymomas (p<0.001) and a 5- and 10-year OS of 92.4% and 79.4% versus 88% and 74.5% in ≤ 5 cm versus > 5 cm thymomas (p=0.002). For thymic carcinoma/NET, the DFS rate in the ≤ 5 cm group was 61.3% at both 5 and 10 years, compared to 53.3% and 46.9% in the > 5 cm group, respectively (p=0.042), while 5- and 10-year OS were 84.9% and 79.4% versus 74.9% and 64.9% in ≤ 5 cm versus > 5 cm groups (p=0.002). Conclusions Tumor size resulted a significant prognosticator in TET, thymoma and thymic carcinoma/NET, confirming its validity in prognosis prediction of these tumors.

Background:Lung segmentectomy is widely used to treat early-stage non-small cell lung cancer (NSCLC), but the risk of local recurrence in the ipsilateral lobe is increased and the surgical treatment of the local recurrence could be a real challenge. The aim of this study is to report our experience in a consecutive series of patients undergoing completion lobectomy (CL) after thoracoscopic segmentectomy. Methods:We retrospectively reviewed all the medical charts of the patients who underwent thoracoscopic segmentectomy for early-stage NSCLC (cIA) between January 2015 and December 2023, focusing on patients who had NSCLC recurrence in the ipsilateral lobe treated with CL. Results:Among the 263 segmentectomies performed, 13 patients (4.9%) experienced local recurrence in the ipsilateral remaining lobe, of whom 9 (3.4%) underwent CL, including 5 in the left upper lobe, with a median interval of 31 months between procedures. All patients underwent CL through thoracotomy with the need of central isolation in 5/9 (55.5%); rupture of the pulmonary artery occurred two patients and vascular sleeve resection was necessary in one. No postoperative deaths were observed, complications occurred in 5/9 patients with major complications, defined as Clavien-Dindo grade >3b, in 2/9 (22.2%) patients. Median hospital stay was 11 days. At the end of follow-up 2 patients had distant recurrence 12 median months after the CL. Conclusions:CL in the left side could be considered a challenging procedure also after minimally invasive segmentectomy and we consider safe to perform CL with thoracotomy due to a scar tissue formation between the bronco-vascular structures leading the need for extensive hilar dissection and central isolation of the pulmonary artery.

Background: Immunotherapy (IO)-based strategies have been demonstrated to significantly prolong survival in the perioperative setting of non-oncogene-addicted non-small cell lung cancer (NSCLC). The adoption of such strategies in clinical practice depends on heterogeneous regulatory approvals and on the agreement between medical oncologists and thoracic surgeons on patients’ selection. Methods: An Expert Panel Meeting of medical oncologists and thoracic surgeons was held virtually by the Italian Association of Thoracic Oncology (AIOT) to discuss results of pivotal clinical trials with perioperative chemo-immunotherapy and reach agreement on open issues for the topic, formulating specific statements based on initially proposed discussion questions. Results: Overall, panelists found agreement on seven statements. With regard to tissue and biomarker analysis, the role of increasing PD-L1 expression in predicting IO efficacy was recognized, whereas ctDNA and pCR were mainly attributed a prognostic role, in the absence of dedicated studies. The panelists acknowledged direct relationship between the benefit of neoadjuvant chemo-immunotherapy approaches and the local burden of disease/mediastinal node involvement, supporting the inclusion of these factors, together with PD-L1, in selecting upfront surgery or induction treatment. The panelists agreed that the current literature data do not answer the issue of assessing the role of the adjuvant phase within a perioperative treatment strategy. Surgical considerations on the role of pneumonectomy and other approaches were also discussed. Conclusions: This experience highlights the importance of a synergistic approach between oncologists and surgeons to leverage the unmet needs in translating results of IO-perioperative clinical trials into clinical practice in patients with resectable NSCLC.

Background: Lung adenocarcinoma exhibits heterogeneity among different histological subtypes, with solid and micropapillary subgroups (classified as high-grade) associated with worse prognosis. The aim of this retrospective study was to investigate the impact of high-grade adenocarcinoma on survival in patients undergoing intentional thoracoscopic segmentectomy. Methods: Patients who underwent segmentectomy for clinical-stage IA non-small-cell lung cancer between 2016 and 2023 were reviewed. The adenocarcinoma population was divided and compared based on the presence of high-grade adenocarcinoma >20%, based on the 2021 WHO classification. Survival probabilities were estimated using the Kaplan–Meier method and log-rank test. The Cox proportional hazard regression model was used to test the association between survival and covariates. Results: The adenocarcinoma population included 216 patients, with high-grade adenocarcinoma >20% in 47 (21.7%). A consolidation-to-tumor ratio >0.8 was more frequent in the high-grade adenocarcinoma population. Survival analyses showed that overall (5-year OS rate 57% vs. 90%, p < 0.01), cancer-specific (5-year CSS rate 66% vs. 91%, p < 0.01) and disease-free survival (5-year DFS rate 53% vs. 75%, p < 0.01) were significantly worse in patients with high-grade adenocarcinoma. No significant differences in overall and disease-free survival were observed when compared to a contemporary cohort of lobectomy patients. Recurrence and high-grade pattern (HR 3.26, 95%CI 1.4–7.6, p < 0.01) were significant risk factors for reduced overall survival, whereas high-grade adenocarcinoma >20% (HR 2.43, 95%CI 1.25–4.71, p < 0.01) and a consolidation-to-tumor ratio >0.8 were risk factors for reduced disease-free survival. Conclusions: The prognosis of high-grade adenocarcinoma is sub-optimal even in radically treated early-stage patients, and close monitoring and a complete bio-molecular assessment should be advisable in light of a multimodal adjuvant approach. However, the different subtypes of adenocarcinoma could be inserted as a staging parameter in future international staging systems.

Background/Objectives: Sleeve and wedge bronchial resections without removal of lung tissue may represent a surgical option in selected cases of low-grade neoplasms. This study is a retrospective analysis of the surgical technique and the short- and long- term results of bronchial sleeve resections performed in the Department of Thoracic Surgery of Careggi Hospital in Florence, Italy, and in the Department of Thoracic Surgery of Marie Lannelongue Hospital in Plessis Robinson, France. Methods: Between January 2017 and October 2024, 25 patients with low-grade tumors underwent bronchial sleeve resection with total lung-sparing. We collected the preoperative data, surgical techniques, postoperative results and long-term oncologic outcomes. Results: We performed 25 bronchial sleeves which resulted in 20 typical carcinoids (TC), 3 atypical carcinoids (AT) and 2 mucoepidermoid carcinomas. Three patients had R1 resection, and one of them also had N1 disease; a multidisciplinary team opted for a “watch and wait” policy without adjuvant therapies. No local recurrences occurred, although three distant recurrences were observed. The five-year overall survival (OR) rate was 100%; the five-year disease-free survival (DFS) rate was 80%. Conclusions: Bronchoplastic procedures without lung parenchyma resection are an appropriate and feasible technique for selected cases of low-grade endobronchial neoplasms.

Despite recent therapeutic advances, the adjuvant treatment of non-small cell lung cancer (NSCLC) remains a challenge. Reducing the risk of recurrence is still a concern, especially in the KRAS G12C population, for which platinum-based adjuvant chemotherapy (CT) remains the gold standard. In this study, we evaluated the efficacy, in terms of cell viability and volumetric reduction, of adding KRAS inhibitors (KRASi) sequentially or concurrently to CT in both parental (PR) and gemcitabine-resistant (GR) KRAS mutated NSCLC cell lines (SW1573 and H23). We demonstrated that KRASi added to CT (both sequential and concurrent treatment strategies) reduced cell viability in SW1573-PR and H23-PR and this effect is less evident in GR cell lines. Interestingly, in the 3D model, the concomitant use of KRASi+CT reduced spheroid volume in both PR and GR spheroids. Our results indicate that KRASi enhances the efficacy of CT in both NSCLC PR and GR cells, suggesting a potential therapeutic strategy to overcome chemoresistance in the adjuvant setting of NSCLC.

Background:Platinum chemotherapy (CT) remains the backbone of systemic therapy for patients with small-cell lung cancer (SCLC). The nucleotide excision repair (NER) pathway plays a central role in the repair of the DNA damage exerted by platinum agents. Alteration in this repair mechanism may affect patients' survival. Materials and Methods:We conducted a retrospective analysis of data from 38 patients with extensive disease (ED)-SCLC who underwent platinum-CT at the Clinical Oncology Unit, Careggi University Hospital, Florence (Italy), from 2015 to 2020. mRNA expression analysis and single nucleotide polymorphism (SNP) characterization of three NER pathway genes-namely ERCC1, ERCC2, and ERCC5-were performed on patient tumor samples. Results:Overall, elevated expression of ERCC genes was observed in SCLC patients compared to healthy controls. Patients with low ERCC1 and ERCC5 expression levels exhibited a better median progression-free survival (mPFS = 7.1 vs. 4.9 months, p = 0.39 for ERCC1 and mPFS = 6.9 vs. 4.8 months, p = 0.093 for ERCC5) and overall survival (mOS = 8.7 vs. 6.0 months, p = 0.4 for ERCC1 and mOS = 7.2 vs. 6.2 months, p = 0.13 for ERCC5). Genotyping analysis of five SNPs of ERCC genes showed a longer survival in patients harboring the wild-type genotype or the heterozygous variant of the ERCC1 rs11615 SNP (p = 0.24 for PFS and p = 0.14 for OS) and of the rs13181 and rs1799793 ERCC2 SNPs (p = 0.43 and p = 0.26 for PFS and p = 0.21 and p = 0.16 for OS, respectively) compared to patients with homozygous mutant genotypes. Conclusions:The comprehensive analysis of ERCC gene expression and SNP variants appears to identify patients who derive greater survival benefits from platinum-CT.

Lung cancer is the first cause of cancer-related death. Awake lung resection is a new frontier of the concept of minimally invasive surgery. Our purpose is to demonstrate the feasibility of this technique for lobar and sublobar lung resection in NSCLC patients. We retrospective reviewed all the medical charts of patients who underwent awake lung resection in our center between March 2018 and March 2024, focusing on patients with NSCLC, and we compared our results with the ones found in literature. Among 45 patients treated with awake lung resections, we selected 15 patients with NSCLC and finally analyzed the results of 12 patients who underwent VATS awake lung resection, 3 lobectomies and 9 wedge resections. The median Charlson comorbidity index (CCI) was 3 and we had 5 patients (41.67

Thymomas are the most common primary tumors of the anterior mediastinum, frequently associated with paraneoplastic syndromes like myasthenia gravis. This preliminary study investigated the correlation between radiomic features extracted from venous-phase CT images, histological grading (WHO), and disease staging (Masaoka-Koga and TNM) in patients with thymomas. A total of 37 patients were analyzed, with 107 radiomic features extracted using PyRadiomics module. Statistical analysis revealed 11 significant radiomic features distinguishing early and advanced thymomas according to Masaoka-Koga/TNM staging (p < 0.05), with shape_Sphericity, shape_Maximum3DDiameter, and firstorder_Skewness being the most predictive. For WHO classification, 7 significant features differentiated low-risk and high-risk thymomas (p < 0.05), with shape_Sphericity, firstorder-Range, and firstorder_RootMeanSquared showing the highest performance. LASSO models demonstrated high accuracy, with an AUC of 0.9 for Masaoka-Koga/TNM staging and 0.82 for WHO classification. These findings suggest that radiomic features can effectively distinguish thymoma stages and risk levels, potentially aiding in treatment planning and prognosis. By enabling noninvasive tumor characterization, radiomic features could support more personalized treatment strategies and improve decision-making in clinical practice.

OBJECTIVE:The 9thTNM proposal for thymic epithelial tumours (TETs) introduced size as category in stage I, confirming tumour infiltration type as descriptor for the other stages. Aim of this study is to evaluate the role of tumour size in TETs considering different possible cut-offs also among different subgroups. MATERIAL AND METHODS:Clinical and pathological data of patients from ESTS thymic database who underwent surgery for TETs from1/2000 to 12/2022 were reviewed and analysed. Patients clinical data, tumour characteristics, size and organs infiltration were collected and correlated to overall survival (OS), Disease free Survival (DFS) and Cancer specific Survival (CSS) using Kaplan Meier curves. The log-rank test was used to assess differences between subgroups. A multivariable model was built using Cox-regression analysis including clinical relevant variables resulting significant at univariable (p-value < 0.05). RESULTS:The final analysis was conducted on 2146 patients. Most patients presented tumours size >5 cm(59 %)and without surrounding structures infiltrations (51.3 %). During FUP, a recurrence occurred in 235 (11%) patients, 199 (9.3%) died, 38 due to tumour progression. Multivariable confirmed as independent negative prognostic factors age (p < 0.001), carcinoma/NETT histology (p < 0.001),TETs size >5 cm (p < 0.001, HR 2.16; 95 %CI 1.32-3.50), and infiltration (p = 0.04) for OS; advanced TNM STAGE 9th edition (p < 0.001) and carcinoma/NETT (p = 0.001) for DFS; infiltration presence (p < 0.001) and carcinoma/NETT (p < 0.001) for CSS. Significant differences in OS, DFS and CSS were present considering size cut-off 5 cm (p < 0.001, p < 0.001 and p = 0.001, respectively), while using 3 cm cut-off only DFS (p < 0.001) and CSS (p = 0.001) resulted statistically significant. Significant differences in OS, DFS and CSS were present considering surrounding organ infiltration in TETs ≤ 5 cm (p = 0.004, p < 0.001 and p = 0.001) and in TETs > 5 cm (p = 0.024, p < 0.001 and p < 0.001). CONCLUSIONS:Tumour size resulted a significant prognosticator in TETs, and its associations with infiltration permits to identify different prognostic groups.

OBJECTIVES:In recent years, targeted therapy and immunotherapy have been demonstrated to improve survival in non-operable, non-small cell lung cancer (NSCLC) patients. The results of salvage lung resection in patients with initially unresectable advanced NSCLC after immune checkpoint inhibitor (ICI) or Target Therapy (TT) treatment remain unclear. This study aimed to define the outcomes of patients undergoing salvage surgery in a multi-center real-life setting. METHODS:An international multicenter retrospective cohort study was conducted. Patients included in the study were judged inoperable, according to a multidisciplinary tumor board decision, before being submitted to ICI or TKI treatment. The rate of complications, the overall survival (OS), and progression-free survival (PFS) were compared. Crude and Multivariable-adjusted analysis were conducted. RESULTS:Nighty-eight patients affected by NSCLC were included in the study. Most patients were female (N = 50-51 %), and the median age at surgery was 62 years. While ICI was performed in 29 patients (30 %), TT was done in 45 (46 %), and ICI plus chemotherapy in 24 (24 %). The inoperability was determined by metastatic disease in 43 cases (44 %), N2-N3 advanced disease in 18 (18 %), local invasiveness in 10 (10 %), a combination of local invasiveness and N-status in 26 (27 %), and other reasons in 1 case (1 %). Overall, the complication rate was 30 %, the mortality rate was 1 %, and the median LOS was 6 days. No residual lung disease (ypT0) was observed in 30 patients (31 %). The 5-year OS was 74 %, while the 5-year PFS was 44 %. Performing sublobar resections was an independent adverse prognostic factor in the multivariable analysis for survival (P < 0.01), while the pathological complete response (pCR) was an independent prognostic predictor of improved survival (P = 0.025). On multivariable analysis performing a sublobar resection (P < 0.01), an increasing ypT stage (P < 0.01), and postoperative therapy (P < 0.01) were independent prognostic predictors, correlating with impaired disease progression. CONCLUSIONS:Patients selected for Salvage Surgery after ICI or TT have reasonable post-operative and long-term outcomes. In this context, Salvage Surgery could be proposed in selected patients after a careful multidisciplinary evaluation.

OBJECTIVES: Robotic thymectomy has been suggested and considered technically feasible for thymic tumours. However, because of small-sample series and the lack of data on long-term results, controversies still exist on surgical and oncological results with this approach. We performed a large national multicentre study sought to evaluate the early and long-term outcomes after robot-assisted thoracoscopic thymectomy in thymic epithelial tumours. METHODS: All patients with thymic epithelial tumours operated through a robotic thoracoscopic approach between 2002 and 2022 from 15 Italian centres were enrolled. Demographic characteristics, clinical, intraoperative, postoperative, pathological and follow-up data were retrospectively collected and reviewed. RESULTS: There were 669 patients (307 men and 362 women), 312 (46.6%) of whom had associated myasthenia gravis. Complete thymectomy was performed in 657 (98%) cases and in 57 (8.5%) patients resection of other structures was necessary, with a R0 resection in all but 9 patients (98.6%). Twenty-three patients (3.4%) needed open conversion, but no perioperative mortality occurred. Fifty-one patients (7.7%) had postoperative complications. The median diameter of tumour resected was 4cm (interquartile range 3-5.5cm), and Masaoka stage was stage I in 39.8% of patients, stage II in 56.1%, stage III in 3.5% and stage IV in 0.6%. Thymoma was observed in 90.2% of patients while thymic carcinoma occurred in 2.8% of cases. At the end of the follow-up, only 2 patients died for tumour-related causes. Five- and ten-year recurrence rates were 7.4% and 8.3%, respectively. CONCLUSIONS: Through the largest collection of robotic thymectomy for thymic epithelial tumours we demonstrated that robotenhanced thoracoscopic thymectomy is a technically sound and safe procedure with a low complication rate and optimal oncological outcomes.

Journal Article The role of minimally invasive surgery on cT4 tumours: still many unanswered question Get access Stefano Bongiolatti, Stefano Bongiolatti Thoracic Surgery Unit, Careggi University Hospital, Florence, Italy Corresponding author. Thoracic Surgery Unit, University Hospital Careggi, Largo Brambilla, 1, 50134 Florence, Italy. Tel: +39-55-7946807; fax: +39-55-7949557; e-mail: stefanobongiolatti@gmail.com (S. Bongiolatti). https://orcid.org/0000-0003-2722-9270 Search for other works by this author on: Oxford Academic PubMed Google Scholar Alessandro Gonfiotti, Alessandro Gonfiotti Thoracic Surgery Unit, Careggi University Hospital, Florence, ItalyDepartment of Experimental and Clinical Medicine, University of Florence, Florence, Italy https://orcid.org/0000-0003-2724-9474 Search for other works by this author on: Oxford Academic PubMed Google Scholar Alberto Salvicchi, Alberto Salvicchi Thoracic Surgery Unit, Careggi University Hospital, Florence, Italy https://orcid.org/0000-0002-9530-9830 Search for other works by this author on: Oxford Academic PubMed Google Scholar Luca Voltolini Luca Voltolini Thoracic Surgery Unit, Careggi University Hospital, Florence, ItalyDepartment of Experimental and Clinical Medicine, University of Florence, Florence, Italy https://orcid.org/0000-0002-2818-859X Search for other works by this author on: Oxford Academic PubMed Google Scholar European Journal of Cardio-Thoracic Surgery, Volume 65, Issue 3, March 2024, ezae049, https://doi.org/10.1093/ejcts/ezae049 Published: 10 February 2024 Article history Received: 01 February 2024 Accepted: 08 February 2024 Published: 10 February 2024 Corrected and typeset: 01 March 2024

Background: Sleeve resection is currently the gold standard procedure for centrally located non-small cell lung cancer (NSCLC). Extended sleeve lobectomy (ESL) consists of an atypical bronchoplasty with resection of >1 lobe and carries several technical difficulties compared with simple sleeve lobectomy (SSL). Our study compared the outcomes of ESL and SSL for NSCLC. Methods: This multicenter, retrospective, cohort study included 1314 patients who underwent ESL (155 patients) or SSL (1159 patients) between 2000 and 2018. The primary end points were 30-day and 90-day mortality, overall survival (OS), disease-free survival (DFS), and complications. Results: No differences were found between the 2 groups in general characteristics and surgical and survival outcomes. In particular, there were no differences in early and late complication frequency, 30- and 90-day mortality, R status, recurrence, OS (54.26 +/- 33.72 months vs 56.42 +/- 32.85 months, P = .444), and DFS (46.05 +/- 36.14 months vs 47.20 +/- 35.78 months, P = .710). Mean tumor size was larger in the ESL group (4.72 +/- 2.30 cm vs 3.81 +/- 1.78 cm, P < .001). Stage IIIA was the most prevalent stage in ESL group (34.8%), whereas stage IIB was the most prevalent in SSL group (34.3%; P < .001). The multivariate analyses found nodal status was the only independent predictive factor for OS. Conclusions: ESL gives comparable short- and long-term outcomes to SSL. Appropriate preoperative staging and exclusion of metastases to mediastinal lymph nodes, as well as complete (R0) resection, are essential for good long-term outcomes.

Background:Elective extra-corporeal membrane oxygenation (ECMO) is rarely used in thoracic surgery, apart from lung transplantation. The purpose of this study was to summarize our institutional experience with the intraoperative use of veno-venous (VV) ECMO in selected cases of main airway surgery.Methods:We retrospectively analyzed the data of 10 patients who underwent main airway surgery with the support of VV-ECMO between June 2013 and August 2022.Results:Surgical procedures included: three carinal resection and reconstruction with complete preservation of the lung parenchyma, one right upper double-sleeve lobectomy and hemi-carinal resection, and one sleeve resection of the left main bronchus after previous right lower bilobectomy, for thoracic malignancies; four tracheal/carinal repair for extensive traumatic laceration; one extended tracheal resection due to post-tracheostomy stenosis in a patient who had previously undergone a left pneumonectomy. The median intraoperative VV-ECMO use was 162.5 minutes. In three cases with complex resection and reconstruction of the carina and in one case of extended post-tracheostomy stenosis and previous pneumonectomy, high-flow VV-ECMO allowed interruption of ventilation for almost 3 hours. In four patients, VV-ECMO was prolonged in the postoperative period to ensure early extubation. There were no perioperative deaths, no complications related to the use of ECMO and no intraoperative change in the planned type of ECMO. Significant complications occurred only in one patient who developed a small anastomotic dehiscence that led to stenosis and required placement of a Montgomery tube. At the median follow-up of 30 months, all 10 patients were still alive.Conclusions:The use of intraoperative VV-ECMO allows safe and precise performance of main airway surgery with minimal postoperative morbidity in patients requiring complex resections and reconstructions and in cases that cannot be managed with conventional ventilation techniques.

Carinal and tracheobronchial angle tumors have long been a contraindication for surgical removal; the technique of tracheal sleeve pneumonectomy makes it possible to approach this malignancy but still represents a surgical challenge. Left sleeve pneumonectomy is less common compared with right sleeve pneumonectomy and represents a minority component in the literature’s case series due to the complexity of the anatomy. In addition, there is no standard for treatment strategy, and it must be assessed on a case-by-case basis. From 2020 to 2023, we performed three left tracheal sleeve pneumonectomies and one neocarina reconstruction surgery for benign lesions without lung resections. All cases were performed without cardiovascular support such as cardiopulmonary bypass and via median sternotomy. With a median length of stay of 21.5 days (between 14 days and 40 days), all patients were transferred to a physiotherapeutic rehabilitation facility for functional reactivation, where they received physiotherapeutic respiratory therapy given the slow functional recovery. The recorded 30-day mortality was 0. There is no standardized approach for left-sided sleeve pneumonectomy, and it is still a surgical challenge due to intraoperative and postoperative difficulties.