Medical and Economic Evaluation of FOREseal Bioabsorbable Reinforcement Sleeves Compared With Current Standard of Care for Reducing Air Leakage Duration After Lung Resection for Malignancy: A Randomized Trial.

OBJECTIVE: The objective of this study was to determine the efficacy of alginate staple-line reinforcement of fissure openings as compared with stapling alone, with or without tissue sealant or glue, in reducing the incidence and duration of air leakage after pulmonary lobectomy for malignancy. SUMMARY BACKGROUND DATA: No randomized trial evaluating alginate staple-line reinforcement has been performed to date. METHODS: The Staple-line Reinforcement for Prevention of Pulmonary Air Leakage study was a multicenter randomized trial, with blinded evaluation of endpoints. Patients over 18 years of age scheduled for elective open lobectomy or bilobectomy for malignancy were eligible for enrollment. At thoracotomy, patients were deemed ineligible if an unanticipated pneumonectomy was indicated, or if air leakage occurred after the liberation of pleural adhesions. Otherwise, if the fissure was incomplete or the lung had an emphysematous appearance, patients were randomized to either standard management or interventional procedure consisting of fissure opening with linear cutting staplers buttressed with paired alginate sleeves (FOREseal). The number of eligible patients necessary in each randomization arm was estimated to be 190, and an outcomes analysis was performed on an intention-to-treat basis. RESULTS: Of the 611 patients consented to study enrollment, 380 met the inclusion criteria and were randomized. Based on an intention-to-treat analysis, the primary endpoint of air leak duration was not different between the 2 groups: 1 day (range: 0-2 d) in the FOREseal group and 1 day (range: 0-3 d) in the control group (P = 0.8357). In addition, the 2 groups were similar in terms of the proportion of patients presenting with prolonged air leakage (7.8% in the FOREseal group vs 11.3% in the control group, P = 0.264) and the average duration of chest drainage (P = 0.107). Procedure costs were comparable for both groups. CONCLUSIONS: FOREseal did not demonstrate a significant advantage over standard treatment alone.

Indications and Results of Reconstructive Techniques with Flaps Transposition in Patients Requiring Complex Thoracic Surgery: A 12-Year Experience.

BACKGROUND: Flap transposition is an infrequent but far from exceptional thoracic surgical procedure. The aim of this retrospective study was to report our experience in a referral unit of general thoracic surgery analyzing the early results after flap transposition. METHODS: We retrospectively analyzed the clinical records, surgical notes, and postoperative results of a cohort of patients who underwent flap transposition in our unit from November 2000 to February 2013. RESULTS: Overall, a surgical approach adopting flap reconstruction techniques was performed in 81 patients (54 males, 27 females) with a median age of 62 years (range 20-87). Flap transposition was necessary to reconstruct chest wall after resection for malignancy (27 patients), to repair intrathoracic viscera perforation (15 patients), and to fill residual cavities secondary to pulmonary/pleural infection (39 patients). A pedicle muscle flap was transposed in most of cases (64 pts, 79 %), while in the remaining 17 cases (11 %), an omental flap was used. There were no immediate postoperative complications, while three in-hospital deaths occurred due to respiratory or multiorgan failure. Among patients undergone flap transposition to fill a residual cavity, we observed a recurrent bronchopleural fistula in three patients (7.7 %); such patients were treated by repeat flap transposition (2 cases) and by repeat cavernostomy (1 case). CONCLUSION: Flap transposition may be indicated as part of a multimodal treatment for severely ill patients requiring complex thoracic surgery.

Which is the Role of Pneumonectomy in the Era of Parenchymal-Sparing Procedures? Early/Long-Term Survival and Functional Results of a Single-Center Experience.

AIM: Despite the increasing adoption of parenchymal-sparing procedures, pneumonectomy is still necessary in several pleural and pulmonary (benign or malignant) diseases. We reviewed clinical data of a large cohort of patients treated by pneumonectomy with the aim of better define its impact on early and long-term results. METHODS: Clinical and pathological characteristics of all consecutive patients treated by pneumonectomy between January 2005 and May 2012 were retrospectively reviewed. Thirty- and 90-day mortality, as well as long-term survival was assessed. Factors associated to long-term survival were analyzed by univariate and multivariate analyses. Evaluation of quality of life was carried out by a standard questionnaire (SF-12) administrated by phone to patients surviving beyond 1 year. RESULTS: A total of 398 patients (293 men; mean age 61 ± 10.9 years) were operated on in the study period. Indication was malignancy in 380 patients (350 primary lung cancers). Thirty-day mortality was 9 % (right: 12.6 % vs. left: 6.3 %, p = 0.013), significantly correlating with age (p = 0.021), comorbidities (p = 0.034), PS > 1 (p = 0.018), preoperative dyspnea (p = 0.0013), and FEV1 (p = 0.0071). Overall 1-, 3-, 5-, and 7-year survival rates were 76.6, 46.6, 34.4, and 29.2 %. In case of primary lung cancer, these figures were 76.8, 46.4, 34.5, and 29.7 %. At univariate analysis, a less favorable survival was associated to PS > 1 (p = 0.0078), right side (p = 0.044), occurrence of postoperative complications (p = 0.00079), and T3-4 status (p = 0.013). At multivariate analysis, PS > 1, right side, and occurrence of postoperative complications were identified as independent worse prognostic factors. SF12 physical score was 39.1 ± 9.0 and was correlated to the presence of preoperative symptoms (p = 0.013). Mental score was 50.68 ± 9.63 and was correlated to preoperative FEV1/FVC ratio (p = 0.023) and side of disease (p = 0.023). CONCLUSION: In current practice, pneumonectomy is still performed for malignancy, sometimes after induction treatment. High postoperative morbidity and mortality are observed; however, at a farer interval time point, long-term survival with preserved quality of life can be observed.

Presence of B cells in tertiary lymphoid structures is associated with a protective immunity in patients with lung cancer.

RATIONALE: It is now well established that immune responses can take place outside of primary and secondary lymphoid organs. We previously described the presence of tertiary lymphoid structures (TLS) in patients with non-small cell lung cancer (NSCLC) characterized by clusters of mature dendritic cells (DCs) and T cells surrounded by B-cell follicles. We demonstrated that the density of these mature DCs was associated with favorable clinical outcome. OBJECTIVES: To study the role of follicular B cells in TLS and the potential link with a local humoral immune response in patients with NSCLC. METHODS: The cellular composition of TLS was investigated by immunohistochemistry. Characterization of B-cell subsets was performed by flow cytometry. A retrospective study was conducted in two independent cohorts of patients. Antibody specificity was analyzed by ELISA. MEASUREMENTS AND MAIN RESULTS: Consistent with TLS organization, all stages of B-cell differentiation were detectable in most tumors. Germinal center somatic hypermutation and class switch recombination machineries were activated, associated with the generation of plasma cells. Approximately half of the patients showed antibody reactivity against up to 7 out of the 33 tumor antigens tested. A high density of follicular B cells correlated with long-term survival, both in patients with early-stage NSCLC and with advanced-stage NSCLC treated with chemotherapy. The combination of follicular B cell and mature DC densities allowed the identification of patients with the best clinical outcome. CONCLUSIONS: B-cell density represents a new prognostic biomarker for NSCLC patient survival, and makes the link between TLS and a protective B cell-mediated immunity.

Pitfalls related to the use of endostaplers during video-assisted thoracic surgery.

BACKGROUND: The use of staplers during thoracoscopic pulmonary resections has entailed several incidents. This study aimed to evaluate the rate of adverse events related to the use of an endostapler during video-assisted thoracic surgery (VATS). METHODS: All thoracoscopic procedures involving the use of an endostapler were prospectively studied. The study was based on the analysis of data prospectively entered into a database and the review of videotapes recorded during the procedure. The video clip of each incident was included into the database. The following events were recorded: oozing or hemorrhage on the staple line, partial or total disruption of the staple line, and any other technical issue. RESULTS: A total of 434 firings were made during 130 thoracoscopic operations. The operations involved 77 wedge resections of lung nodules, 11 pulmonary biopsies, 34 bullectomies, and 8 thoracoscopic lobectomies. Although firing was uneventful for most patients, a minor or major problem was encountered during 34 firings (7.6%). Two technical malfunctions of the device occurred, both of them noticed by the scrub nurse before introduction of the stapler into the trocar. The other pitfalls were oozing (13 cases) and active hemorrhages (5 cases) on the staple line and disruption of the staple line, either partial (13 cases) or total (1 case). Conversion to thoracotomy was never necessary. Whereas no specific action was imposed by the pitfall in 12 cases, the incident led to a repair in 22 cases. None of the incidents had a clinical consequence in the postoperative course. The video tapes were reviewed to check whether the accident was unpredictable or due the surgeon's misuse or misjudgment. In 14 cases, no cause was found. In 5 cases, the lung parenchyma probably was too thick for the staples chosen, whereas no technical error was found in the remaining 15 cases. CONCLUSION: Although some adverse events are attributable to surgical errors, many are linked to the device. This underscores the need for improving staplers and evaluating new technologies.

Synchronous Oligometastatic Lung Cancer Deserves a Dedicated Management.

BACKGROUND: Oligometastatic stage IV non-small lung cancer (NSCLC) patients have a 5-year overall survival of 30% versus 4% to 6% in historical cohorts of stage IV NSCLC patients. We reviewed data and patterns of care of patients affected by oligometastatic NSCLC in our center between 2001 and 2017. METHODS: We retrospectively reviewed clinical and pathological files of all patients with lung cancer and synchronous isolated adrenal or brain metastases, or both, treated by locally ablative treatments (surgery or radiotherapy, or both) of both primary cancer and distant metastasis. Statistical analysis was performed to assess the effect on overall survival of patient- and tumor-related characteristics and therapeutic approaches. Overall survival was assessed by the Kaplan-Meier method. Survival rates were compared by log-rank test. Significance was accepted at a level of p of less than 0.05. RESULTS: Our department treated 51 patients affected by NSCLC and synchronous brain metastasis (n = 41), adrenal metastasis (n = 9), or both (n = 1). Median survival was 42 months (95% confidence interval, 22.3 to 63.7). Overall survival was 62% at 2 years and 34.4% at 5 years. A univariate and multivariate analysis the positive prognostic factors for survival was cessation of smoking (p = 0.006) and lymphovascular and perineural spreading in the tissues (p = 0.024). CONCLUSIONS: In selected oligometastatic synchronous NSCLC patients, a multimodality approach encompassing radical treatment of the primary tumor and ablative treatment of concurrent metastases is recommended, with encouraging results. Smoking cessation is a part of the treatment sequence.

CT-guided percutaneous core biopsy for assessment of morphologically normal adrenal glands showing high FDG uptake in patients with lung cancer.

OBJECTIVE:: Increased fludeoxyglucose (FDG) uptake in morphologically normal adrenal glands on positron emission tomography-CT (PET-CT) is a diagnostic challenge with major implications on treatment. The purpose of this retrospective study was to report our experience of CT-guided percutaneous core biopsy of morphologically normal adrenal glands showing increased FDG uptake in a context of lung cancer. METHODS:: Biopsies for non-enlarged adrenal glands showing increased FDG uptake in lung cancer patients performed at our institution from December 2014 to December 2016 were retrospectively analyzed. Six biopsies were performed in five patients during the study period. All procedures were performed with the patients in the prone position, using a posterior approach and coaxial 17-gauge needles with 18-gauge automated cutting needles. Patient characteristics, procedural details and final pathological diagnosis were analyzed, as well as the duration of hospitalization. RESULTS:: Five of the six biopsies (83.3%) confirmed adrenal metastasis from the primary lung cancer. No complications were reported and the patients were discharged the day after the procedure. CONCLUSION:: The high confirmation rate of metastasis and lack of complications support performing CT-guided percutaneous biopsy of non-enlarged adrenal glands showing increased FDG uptake, for optimal management in lung cancer patients. ADVANCES IN KNOWLEDGE:: Morphologically normal adrenal glands showing high FDG uptake in patients with lung cancer are metastasis. This manuscript shows that CT-guided percutaneous biopsy should be proposed. Increased FDG uptake in morphologically normal adrenal glands may indicate metastasis.

Is Cure Possible After Sequential Resection of Hepatic and Pulmonary Metastases From Colorectal Cancer?

BACKGROUND: Surgical resection is an established therapeutic strategy for colorectal cancer (CRC) metastasis. However, controversies exist when CRC liver and lung metastases (CLLMs) are found concomitantly or when recurrence develops after either liver or lung resection. No predictive score model is available to risk stratify these patients in preparation for surgery, and cure has not yet been reported. PATIENTS AND METHODS: All consecutive patients who had undergone surgery for CLLMs at our institution during a 20-year period were reviewed. Our policy was to propose sequential surgery of both sites with perioperative chemotherapy, if the strategy was potentially curative. Overall survival, disease-free survival, and cure were evaluated. RESULTS: Sequential resection was performed in 150 patients with CLLMs. The median number of liver and lung metastases resected was 3 and 1, respectively. The median follow-up period was 59 months (range, 7-274 months). The median, 5-year, and 10-year overall survival was 76 months, 60%, and 35% respectively. CRC that was metastatic at the initial diagnosis (P = .012), a prelung resection carcinoembryonic antigen level > 100 ng/mL (P = .014), a prelung resection cancer antigen 19-9 level > 37 U/mL (P = .034), and an interval between liver and lung resection of < 24 months (P = .024) were independent poor prognostic factors for survival. The 5-year survival was significantly different for patients with ≤ 2 and ≥ 3 risk factors (77.3% vs. 26.5%). Of 75 patients with ≥ 5 years of follow-up data available from the first metastasis resection, 15 (20%) with disease-free survival ≥ 5 years were considered cured. The use of targeted therapy was the only independent predictor of cure. CONCLUSION: Curative-intent surgery provides good long-term survival and offers a chance of cure in select patients. Patients with ≤ 2 risk factors are good candidates for sequential resection.

Thoracoscopic resection of bulky intrathoracic benign lesions.

BACKGROUND: Video-assisted thoracic surgery (VATS) is used for the diagnosis and treatment of some mediastinal lesions. However, large-size tumours are usually approached by thoracotomy or sternotomy. We report our experience of a full thoracoscopic approach for bulky intrathoracic lesions. METHODS: From November 2002 to March 2007, 14 patients with a bulky intrathoracic mass were referred for resection. The study group consisted of eight females and six males with a mean age of 44 years (range: 13-74). We defined as bulky a mass with a minimal cross-sectional diameter equal to or larger than 50 mm, as measured on the specimen by the pathologist. RESULTS: Thoracoscopic resection was completed in all patients. In 4 cases, the mass originated from the pleura, and in 10 cases from the mediastinum. The larger diameter of the lesion ranged from 50 mm to 160 mm, with a median of 90.2 mm. Operative time, calculated from insertion of the first trocar to skin closure, ranged from 40 to 190 min (mean: 102). Mean chest drain duration was 2.1 days (range: 1-4 days) and the mean hospital stay was 4.3 days (range: 3-11 days). There were no major postoperative complications. The final pathological diagnoses were the following: solitary fibrous tumours of the pleura (4), benign thymic cysts (2), teratomas (2), bronchogenic cyst (1), benign thymoma (1), pleuropericardial cyst (1) and benign neurogenic tumours (3). CONCLUSIONS: With experience and use of appropriate instrumentation, resection of bulky intrathoracic lesions by thoracoscopy is feasible and safe. It should be considered as a reliable alternate for tumours that are benign and most often asymptomatic.

Risk factors for hemoptysis complicating 17-18 gauge CT-guided transthoracic needle core biopsy: multivariate analysis of 249 procedures.

PURPOSE: We aimed to identify modifiable and nonmodifiable risk factors for hemoptysis complicating computed tomography (CT)-guided transthoracic needle biopsy. METHODS: All procedures performed in our institution from November 2013 to May 2015 were reviewed. Hemoptysis was classified as mild if limited to hemoptoic sputum and abundant otherwise. Presence of intra-alveolar hemorrhage on postbiopsy CT images was also evaluated. Patient- and lesion-related variables were considered nonmodifiable, while procedure-related variables were considered modifiable. RESULTS: A total of 249 procedures were evaluated. Hemoptysis and alveolar hemorrhage occurred in 18% and 58% of procedures, respectively, and were abundant or significant in 8% and 17% of procedures, respectively. Concordance between the occurrence of significant alveolar hemorrhage (grade ≥2) and hemoptysis was poor (κ=0.28; 95% CI [0.16-0.40]). In multivariate analysis, female gender (P = 0.008), a longer transpulmonary needle path (P = 0.014), and smaller lesion size (P = 0.044) were independent risk factors for hemoptysis. Transpulmonary needle-path length was the only risk factor for abundant hemoptysis with borderline statistical significance (P = 0.049). CONCLUSION: The transpulmonary needle path should be as short as possible to reduce the risk of abundant hemoptysis during CT-guided transthoracic needle biopsy.

Thoracic Endometriosis Syndrome Other Than Pneumothorax: Clinical and Pathological Findings.

BACKGROUND: Thoracic endometriosis syndrome refers to a broad spectrum of clinical manifestations related to the presence of ectopic intrathoracic endometrial tissue. Few studies have reported on manifestations other than pneumothorax. METHODS: Clinical, surgical, and pathology records of all consecutive women of reproductive age referred to our institution from September 2001 to August 2016 for clinically suspected thoracic endometriosis syndrome were retrospectively reviewed. After excluding women with pneumothorax, we enrolled 31 patients, divided into three subgroups: catamenial chest pain (n = 20), endometriosis-related diaphragmatic hernia (n = 6), and endometriosis-related pleural effusion (n = 5). RESULTS: Surgery was performed in 11 patients with catamenial thoracic pain (median age, 30 years; range, 23 to 42). Median pain intensity assessed on the 0 to 10 Visual Analogue Scale was 8 (range, 8 to 9) before surgery. At surgery, 8 patients had diaphragmatic endometriosis implants, which were resected with direct suture of diaphragm. At follow-up, median pain score was 3 (range, 0 to 8). In the group presenting with diaphragmatic hernia (median age, 36 years; range, 29 to 50), diaphragm was repaired by direct suture or placement of prosthesis in 4 and 2 cases, respectively. At follow-up, no sign of recurrent hernia was observed. Finally, among women with endometriosis-related pleural effusion (median age, 30 years; range, 25 to 42), surgical treatment was represented by evacuation of the pleural effusion and biopsy (n = 4) or removal (n = 1) of visible endometrial foci. CONCLUSIONS: Thoracic endometriosis syndrome is a poorly recognized entity responsible for various manifestations other than pneumothorax. In case of catamenial thoracic pain, diaphragmatic hernia and catamenial pleural effusion surgery should be advised in a multidisciplinary setting.

Prognostic factors after pulmonary metastasectomy of colorectal cancers: a single-center experience.

BACKGROUND: Surgical resection has been widely admitted as the treatment of choice for pulmonary metastases of colorectal cancer (CRC). Nevertheless, this practice is not supported by high level of evidence and patients' eligibility remains controversial. Aim of this study was to evaluate long terms results and factors influencing survival after lung metastasectomy of CRC. METHODS: A single-center retrospective analysis of patients with pathologically proven colorectal metastasis, operated from 2004 to 2013, was performed. Patients were treated with a multidisciplinary approach and selected for surgery if complete resection was considered feasible. RESULTS: Three hundred and six patients were considered for analysis. Mean number of lesions at CT scan was 2.6±2.3. Ratios of each largest resection type at first side surgery were: segmentectomy 20.6%, lobectomy 12.9%, bilobectomy 1.2%, pneumonectomy 1.2% and sub-lobar resection 64.1%, respectively. No in-hospital death occurred. At pathology, mean number of resected metastasis was 2.6±2.3, ranging from 1 to 12. Resection was complete in 92.5% of patients. Nodal involvement was proven in 40 (12.9%) patients. The initially planned complete resection could not be achieved in 23 (7.5%) cases. Mean follow-up was 3.06±2.36 years. Kaplan-Meier analysis revealed that recurrence-free survival (RFS) was 76.3% [95% confidence interval (95% CI), 71-80.7%], 38.9% (95% CI, 33-44.7%), 28.3% (95% CI, 22.5-34.4%) and 22.7% (95% CI, 16.5-29.5%) at 1, 3, 5 and 7 years, respectively. Overall survival (OS) estimates were 77.8% (95% CI, 72.7-82.7%), 59.0% (95% CI, 51.2-66.4%), and 56.9% (95% CI, 48.4-65.0%) at 3, 5 and 7 years, respectively. Multivariate analysis, including pT parameter of the primary tumor, number of lesions, one-sided versus bilateral lung disease, and body mass index (BMI) (all significant at univariate analysis), showed that bilateral disease (P<0.001) and pT4 primary (P=0.005) were independent pejorative predictors of OS, whereas BMI ≥25 was protective (P=0.028). CONCLUSIONS: Bilateralism and primary tumor local extension influence the prognosis of patients surgically treated for pulmonary colorectal metastases. Specifically designed randomized trials are necessary.

The transmanubrial approach: a new operative approach to cervicothoracic neuroblastoma in children.

BACKGROUND: Cervicothoracic neuroblastoma originates from the cervical sympathetic nerves and ganglia and thus presents a problem when dissecting the vascular and nervous elements of the subclavian region. The standard operation is based on thoracotomy or dual cervicotomy/thoracotomy, but these approaches do not provide optimal control of the subclavian vessels. We report our experience in children with cervicothoracic neuroblastoma by using a technique usually performed for apical lung cancer. METHODS: Four patients with localized cervicothoracic neuroblastoma with no N-myc amplification were resected after chemotherapy by this approach. The anatomic evaluation was performed preoperatively with angio-magnetic resonance imaging. This transmanubrial approach, performed through a manubrial L-shaped transection and first costal cartilage resection, affords excellent access to the subclavian region with safe control of the vessels and nerves and exposure of the first 4 thoracic intervertebral foramina. RESULTS: Removal of more than 90% of the tumor was possible in all cases. The postoperative course was uneventful in 3 cases, and the fourth patient with a left-sided tumor had a transient chylothorax. No recurrence occurred with a follow-up period of 8 to 32 months. CONCLUSIONS: The transmanubrial approach is an osteomuscular-sparing technique that seems particularly suitable for the treatment of these tumors, which require a resection that is as complete as possible to avoid postoperative chemotherapy and tumor relapse.

Early and long-term results of lung resection for non-small-cell lung cancer in patients with severe ventilatory impairment.

OBJECTIVE: To study clinical characteristics, surgical treatment modalities, early and long-term outcome of patients with severe ventilatory impairment undergoing lung resection for NSCLC. METHODS: We performed a retrospective review of clinical records of all patients with severe chronic ventilatory impairment (FEV1 and/or FVC< or =50% of predicted values) operated on for NSCLC in a 21-year period (1983-2003). RESULTS: One hundred and six patients were operated on. Mean FEV1 and FVC were 40% (range 23-50%) and 69% (17-117%), respectively. An obstructive pattern was observed in 87 cases (82%). Extent of maximal exeresis was based on the assessment of predicted post-operative FEV1 (ppoFEV1). Major resections were contraindicated if ppoFEV1 was lower than 30%. Sixteen pneumonectomies, 73 lobectomies and 17 sublobar resections were carried out. Pathologic stages were I, II, IIIA and IIIB in 58, 26, 18 and 4 cases, respectively. Resection was complete in 104 patients. Operative mortality and morbidity were 8.5% (n=9) and 70% (n=74), respectively. Twenty-two patients needed prolonged (>48 h) mechanical ventilation. Overall mean ppoFEV1 loss was 9.1% (0-34%). If ppoFEV1 loss was >15%, the morbidity rate was 100%. Mean PaCO2 and ppoFEV1 loss were higher among patients who died (41 mmHg versus 37 mmHg, P=0.02 and 13.2% versus 8.5%, P=0.025, respectively) as compared with operative survivors. Among patients with PaCO2>39 mmHg and ppoFEV1 loss>15% (n=9), mortality rate was 33%. Overall 1-year and 5-year survival rates were 82 and 33%, respectively. Respiratory failure was the cause of late death in 2 patients. Among patients available at follow-up (n=85), respiratory function was considered subjectively improved, stable and worsened in 6 (7%), 62 (73%) and 17 (20%) cases, respectively. Eleven patients needed continuous oxygen therapy. CONCLUSIONS: Lung resection should not be denied a priori in patients with severe ventilatory impairment. Evaluation of predicted post-operative function often allows major resections, which are functionally economic, at the price of a high operative morbidity. Operative mortality, long-term survival and respiratory function are acceptable in the absence of a valid therapeutic alternative.

Surgical treatment of superior sulcus tumors: results and prognostic factors.

OBJECTIVES: To study the clinical characteristics, treatment modalities, and outcome of patients with superior sulcus tumors who underwent surgery over a 15-year period. DESIGN: Retrospective clinical study. METHODS: Clinical records of all patients operated on for superior sulcus tumors by the same surgical team between 1988 and 2002 were reviewed retrospectively. RESULTS: Sixty-seven patients were operated on in this period. All the patients underwent en bloc lung and chest wall resection. Surgical approaches were as follows: posterolateral thoracotomy according to Paulson (n = 33), combined transcervical and transthoracic approach (n = 33), and isolated transcervical approach (n = 1). Types of pulmonary resection included lobectomies (n = 59), pneumonectomies (n = 2), and wedge resections (n = 6). Pathologic stages were IIB, IIIA, and IIIB in 49 cases, 12 cases, and 6 cases, respectively. Resection was complete in 55 patients (82%). Operative mortality was 8.9% (n = 6). Postoperative treatment was administered in 53 patients (radiotherapy, n = 42; chemoradiotherapy, n = 9; and chemotherapy, n = 2). Overall 2-year and 5-year survival rates were 54.2% and 36.2%, respectively. Five-year survival was significantly higher after complete resection than after incomplete resection (44.9% vs 0%, p = 0.000065). The presence of associated major illness negatively affected the outcome (5-year survival, 16.9% vs 52%; p = 0.043). Age, weight loss, respiratory impairment, tumor size, presence of nodal disease, and histologic type did not influence the long-term outcome. At multivariate analysis, only the completeness of resection and the absence of associated major comorbidities had an independent positive prognostic value. CONCLUSIONS: Superior sulcus tumor remains an extremely severe condition, but long-term survivals may be achieved in a large percentage of cases. The presence of associated major illness and the completeness of resection are the two most important factors affecting the long-term outcome.

Catamenial pneumothorax: a prospective study.

OBJECTIVES: To evaluate the incidence of catamenial pneumothorax (CP) among women who have been referred for the surgical treatment of spontaneous pneumothorax (SP) and to study its pathogenic mechanisms. DESIGN: A prospective study of women of reproductive age who have been referred to our center for the surgical treatment of SP. Patients with pneumothorax secondary to a known lung disease were excluded. SETTING: A university hospital. METHODS: At the preoperative evaluation, special attention was given to the investigation of a possible temporal relationship between pneumothorax and menses. Video-assisted thoracoscopy constituted the operative technique of choice. The lung was inspected to identify blebs or bullae and the origin of possible air leaks. Signs of thoracic endometriosis were also carefully searched for. The diaphragm was systematically inspected to search for holes and/or endometrial implants. When limited diaphragmatic abnormalities were found, a partial diaphragmatic resection was carried out using an endoscopic stapler. In case of lesions that were not accessible by a purely endoscopic approach, a utility minithoracotomy was used. RESULTS: In an 18-month period, 32 women with SP were referred for surgery. In eight cases, the catamenial character of the pneumothorax was recognized by clinical history. In all these patients, the following diaphragmatic abnormalities were found at surgery: holes (one patient); endometrial implants (three patients); and both (four patients). Visceral pleural endometriosis was found in one patient. During pathologic examination, diaphragmatic endometriosis was confirmed in seven of the eight cases. In one patient, it was associated with pulmonary and pleural endometriosis. In only one patient (with multiple diaphragmatic holes and a pulmonary nodular brown lesion), endometriosis could not be confirmed at histology, but signs of parenchymal focal hemorrhages were found. CONCLUSIONS: Our experience shows that (1) CP is more frequent than expected and (2) diaphragmatic abnormalities seem to play a fundamental role in its pathogenesis.

Results of superior vena cava resection for lung cancer. Analysis of prognostic factors.

AIMS: The benefits of superior vena cava (SVC) resection for lung cancer remain controversial. Data obtained in four international centers were analyzed in order to identify prognostic factors and thus guide in future patient selection. MATERIALS AND METHODS: Retrospective study. Prognostic factors were examined by logistic regression for postoperative morbidity/mortality using the Kaplan-Meier method (log rank test) and the Cox proportional-hazard model for survival. RESULTS: From 1963 to 2000, 109 patients underwent SVC resection. Induction treatment was given to 23 (21%) patients. The SVC was resected for T involvement in 78 (72%) cases and for N involvement in 31 (28%) cases. Fifty-five (50.5%) patients underwent pneumonectomy (20 with carinal resection), while the remaining underwent lobar resections. Prosthetic SVC replacement was performed in 28 (26%) patients; partial resection with running suture (53%), vascular stapler (13%), or patch (7%) was performed in 80 patients; 1 patient did not undergo reconstruction. Pathological examination identified direct involvement (T4) in 66 (60%) patients and N2 disease in 55 (50%) patients. Major postoperative morbidity and mortality were 30 and 12%, respectively. Median intensive care unit stay was 3 days, while median hospital stay was 16 days. Five-year survival was at 21%, with median survival at 11 months. In multiple regression analysis, induction treatment was associated with an increased risk of major complications (P = 0.016). None of the factors assessed demonstrated an association with postoperative death. In multivariate survival analysis, both pneumonectomy and complete resection of the SVC with prosthetic replacement were associated with a significant increased risk of death (P = 0.0013 and 0.014, respectively). CONCLUSIONS: The radical resection of lung cancer involving the SVC may result in a permanent cure in carefully selected patients. The type of pulmonary resection (i.e., pneumonectomy) and the type of SVC resection (i.e., complete resection with prosthetic replacement) are the prognostic factors with the greatest adverse effect on survival.

Postpneumonectomy syndrome and pre-existing thoracic scoliosis.

We report a case of postpneumonectomy syndrome in a 75-year-old man operated on for right lung cancer 18 months previously. The patient had a pre-existing severe thoracic scoliosis. Treatment involved positioning of an expandable silastic prosthesis in the postpneumonectomy cavity. A favorable outcome was observed. We think that a pre-existing scoliosis could be considered as a potentially predisposing factor to the development of the syndrome.

Superior vena cava resection with prosthetic replacement for non-small cell lung cancer: long-term results of a multicentric study.

OBJECTIVES: Superior vena cava (SVC) resection with prosthetic replacement for non-small cell lung cancer (NSCLC) is infrequently performed and oncological results are unclear. To establish a historical benchmark for this extended surgery, we have updated and reviewed data from four international centers. METHODS: Data were obtained through retrospective chart review. Prognostic factors were analyzed using first univariate techniques and subsequently multiple regression (logistic regression). Kaplan-Meier overall survival was calculated and prognostic factors examined by log-rank test and the estimation of hazard ratios using Cox regression. RESULTS: From 1985 to 2000, 28 patients underwent SVC resection with prosthetic replacement for NSCLC. During the same period, 65 patients underwent partial SVC resection. Induction treatment was performed in 25% of patients. The resection was done for T involvement in 22 patients (79%), and for N2 involvement in the remaining. There were 12 tracheal sleeve resections, four pneumonectomies, and 12 lobar or sublobar resections with or without bronchoplasty. The median clamping time was 40 min. The median diameter of the prosthesis used was No. 14. Pathological examination showed direct SVC invasion (T4) in 79% of patients, whereas N2 disease was present in 50% of patients. Median intensive care unit and hospital stay were 3 and 20 days, respectively. The postoperative morbidity and mortality were 39 and 14%, respectively. The overall 5-year probability of survival was 15% (median of 9 months, range 0-105 months). Patients who underwent partial SVC resection during the same period had a significantly higher probability of survival (P=0.03). Induction chemotherapy was associated with a significant increase of postoperative morbidity in multivariate analysis. None of the potential prognostic factors analyzed in multivariate analysis were associated with survival, but the type of resection (sleeve pneumonectomy/pneumonectomy) were borderline significant. CONCLUSIONS: SVC resection with prosthetic replacement should not be considered an absolute contraindication in patients with NSCLC; however, the poor oncological results suggest more restrictive and severe criteria of patient selection (mediastinoscopy, induction treatment, no pneumonectomy, no N2 disease).