SOSTIENICI
Conforti Dott.ssa Serena
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Management of COVID-19-related post-intubation tracheal stenosis.
Front Surg2023 ;10():1129803. doi: 1129803.
Conforti Serena, Licchetta Gloria, Reda Marco, Astaneh Arash, Pogliani Luca, Fieschi Stefano, Rinaldo Alessandro, Torre Massimo
Abstract
INTRODUCTION:
The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic has affected Italy since the beginning of 2020. Endotracheal intubation, prolonged mechanical ventilation, and tracheostomy are frequently required in patients with severe COVID-19. Tracheal stenosis is a potentially severe condition that can occur as a complication after intubation. The aim of this study was to evaluate the utility and safety of endoscopic and surgical techniques in the treatment of tracheal stenosis related to COVID-19.
MATERIALS AND METHODS:
Between June 2020 and May 2022, consecutive patients with tracheal stenosis who were admitted to our surgical department were considered eligible for participation in the study.
RESULTS:
A total of 13 patients were included in the study. They consisted of nine women (69%) and four men (31%) with a median age of 57.2 years. We included seven patients with post-tracheostomy tracheal stenosis. Bronchoscopy was performed to identify the type, location, and severity of the stenosis. All patients underwent bronchoscopic dilation and surveillance bronchoscopy at 7 and 30 days after the procedure. We repeated endoscopic treatment in eight patients. Three patients underwent tracheal resection anastomosis. Final follow-up bronchoscopy demonstrated no residual stenosis.
CONCLUSIONS:
The incidence of and risk factors associated with tracheal stenosis in critically ill patients with COVID-19 are currently unknown. Our experience confirms the efficacy and safety of endoscopic management followed by surgical procedures in cases of relapsed tracheal stenosis.
© 2023 Conforti, Licchetta, Reda, Astaneh, Pogliani, Fieschi, Rinaldo and Torre.
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Diagnostic accuracy of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) for mediastinal lymph node staging of lung cancer.
Mediastinum2021 ;5():15. doi: 15.
Torre Massimo, Reda Marco, Musso Valeria, Danuzzo Federica, Mohamed Shehab, Conforti Serena
Abstract
Lung cancer is one of the leading causes of cancer-related mortality around the world. A prompt diagnosis and accurate staging are of the essence in order to establish the appropriate treatment plan. Mediastinal lymph nodes involvement is the most important parameter to define the therapeutic path, and particularly to decide whether a patient can be offered a potentially curative surgery. Endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA), together with oesophageal ultrasound (EUS), has a pivotal role in the diagnosis and staging of lung cancer. These procedures have excellent diagnostic performances, can be performed without requiring general anaesthesia, and are far less invasive than mediastinoscopy and video-assisted thoracic surgery (VATS). Moreover, EBUS-TBNA allows to biopsy intrapulmonary lymph nodes. Different studies have been investigated the diagnostic accuracy of EBUS-TBNA for the diagnosis and staging of lung cancer, with always good but heterogeneous results. In some studies, EBUS-TBNA has shown to yield adequate samples for molecular testing and immunocytochemistry too. Rapid on site cytologic evaluation (ROSE) can be used to assess the adequacy of samples during the endoscopic procedure. The aim of this review article is to describe the current evidence on the diagnostic accuracy of EBUS-TBNA for the diagnosis of lung cancer. We also reported our centre's experience and the results of 456 EBUS-TBNA performed between April 2016 and March 2020.
2021 Mediastinum. All rights reserved.
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Tracheostomy in Mechanically Ventilated Patients With SARS-CoV-2-ARDS: Focus on Tracheomalacia.
Respir Care2021 Dec;66(12):1797-1804. doi: 10.4187/respcare.09063.
Guarnieri Marcello, Andreoni Patrizia, Gay Hedwige, Giudici Riccardo, Bottiroli Maurizio, Mondino Michele, Casella Gianpaolo, Chiara Osvaldo, Morelli Oscar, Conforti Serena, Langer Thomas, Fumagalli Roberto
Abstract
BACKGROUND:
The SARS-CoV-2 pandemic increased the number of patients needing invasive mechanical ventilation, either through an endotracheal tube or through a tracheostomy. Tracheomalacia is a rare but potentially severe complication of mechanical ventilation, which can significantly complicate the weaning process. The aim of this study was to describe the strategies of airway management in mechanically ventilated patients with respiratory failure due to SARS-CoV-2, the incidence of severe tracheomalacia, and investigate the factors associated with its occurrence.
METHODS:
This retrospective, single-center study was performed in an Italian teaching hospital. All adult subjects admitted to the ICU between February 24, 2020, and June 30, 2020, treated with invasive mechanical ventilation for respiratory failure caused by SARS-CoV-2 were included. Clinical data were collected on the day of ICU admission, whereas information regarding airway management was collected daily.
RESULTS:
A total of 151 subjects were included in the study. On admission, ARDS severity was mild in 21%, moderate in 62%, and severe in 17% of the cases, with an overall mortality of 40%. A tracheostomy was performed in 73 (48%), open surgical technique in 54 (74%), and percutaneous Ciaglia technique in 19 (26%). Subjects who had a tracheostomy performed had, compared to the other subjects, a longer duration of mechanical ventilation and longer ICU and hospital stay. Tracheomalacia was diagnosed in 8 (5%). The factors associated with tracheomalacia were female sex, obesity, and tracheostomy.
CONCLUSIONS:
In our population, approximately 50% of subjects with ARDS due to SARS-CoV-2 were tracheostomized. Tracheostomized subjects had a longer ICU and hospital stay. In our population, 5% were diagnosed with tracheomalacia. This percentage is 10 times higher than what is reported in available literature, and the underlying mechanisms are not fully understood.
Copyright © 2021 by Daedalus Enterprises.
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Pulmonary Resection for Metastasis of Hepatocellular Carcinoma Recurring After Liver Transplant: An Italian Multicenter Experience.
Front Oncol2020 ;10():381. doi: 381.
Invenizzi Federica, Iavarone Massimo, Donato Maria Francesca, Mazzucco Alessandra, Torre Massimo, Conforti Serena, Rimessi Arianna, Zavaglia Claudio, Schiavon Marco, Comacchio Giovanni, Rea Federico, Boetto Riccardo, Cillo Umberto, Dondossola Daniele, De Carlis Luciano, Lampertico Pietro, Nosotti Mario, Mendogni Paolo
Abstract
Liver transplantation (LT) is a validated treatment for hepatocellular carcinoma (HCC). HCC recurrence occurred between 8 and 20% of patients and lung is the most frequent site. Pulmonary metastases resection (PMR) prolongs survival, however in LT-setting the impact on survival is unclear. To give new lights on this issue, we report the experience of three Italian LT Centers. All consecutive HCC transplanted patients in three Italian LT Centers, who developed pulmonary metastasis from HCC (PM-HCC), as first metastasis, from 2008 to 2018, were included whenever treated with PMR. Twenty-five patients were enrolled (median age 58 yrs, 84% male, 3% cirrhotics). HCC recurred after 34 months (9-306) since LT and PMR was performed after 2.4 months (0-43.1). A total of 28 PMR (19 single resections; 9 multiple resections; 16 right; 2 left) have been performed on 24 patients while in one case percutaneous microwave ablation (MWA) was preferred. Four patients have been re-operated due to pulmonary HCC-recurrence after surgery. The majority of surgical resection type was wedge resection (26, 89%). Surgical access was: video-assisted thoracic surgery (VATS) in 17 cases (59%); thoracotomy in 11 (38%); MWA in 1 (3%). The 48% of nodule was in right lower lobe. Perioperative in-hospital mortality and 30 days mortality were nil; median surgical time 90 min (50-365); median post-operative overall stay 5 days (2-11). Post-operative ICU treatment was necessary in 1 case (3%) for 3 days; blood transfusions in 2 cases (7%). Overall, 5 complications (2 bleeding; 1 AKI; 1 major cardiac; 1 wound dehiscence) occurred, with an overall complications rate of 23%. Eight (32%) patients died during a follow-up after HCC recurrence of 32 months (7-213): 7 for HCC progression, 1 for severe liver failure due to chronic rejection. The 1 and 5 year cumulative probability of OS from recurrence were 100 and 43% (95%CI 12-74), respectively, with a median OS of 51 months (95%CI 24-78). Selected patients with isolated pulmonary HCC-recurrence after LT and with preserved hepatic function showed that a pulmonary metastasectomy could be efficacious in managing a PM-HCC and could give an opportunity for long-term survival.
Copyright © 2020 Invenizzi, Iavarone, Donato, Mazzucco, Torre, Conforti, Rimessi, Zavaglia, Schiavon, Comacchio, Rea, Boetto, Cillo, Dondossola, De Carlis, Lampertico, Nosotti and Mendogni.
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CPAP after endoscopic procedures as add-on therapy for the treatment of tracheal stenosis: a case series.
Monaldi Arch Chest Dis2019 Oct;89(3):. doi: 10.4081/monaldi.2019.1121.
Gesuele Adriano, Gambazza Simone, Lazzeri Marta, Conforti Serena
Abstract
Tracheal stenosis represents a possible complication in intubated or tracheotomised patients. Tracheal resection is currently the gold standard for the treatment of complex stenosis while granulomas and simple stenosis (e.g., web-like) are often treated by endoscopic procedures, which do not consistently give satisfactory long-term results, due to frequent relapses. Administering continuous positive airway pressure (CPAP) after endoscopic procedures might represent a new add-on option for the treatment of this complication. In this case series are presented two patients with tracheal stenosis showed after the removal of tracheostomy tube, both treated with CPAP. The results were straightforward: CPAP treatment helped to keep stable the tracheal lumen, without adverse effects. No further endoscopic dilations were necessary thereafter, with a likely positive impact on patients' quality of life and on health expenditure.
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Complications related to endoscopic lung volume reduction for emphysema with endobronchial valves: results of a multicenter study.
J Thorac Dis2018 Oct;10(Suppl 27):S3315-S3325. doi: 10.21037/jtd.2018.06.69.
Fiorelli Alfonso, D'Andrilli Antonio, Bezzi Michela, Ibrahim Mohsen, Anile Marco, Diso Daniele, Cusumano Giacomo, Terminella Alberto, Luzzi Valentina, Innocenti Margherita, Novali Mauro, Carelli Emanuele, Freda Chiara, Natale Giovanni, Peritore Valentina, Poggi Camilla, Failla Giuseppe, Basile Marco, Mazzucca Emilia, Conforti Serena, Serra Nicola, Torre Massimo, Venuta Federico, Rendina Erino Angelo, Santini Mario, Andreetti Claudio
Abstract
BACKGROUND:
Despite bronchoscopic lung volume reduction (BLVR) with valves is a minimally invasive treatment for emphysema, it can associate with some complications. We aimed at evaluating the rate and type of complications related to valve treatment and their impact on clinical outcomes.
METHODS:
It is a retrospective multicenter study including all consecutive patients with severe heterogeneous emphysema undergoing BLVR with endobronchial valve treatment and developed any complications related to this procedure. The type of complication, the time of onset, the treatment required and the out-come were evaluated. Response to treatment was assessed according to the minimal clinically important difference (MCID) as follows: an improvement of ?15% in forced expiratory volume in one second (FEV); of -8% in residual volume (RV); of ?26 m in 6-minnute walking distance (6MWD); and of ?4 points on the St. George's Respiratory Questionnaire (SGRQ). Target lobe volume reduction (TLVR) ?350 mL was considered significant.
RESULTS:
One hundred and seven out of 423 (25.3%) treated patients had complications related to valve treatment including pneumothorax (17.3%); pneumonia (1.7%), chronic obstructive pulmonary disease (COPD) exacerbation (0.9%), respiratory failure (1.4%), valve migration (2.1%), and hemoptysis (1.9%). In all cases complications resolved with appropriate treatment including removal of valves in 21/107 cases (19.6%). Patients with TLVR ?350 mL (n=64) those
CONCLUSIONS:
Valve treatment is a safe and reversible procedure. The presence of complications seems not to have a significant impact on clinical outcome in patients with lobar atelectasis. Due to poor clinical conditions and possible complications, BLVR should be performed in high volume centers with a multidisciplinary approach.
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A Smooth Esophageal Stricture Causing Dysphagia.
Dysphagia2018 Jun;33(3):399-402. doi: 10.1007/s00455-018-9891-x.
Forti Edoardo, Bonato Giulia, Dioscoridi Lorenzo, Cintolo Marcello, Pugliese Francesco, Cristoferi Laura, Tringali Alberto, Caputo Valentina, Motta Valentina, Torre Massimo Domenico, Conforti Serena, Mutignani Massimiliano
Abstract
Dysphagia in patients with lung cancer is usually due to direct invasion from bronchogenic carcinomas or nodal localizations, while metastases from distant lung neoplasms are considered rare. We report a case of a smooth esophageal narrowing secondary to intramural metastasis from pulmonary adenocarcinoma in a patient with no previous history of neoplasia. Since standard linear echoendoscope could not overpass the malignant stricture, we obtained a histological diagnosis by fine-needle aspiration biopsy using an echobronchoscope (EBUS), due to its lower diameter. The EBUS scope represents a valuable tool to obtain cytological specimens in patients with esophageal strictures.
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Self-expanding y stent for the treatment of malignant tracheobronchial stenosis. Retrospective study.
Arch Bronconeumol2016 Nov;52(11):e5-e7. doi: 10.1016/j.arbres.2016.02.019.
Conforti Serena, Durkovic Sava, Rinaldo Alessandro, Gagliardone Maria Pia, Montorsi Emanuela, Torre Massimo
Abstract
Palliation of malignant tracheobronchial stenosis is challenging. Published experience with self-expanding Y-shaped stents is limited and it seems necessary to evaluate whether they improve clinical results with respect to alternative prostheses. We present a retrospective case series of 20 consecutive patients with malignant tracheobronchial stenosis that underwent placement of a single-unit, Y-shaped covered metallic stent. Outcomes were: safety of the procedure, palliation of dyspnea, complications, and survival. All stents were safely and easily placed using a rigid tracheoscope within 24hours of admission. Dyspnea was effectively palliated in all patients, and no early or late adverse stent-related events were observed. Thirty-day mortality was 40%. Median survival was 12.2 weeks. Placement of Y-shaped self-expanding stents is a safe and effective procedure for the palliation of malignant tracheobronchial stenosis, and is currently our stent of choice for this subgroup of patients.
Copyright © 2016 SEPAR. Publicado por Elsevier España, S.L.U. All rights reserved.
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Long-term results of lung cancer after heart transplantation: single center 20-year experience.
Lung Cancer2009 Jan;63(1):146-50. doi: 10.1016/j.lungcan.2008.04.018.
Bruschi Giuseppe, Conforti Serena, Torre Massimo, Colombo Tiziano, Russo Claudio F, Pedrazzini Giovanna, Frigerio Maria, Ravini Mario
Abstract
OBJECTIVE:
The present study analyses, long-term lung cancer survival rate in the Niguarda heart transplant population and the results of surgical treatments.
METHODS:
From November 1985 to December 2006, 786 heart transplants were performed in our Center; we underwent a retrospective review of patients developing primary lung cancer.
RESULTS:
Among 660 heart transplant recipients valuable in this study, 22 (3.3%) developed a primary lung cancer (20 male, 91%), their mean age at time of heart transplant was 54.5+/-5.2 years (range, 42-65). The mean time from transplantation to lung cancer diagnosis was 73.7+/-30 months. Eleven patients (50%) were in stage IIIB or higher at the time of presentation. The 5-year survival rate of the entire study population was 21.4%, with a median survival time (MST) of 10.1 months. Ten patients underwent surgical resection (9 lobectomies and 1 wedge resection) and demonstrated improved long-term survival with 5-year survival of 56% and MST 70.4 months, compared to patients who did not undergo any surgical procedure, all of whom died during follow-up, with 1-year survival of 33%.
CONCLUSIONS:
Long-term results following lung cancer surgery in heart transplant recipients are satisfactory when performed at the early stage of the disease. Preventive computed tomography screen should be considered as a routine method for early diagnosis in this group of high-risk patients.
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[Cardiac troponin-I elevations after thoracic surgery. Incidence and correlations with baseline clinical characteristics, C-reactive protein and perioperative parameters].
Rev Esp Cardiol2007 Nov;60(11):1159-66.
Lucreziotti Stefano, Conforti Serena, Carletti Francesca, Santaguida Giulia, Meda Stefano, Raveglia Federico, Tundo Fabrizio, Panigalli Tiziana, Biondi Maria L, Mezzetti Maurizio, Fiorentini Cesare
Abstract
INTRODUCTION AND OBJECTIVES:
The exact incidence of cardiac troponin-I elevation after thoracic surgery and its correlation with other clinical parameters have not been fully described. The aims of this study were to determine the frequency of postoperative cardiac troponin-I elevation following lung or pleural surgery for suspected cancer, and to investigate correlations with baseline clinical characteristics, the C-reactive protein level, and perioperative parameters.
METHODS:
Fifty consecutive patients were enrolled in the study. In each patient, the following parameters were measured: clinical characteristics and C-reactive protein level at baseline, cardiac troponin-I level on postoperative days 1, 3 and 5, and blood pressure, heart rate and ECG parameters every day from the day of the operation until postoperative day 5.
RESULTS:
The cardiac troponin-I level was elevated postoperatively in 20% of patients. There were significant associations with either a history of coronary artery disease or the presence of more than two coronary risk factors (80% vs. 32.5%; P=.011), a history of chronic antiplatelet therapy (50% vs. 17.5%; P=.046), pneumonectomy compared with less invasive procedures (40% vs. 10%; P=.041), pericardiotomy (30% vs. 2.5%; P=.022), and transient ST-segment alterations on perioperative ECGs (60% vs. 20%; P=.02). No significant correlation was found between cardiac troponin-I elevation and the baseline C-reactive protein level.
CONCLUSIONS:
Cardiac troponin-I elevation occurs frequently after thoracic surgery and it is associated with clinical markers of coronary artery disease, extensive surgical procedures, and ischemic changes observed on perioperative ECGs.
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A case of fibrous histiocytoma of the trachea in an infant treated by endobronchial ND:YAG laser.
Lung Cancer2007 Jul;57(1):112-4.
Conforti Serena, Bonacina E, Ravini M, Torre Massimo
Abstract
Fibrous histiocytomas are uncommon tracheal tumors. They generally involve only the lung parenchyma; endobronchial involvement is extremely rare. At present, surgical resection is considered the therapy of choice for definitive diagnosis and cure. Endoscopical treatment is uncommon in pediatric patients because of the technical endoscopical difficulties and the high recurrence rate of treatment by endoscopy alone. We report the first case of fibrous histiocytoma in an infant successfully treated by endoscopy and yttrium alluminum garnet (YAG)-laser.
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Personal experience in surgical management of pulmonary pleomorphic carcinoma.
Ann Thorac Surg2004 Nov;78(5):1742-7.
Raveglia Federico, Mezzetti Maurizio, Panigalli Tiziana, Furia Simone, Giuliani Luigi, Conforti Serena, Meda Stefano
Abstract
BACKGROUND:
Pleomorphic carcinoma is a rare epithelial malignant tumor. Pulmonary pleomorphic carcinoma was introduced by the 1999 World Health Organization classification as a new peculiar type of lung carcinoma showing concurrent malignant epithelial and sarcomatoid spindle cell elements. Few reports describe its clinical behavior. My colleagues and I report a series of patients surgically treated for pulmonary pleomorphic carcinoma to describe our experience with this malignant neoplasm.
METHODS:
Twenty cases of pleomorphic pulmonary carcinoma were collected and studied clinicopathologically. All patients underwent surgical resection. The cases were as follows: 6 stage I, 12 stage II, and 2 stage IIIA. Histologic diagnosis was established by using light microscopic examination and immunohistochemistry. Survival rates were calculated with the Kaplan-Meier method.
RESULTS:
We postoperatively diagnosed 20 cases of pleomorphic carcinoma: 14 cases were exclusively spindle and giant-cell carcinomas, 2 cases were spindle and giant-cell carcinoma combined with adenocarcinoma, 2 were combined with squamous cell carcinoma, and 2 were combined with large cell carcinoma. At last follow-up, 4 patients were still alive; they were postoperative T1 N0 and T2 N0. The remaining 16 patients died from early distant metastases. The median duration of disease-free survival was 5 months. The median duration of overall survival was 8 months.
CONCLUSIONS:
The prognosis of patients with pleomorphic carcinoma was poor, despite surgery and adjuvant chemotherapy, because of early relapse of disease. Nodal involvement was a determinant prognostic variable, because advanced stages were related to worse prognosis. In case of preoperatively proven pulmonary pleomorphic carcinoma, surgery should be recommended to N0 patients.
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Assessment of outcomes in typical and atypical carcinoids according to latest WHO classification.
Ann Thorac Surg2003 Dec;76(6):1838-42.
Mezzetti Maurizio, Raveglia Federico, Panigalli Tiziana, Giuliani Luigi, Lo Giudice Fabio, Meda Stefano, Conforti Serena
Abstract
BACKGROUND:
Pulmonary carcinoid tumors represent a group of malignant neoplasms comprised of neuroendocrine cells. In 1999, the World Health Organization (W.H.O.) proposed the definitive classification of neuroendocrine tumors based on the criteria from Travis and associates. The W.H.O. described two different groups of carcinoid tumors: typical carcinoids (TC) and atypical carcinoids (AC). Few reports have reviewed their data according to the current classification, and therefore, prognosis and standard therapy for TC and AC are still uncertain.
METHODS:
From 1980 to 2001, 98 pulmonary resections have been performed for primary bronchial carcinoid tumors in our Thoracic Department of the University of Milan. We reviewed original histology using the current W.H.O. criteria and identified 88 patients with TC and 10 with AC. We reviewed the outcomes in each group.
RESULTS:
The 5 year-overall survival rate was 91.9% for TC and 71% for AC. The 10-year overall survival rate was 89.7% for TC and 60% for AC. The 5-year TNM-related survival rates in the TC group were: IA-B, 100%; IIA-B, 75%; and IIIA, 50%. At 10 years, they were: IA-B, 100%; IIA-B, 75%; and IIIA, 0%. The 5-year survival rates in the AC group were: IA-B, 100%; IIA-B, 100%; and IIIA, 0%. At 10 years, they were: IA-B, 100%; IIA-B, 66%; and IIIA, 0%.
CONCLUSIONS:
Prognosis is favorable for both subtypes in the early stage. Advanced stages are related to better prognosis in TC. Recurrences rate is worse in the AC subtype. Our data suggest avoiding limited resections when feasible in AC. Parenchyma-sparing resections should be encouraged in TC.
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