The Authors report the case of a patient who underwent resection of a huge anterior mediastinal mass, revealing to be a necrotic thymoma. The patient had been previously submitted to surgical biopsies of the mass yielding non-diagnostic results due to extensive necrosis. A sternotomy was then performed to resect the mediastinal mass originating from the thymus, en-bloc with the mediastinal fat and the apparently infiltrated lung. Histopathology showed a possible cyst/thymoma in massive necrosis, not further definable; revision by a specialized experienced pathologist (J. Rosai) confirmed total mass necrosis and no lung infiltration, thus orientating diagnosis towards a necrotic thymoma and excluding a lymphoblastic lymphoma, with similar histopathological features but more frequent in children or characterized by neoplastic infiltration of surrounding lung. Total body computed tomography (CT) scan and fluorodeoxyglucose positron emission tomography (18F-FDG-PET)/CT, show neither local recurrence, nor distant metastases two years after surgery. In case of anterior mediastinal mass with difficult histopathological diagnosis due to massive necrosis, the hypothesis of a necrotic thymoma should be considered. After radical removal prognosis is generally favourable and no adjuvant treatment is required.

Tracheal tumors are rare neoplasms with extremely heterogeneous histological aspects and can be potentially life-threatening, due to airway obstruction. We report our results in medical, endoscopic and surgical treatment of primary and secondary tracheal tumors. From January 2008 to June 2015, on 35 patients treated for various tracheal diseases, we observed 6 patients (2 males, 4 females; median age: 50, 5 years, range: 2 months-72 years) with tracheal tumors: 5 primary (subglottic hemangioma, inflammatory pseudotumor, condromatous hamartoma, squamous cell carcinoma, acinic cell carcinoma), 1 secondary (pulmonary adenocarcinoma). Treatments were: medical in 1 case (subglottic hemangioma), endoscopic in 2 (squamous carcinoma; metastatic adenocarcinoma), surgical in 3 (inflammatory pseudotumor; condromatous hamartoma; acinic cell carcinoma). Post-treatment course was uneventful and with radical results in all patients. At a median follow-up of 42 months (range: 11-89 months) five of six patients are alive, in good conditions and without local or distant recurrence. Treatment of tracheal tumors may vary in relationship to clinical condition of patients, grade of tracheal obstruction, tumor extension, stage, histology and biological behavior, which are factors affecting prognosis and long-term survival. Endoscopic evaluation and histological diagnosis are mandatory to select the most adequate treatment; whenever possible, radical surgical resection should be performed.

Gynecomastia is a common finding in males, with an incidence that varies widely globally. In 10-25% of cases, it is caused by drugs. Its pathophysiologic mechanism includes exposure to exogenous estrogens and medications that cause hypogonadism, antiandrogenic effects and hyperprolactinemia. Gynecomastia is associated with exposure to antiretroviral therapy (ART), particularly efavirenz. Sometimes surgery may be required as treatment. We report a case of a 46-year-old man receiving ART presenting with a marked bilateral breast enlargement who underwent bilateral mastectomy as the only successful treatment in a low-income setting.

Objective: In the general thoracic surgery department peripherally inserted central catheters (PICCs) may be an alternative option to standard central and peripheral venous catheters for patients undergoing surgical procedures and possible candidates to adjuvant chemotherapy. We report the results of our experience with PICCs in patients undergoing lung resections. Materials and Methods: We retrospectively reviewed data of 54 PICCs inserted in adult patients who underwent lung resection. Rate of complications at insertion and during maintenance were recorded. Each patient was followed from the implant to the removal of the device (median 20 days, range 10-370 days). In 23 cases PICCs were also used for adjuvant chemotherapy. Results: Insertion was successful in 98% of cases. There were no major complications and 15% minor complications (local hematoma, repeated punctures of the vein, difficulty in progression of the catheter and malposition) at insertion. During maintenance there were no episodes of catheterrelated bloodstream infection; two (3,7%) episodes of symptomatic thrombosis occurred during the chemotherapy period, associated to deep vein thrombosis of the legs, treated with medical therapy. Accidental removal of the catheter was observed in one patient. Removal of the catheter was never required because of complications. Conclusion: PICCs are a useful and safe device for patients undergoing lung resections. Their insertion is successful in 98% of cases and is not associated with significant risks, even in patients with coagulation disorders. Their maintenance is associated with an extremely low rate of infectious and non-infectious complications.

AIM: The authors report a retrospective study on surgical treatment of primary spontaneous pneumothorax (PSP). Surgical approaches by Videoassisted axillary mini-thoracothomy (VAMT) and three-port VATS (t-VATS) are compared. Mean post-operative stay (MPS) and ipsilateral recurrence rate (IRR) are assessed. Secondary endpoints were about complications, early post-operative pain and long term neurologic symptoms. PATIENTS AND METHODS: From January 2009 to December 2011 we consecutively observed 85 cases of PSP. Treatment was represented by surgery in 52 patients: the approach was by VAMT in 39 instances and t-VATS in 13. Median follow up was 30 months. RESULTS: Patients submitted to surgery had a MPS of 6.62 ± 1.5 days for VAMT and 6.69 ± 3.4 days for t-VATS (p=0,94). The IRR was 0% in both surgical approaches, comparing to 7,2% for the group of patients treated by simple drainage. Complications were observed in VAMT group: 2 conversions to thoracothomy for technical difficulties (extensive pleural adherences) and one case of re-thoracothomy for hemothorax. Mean Visual Analogic Scale (VAS) score for early post-operative pain was: 2.10±0.71 for VAMT and 1.92±0.64 for t-VATS, p=0.42 at t-student test. Paresthesia complain rate was 33.3% (VAMT) vs 30.7% (t-VATS) for moderate symptoms (p=0.72 at chi square test). The remaining patients complained only slight symptoms or no symptoms at all. CONCLUSIONS: Our experience suggested that both surgical approaches to PSP are safe and effective. No differences were found for early post-operative pain and long term paresthesia rate, between the two approaches. No recurrence occurred during follow up.

OBJECTIVES: Tracheo-oesophageal fistula (TOF) is a rare, life-threatening condition. We report our results of surgical treatment and evaluation of the outcome of acquired non-malignant TOF. METHODS: Twenty-five patients (aged 49 ± 21 years) with TOF were operated on between 2001 and 2011. Tracheo-oesophageal fistula was due to prolonged intubation/tracheostomy (84%), was secondary to other surgery (8%) or trauma (4%) or was idiopathic (4%). The tracheal defect was 2.4 ± 1.3 cm long and was associated with tracheal stenosis in seven (28%) patients. Surgical treatment consisted of direct suturing of the oesophageal defect in two layers (or end-to-end oesophageal resection and anastomosis in one case) associated with tracheal suturing (n = 15; 60%), tracheal resection and anastomosis (n = 8; 32%) or covering of a large tracheal defect by an intercostal muscle flap or by a resorbable patch with muscle apposition (n = 2; 8%). The surgical approach was cervicotomy (n = 14; 56%), cervicotomy plus median sternotomy or split (n = 6; 24%), thoracotomy (n = 4; 16%) or cervicotomy plus sternal spit plus thoracotomy (n = 1; 4%). In 18 (72%) cases a muscular flap was used and in six (24%) a protective tracheostomy was performed. RESULTS: No perioperative deaths occurred. Morbidity occurred in eight (32%) patients; none of them required a second surgical look. At median follow-up of 41 months, the outcome was excellent or good for 22 patients (88%), two (8%) are still dependent on jejunostomy and tracheostomy for neurological diseases and one (4%) is under mechanical ventilation for end-stage respiratory failure. CONCLUSIONS: Surgical treatment of TOF is associated with good results in terms of control of acute symptoms and long-term outcome, particularly concerning oral intake and spontaneous breathing.

Objective: To develop sustainable recipes, using local food resources, as a possible solution to manage children malnutrition and nutritional lack in Mozambique, thus preventing infectious diseases. Methods: Our work was based on the Dietary Reference Intake (DRI) reports for children aged 4-8 years old. After having listed more than 60 commonly consumed local foods in Mozambique, we developed some recipes, indicating composition, energy and nutrients values. Information on nutrients concentrations was taken from the National Nutrient Database for Standard References, the Food Composition Tables for Mozambique and the Research Center for Aliments and Nutrition. In the recipes, the traditional way of listing ingredients was reported, which were then turned into international, standardized values. Results: We elaborated some different local food recipes, easy to prepare, at low cost and useful in a systematic approach in order to fight malnutrition in Sofala Province, Mozambique. Each recipe included functions and daily Recommended Dietary Allowance (RDA) of: water, proteins, lipids, carbohydrates, fibers, sodium, potassium, iron, calcium, phosphorus and vitamins. We suggested recipes richer in vitamins and micro/macro nutrients for breakfast, while those providing high caloric intake were more indicated for the main meal. The resulting recipes have been made understandable, for both local and international population, thanks to the coexistence of traditional and international description of ingredients. Conclusion: Local recipes approach is a possible promising tool among the most cost-effective/high impact interventions against child malnutrition and mortality from infectious diseases in Mozambique.

Background: The aim of this study was to determine both prognostic clinical-morphological and predictive biomolecular factors affecting course of disease and survival in malignant pleural mesothelioma (MPM). Methods: We retrospectively analyzed (2004-2014) clinical and pathological data of 108 consecutive patients with diagnosis of MPM. Age, stage (WHO 2015), chemotherapy, histotype, nuclear atypia, mitotic count (1/mm2), Ki-67 percentage and 9p21 (p16/CDKN2A) deletion (43 cases) were analyzed and correlated to survival. Survival was evaluated with Kaplan-Meier method and statistical significance with Log-Rank test (SPSS software, 18.0). Results: There were 83 (76.9%) males, 25 (23.1%) females (ratio 3.3/1); median age at diagnosis was 68 (mean 67.2±9.8; range 42-90) years; 94 (87%) patients had asbestos exposure. Overall median survival was 13.3 (mean 19.15±22.4; range 1-136) months. Mean survival (months) was: 30.2±4.6 and 12.4±1.6 in age ≤ 65 and > 65 years (p=0.0001); 24±4.3 in stage I, 21.3±4.5 in II, 21.1±5.8 in III, 9.7±1.7 in IV (p=0.005); 25.9±2.8 and 5±1.3 in patients receiving complete (n=73) and palliative (n=35) chemotherapy (p=0.0001); 21.4±2.5, 11.6±2.7 and 8.5±2.3 in epithelioid, biphasic and sarcomatoid histotypes (p=0.0001); 26.3±3.3 and 12.4±2.5 in moderate and severe nuclear atypia (p=0.0001); 26±3.4 and 9.9±1,3 in low (≤ 5 mm2) and high (> 5 mm2) mitotic count (p=0.0001); 27.2±3.4 and 9.1±1.1 in low (≤ 25%) and high (> 25%) Ki-67 expression (p=0.0001); 35.8±7.7 in absence of p16/CDKN2A deletion, 17.4±3.4 in heterozygous and 8.9±1.9 in homozygous deletion (p=0.0001). Mean survival (months) in patients receiving complete chemotherapy compared to those receiving palliative one was: stage I 30.7±5.4 and 8.2±4.4 (p=0.0001), stage II 25.8±5.3 and 4.2±1.0 (p=0.0001), stage III 25.2±6.8 and 3.0±0.4 (p=0.0001), stage IV 17.7±2.5 and 3.8±0.7 (p=0.0001). Conclusion: Age, stage, chemotherapy, histotype, nuclear atypias, mitoses, proliferating index and loss of 9p21 gene are predictors of survival in MPM and strongly influence the therapeutic strategy. Chemotherapy significantly affects survival in different stages of MPM.

OBJECTIVES: To analyse clinical and biomolecular prognostic factors associated with the surgical approach and the outcome of 247 patients affected by primary atypical carcinoids (ACs) of the lung in a multi-institutional experience. METHODS: We retrospectively evaluated clinical data and pathological tissue samples collected from 247 patients of 10 Thoracic Surgery Units from different geographical areas of our country. All patients were divided into four groups according to surgical procedure: sub-lobar resections (SURG1), lobar resections (SURG2), tracheobronchoplastic procedures (SURG3) and pneumonectomies (SURG4). Overall survival analysis was performed using the Kaplan-Meier method and log-rank test. Survival was calculated from the date of surgery to the last date of follow-up or death. The parameters evaluated included age, gender, smoking habits, laterality, type of surgery, 7th edition of TNM staging, mitosis Ki-67 (MIB1), multifocal forms, tumourlets, type of lymphadenectomy and neo/adjuvant therapy. For multivariate analysis, a Cox regression model was used with a forward stepwise selection of covariates. RESULTS: Two hundred and forty-seven patients (124 females and 123 males; range 10-84, median 60 years) underwent surgical resection for AC in the last 30 years as follows: n = 38 patients in SURG1, 181 in SURG2, 15 in SURG3 and 14 in SURG4. A smoking history was present in 136 of 247 (55%) patients. The median follow-up period was 98.7 (range 11.2-369.9) months. The overall survival probability analysis of the AC was 86.7% at 5 years, 72.4% at 10 years, 64.4% at 15 years and 58.1% at 20 years. Neuroendocrine multicentric forms were detected in 12 of 247 patients (4.8%; 1 of 12 pts) during the follow-up (range 11.2-200.4, median 98.7 months) and 33.4% had recurrence of disease. There were no significant differences between gender, tumour location and type of surgery at the multivariate analysis. Age [P < 0.001, hazard ratio (HR) 0.60; confidence interval (CI) 0.32-1.12], smoking habits (P = 0.002; HR 0.43, 95% CI 0.23-0.80) and lymph nodal metastatic involvement (P = 0.008; HR 0.46, 95% CI 0.26-0.82) were all significant at multivariate analysis. CONCLUSIONS: ACs of the lung are malignant neuroendocrine tumours with a worst outcome in patients over 70 years and in smokers. With the exception of pneumonectomy, the extent of resection does not seem to affect survival and should be accompanied preferably by lymphadenectomy. Pathological staging, along with a mitotic index more than Ki-67 (MIB1), appears to be the most significant prognostic factor at the univariate analysis.

Subglottic hemangioma (SGH) is a rare benign tumour of childhood that can be potentially lifethreatening because of airway obstruction. We report the case of a term 2-month-old infant girl admitted to our Institution with stridor, dyspnea and oxygen desaturation caused by a SGH and treated with propranolol. Neck-chest computed tomography (CT) revealed a contrast-enhancing 10 mm subglottic elliptic lesion, referable to SGH. Pre-treatment fiberbronchoscopy showed a sub-occlusive SGH, closing more than 75% of the laryngotracheal airway. In agreement with our neonatologists and ear-nose-throat (ENT) specialists, we decided to begin oral propranolol therapy, that rapidly and dramatically improved respiratory symptoms. Fiberbronchoscopy 6 days after treatment confirmed the reduction of the degree of subglottic narrowing. Six months later the patient is doing well without respiratory symptoms. To the best of our knowledge, this is the first reported case of SGH obstructing more than 75% of the airway, successfully treated with propranolol. The case evidences the effectiveness of oral propranolol as first-line treatment in the management of severely obstructive paediatric SGH and the importance of CT and fiberbronchoscopy in the diagnosis; it also proves the importance of multidisciplinary cooperation between thoracic surgeons, anaesthesiologists, neonatologists and ENT specialists for the treatment of these patients.

The authors describe the case of a woman with a 2-year history of dyspnea and stridor caused by a tracheal hamartoma. The patient underwent tracheal resection and end-to-end anastomosis under monitored local anesthesia and conscious sedation, which was achieved by boluses of ketamine and midazolam. Local anesthesia was obtained by the use of stepwise local infiltration of 2% lidocaine and 7.5 mg/mL ropivacaine during the operation. The patient remained awake during the entire procedure, thus permitting the movement of the vocal cords to be monitored. Mechanical ventilation was never required. The postoperative period was uneventful, and the patient did not describe having any discomfort.