Impact of inappropriate lymphadenectomy on lung metastasectomy for patients with metastatic colorectal cancer.

PURPOSE: To evaluate the characteristics of lymph node assessment in the Spanish Colorectal Metastasectomy Registry (GECMP-CCR) and to analyze and compare the survival of patients with pathological absence or presence of lymph node metastases (LNM) with the survival of those with uncertain lymph node status (uLNs). METHODS: A total of 522 patients with lung metastases from colorectal carcinoma were prospectively registered from 2008 to 2010. To confirm the pathologic absence of LNM, systematic nodal dissection or systematic sampling was required, or the lymph node status was coded as uncertain. Disease-specific survival and disease-free survival were calculated by the Kaplan-Meier method with the log-rank test for comparisons. RESULTS: Lymphadenectomy was performed in 250 (48%) patients. LNM was found in 25 (10%) of the patients who had lymph node assessment done. The 3- and 5-year disease-specific survival rates according to lymph node status were 73.5 and 58.3% in the absence of LNM, 50.5 and 24.8% when LNM was confirmed, and 69 and 44% for those with uLNs, respectively (p = 0.006). CONCLUSIONS: The presence of LNM and uLNs is associated with an increased risk of death. The association of nodal assessment at the time of metastasectomy to identify LNM helps us to refine the postoperative prognosis; therefore, its impact should be properly studied in a prospective clinical trial.

Correlation between preoperative CT scan and lung metastases according to surgical approach in patients with colorectal cancer.

INTRODUCTION: The number of lung metastases (M1) of colorectal carcinoma (CRC) in relation to the findings of computed tomography (CT) is the object of study. METHODS: Prospective and multicenter study of the Spanish Group for Surgery of CRC lung metastases (GECMP-CCR). The role of CT in the detection of pulmonary M1 is evaluated in 522 patients who underwent a pulmonary metastasectomy for CRC. We define M1/CT as the ratio between metastatic nodules and those found on preoperative CT. Disease-specific survival (DSS), disease-free survival (DFS), and surgical approach were analyzed using the Kaplan-Meier method. RESULTS: 93 patients were performed by video-assisted surgery (VATS) and 429 by thoracotomy. In 90%, the M1/CT ratio was ≤1, with no differences between VATS and thoracotomy (94.1% vs 89.7%, p=0.874). In the remaining 10% there were more M1s than those predicted by CT (M1/CT>1), with no differences between approaches (8.6% vs 10%, p=0.874). 51 patients with M1/CT>1, showed a lower median DSS (35.4 months vs 55.8; p=0.002) and DFS (14.2 months vs 29.3; p=0.025) compared to 470 with M1/CT≤1. No differences were observed in DSS and DFS according to VATS or thoracotomy. CONCLUSIONS: Our study shows equivalent oncological results in the resection of M1 of CRC using VATS or thoracotomy approach. The group of patients with an M1/CT ratio >1 have a worse DSS and DFS, which may mean a more advanced disease than predicted preoperatively.

Correlation between preoperative CT scan and lung metastases according to surgical approach in patients with colorectal cancer.

INTRODUCTION: The number of lung metastases (M1) of colorectal carcinoma (CRC) in relation to the findings of computed tomography (CT) is the object of study. METHODS: Prospective and multicenter study of the Spanish Group for Surgery of CRC lung metastases (GECMP-CCR). The role of CT in the detection of pulmonary M1 is evaluated in 522 patients who underwent a pulmonary metastasectomy for CRC. We define M1/CT as the ratio between metastatic nodules and those found on preoperative CT. Disease-specific survival (DSS), disease-free survival (DFS), and surgical approach were analyzed using the Kaplan-Meier method. RESULTS: 93 patients were performed by video-assisted surgery (VATS) and 429 by thoracotomy. In 90%, the M1/CT ratio was ≤1, with no differences between VATS and thoracotomy (94.1% vs 89.7%, p=0.874). In the remaining 10% there were more M1s than those predicted by CT (M1/CT>1), with no differences between approaches (8.6% vs 10%, p=0.874). 51 patients with M1/CT>1, showed a lower median DSS (35.4 months vs 55.8; p=0.002) and DFS (14.2 months vs 29.3; p=0.025) compared to 470 with M1/CT≤1. No differences were observed in DSS and DFS according to VATS or thoracotomy. CONCLUSIONS: Our study shows equivalent oncological results in the resection of M1 of CRC using VATS or thoracotomy approach. The group of patients with an M1/CT ratio >1 have a worse DSS and DFS, which may mean a more advanced disease than predicted preoperatively.

Typical trigeminal neuralgia associated with brainstem white matter lesions on MRI in patients without criteria of multiple sclerosis.

INTRODUCTION: Although compression of the trigeminal nerve by a vascular loop is thought to be the most common cause of trigeminal neuralgia (TN), other aetiologies, such as multiple sclerosis or brainstem infarction may be associated with this disorder. MRI may detect lesions different from vascular loop compression of the trigeminal nerve that may be related to TN. PATIENTS AND METHODS: The pre-operative MRIs of 68 patients without the diagnosis of multiple sclerosis who were operated for typical TN between 1998 and 2003 were retrospectively reviewed Four of these showed hyperintense lesions in the pons on T2 MRI sequences. No patient had prior surgery. These four patients underwent different operations for the control of pain but in two of them only ablative procedures were effective DISCUSSION: Although it is uncertain whether the occurrence of TN in our patients may be attributed to the brainstem abnormalities seen on MRI, the presence of these lesions appears to be the most convincing explanation for the occurrence of pain. We believe that, in the presence of such imaging changes, a destructive procedure should be regarded as the elective surgical treatment in patients presenting with typical TN with or without apparent vascular loop compression of the trigeminal root.

Combined Hepatic and Pulmonary Metastasectomies From Colorectal Carcinoma. Data From the Prospective Spanish Registry 2008-2010.

INTRODUCTION: Resection of both liver and lung metastases from colorectal carcinoma (CRC) is a standard of care in selected patients with oligometastatic disease. We present here the analysis of the subgroup of patients undergoing combined surgery from the Spanish Group of Surgery of Pulmonary Metastases (PM) from Colorectal Carcinoma (GECMP-CCR-SEPAR). METHODS: We analyze characteristics, survival and prognostic factors of patients undergoing combined resection from March-2008 to February-2010 and followed-up during at least 3 years, from the prospective multicenter Spanish Registry. RESULTS: A total of 138 patients from a whole series of 543 cases from 32 thoracic surgery units underwent both procedures. Seventy-seven (43.8%) resected liver metastases were synchronic with colorectal tumor. Median disease specific survival (DSS) from first pulmonary metastasectomy was 48.9 months, being three and 5-year DSS 65.1% and 41.7%, respectively. From CRC-surgery median DSS was 97.2 months, with 3 and 5-year DSS rates of 96.7% and 77%, respectively. Five-year DSS from pulmonary metastasectomy was 41.7% for patients with combined resection and 52.4% for those without hepatic involvement (P=.04). Differences disappeared when considering DSS from colorectal surgery. Carcinoembrionary antigen (CEA) before lung surgery over 10mg/dl and bilateral PM were independent prognostic factors for survival (hazard ratio 2.4 and 2.5, respectively). CONCLUSIONS: Patients with resection of PM of CRC with history of resected hepatic metastases presented significantly lower disease specific survival rates than those undergoing pulmonary metastasectomy alone. CEA before lung surgery and bilateral PM associated worse prognosis.

Agreement Between Computed Tomography and Pathologic Nodule Counts in Colorectal Lung Metastases.

BACKGROUND: Computed tomography is the most common technique used to estimate the number of pulmonary metastases and their resectability. A lack of agreement between radiologic and surgical pathologic findings could potentially lead to incomplete resection or to rejection of patients for potentially curative treatments. The objective of this study was to estimate the disagreement between the number of radiologic lesions and the number of histologically confirmed malignant lesions excised from patients with pulmonary metastases from colorectal cancer. METHODS: This was a multicenter longitudinal study using a national registry. All patients underwent open surgery for pulmonary metastasectomy. RESULTS: Radiologic unilateral involvement was documented in 345 of 404 patients (85%); 253 (73%) presented with single nodules. The radiologic and malignant pathologic findings were concordant in 316 (78%) patients. The two independent predictors of discordance between computed tomography and the number of pathologic metastases were the bilateral involvement and the number of radiologic nodules. This model explained 28% of the variability in the disagreement frequency and discriminated between agreement and disagreement in 85% of the patients. Discrepancies increased with the nodule count with an odds ratio of 6.17 (95% confidence interval, 4.08 to 9.33) per additional nodule. For similar nodule counts, a lower disagreement frequency was observed among bilateral cases (odds ratio, 0.2; 95% confidence interval, 0.07 to 0.55). CONCLUSIONS: Differences between the radiologic and pathologic findings were documented in 1 of every 5 patients. The correlation was very accurate in patients with single radiologic nodules. However, half of the patients with more nodules showed discrepancies.

Pathogenic potential of a Costa Rican strain of 'Candidatus Rickettsia amblyommii' in guinea pigs (Cavia porcellus) and protective immunity against Rickettsia rickettsii.

'Candidatus Rickettsia amblyommii' is a spotted fever group rickettsia that is not considered pathogenic, although there is serologic evidence of possible infection in animals and humans. The aim of this study was to evaluate the pathogenic potential of a Costa Rican strain of 'Candidatus R. amblyommii' in guinea pigs and determine its capacity to generate protective immunity against a subsequent infection with a local strain of Rickettsia rickettsii isolated from a human case. Six guinea pigs were inoculated with 'Candidatus R. amblyommii' strain 9-CC-3-1 and two controls with cell culture medium. Health status was evaluated, and necropsies were executed at days 2, 4, and 13. Blood and tissues were processed by PCR to detect the gltA gene, and end titers of anti-'Candidatus R. amblyommii' IgG were determined by indirect immunofluorescence. To evaluate protective immunity, another 5 guinea pigs were infected with 'Candidatus R. amblyommii' (IGPs). After 4 weeks, these 5 IGPs and 3 controls (CGPs) were inoculated with pathogenic R. rickettsii. Clinical signs and titers of anti-Rickettsia IgG were determined. IgG titers reached 1:512 at day 13 post-infection with 'Candidatus R. amblyommii'. On day 2 after inoculation, two guinea pigs had enlarged testicles and 'Candidatus R. amblyommii' DNA was detected in testicles. Histopathology confirmed piogranulomatous orchitis with perivascular inflammatory infiltrate in the epididymis. In the protective immunity assay, anti-Rickettsia IgG end titers after R. rickettsii infection were lower in IGPs than in CGPs. IGPs exhibited only transient fever, while CGP showed signs of severe disease and mortality. R. rickettsii was detected in testicles and blood of CGPs. Results show that the strain 9-CC-3-1 of 'Candidatus R. amblyommii' was able to generate pathology and an antibody response in guinea pigs. Moreover, its capacity to generate protective immunity against R. rickettsii may modulate the epidemiology and severity of Rocky Mountain spotted fever in areas where both species circulate.

Comparison between perimesencephalic nonaneurysmal subarachnoid hemorrhage and subarachnoid hemorrhage caused by posterior circulation aneurysms.

OBJECT: Some authors have questioned the need to perform cerebral angiography in patients presenting with a benign clinical picture and a perimesencephalic pattern of subarachnoid hemorrhage (SAH) on initial computerized tomography (CT) scans, because the low probability of finding an aneurysm does not justify exposing patients to the risks of angiography. It has been stated, however, that ruptured posterior circulation aneurysms may present with a perimesencephalic SAH pattern in up to 10% of cases. The aim of the present study was twofold: to define the frequency of the perimesencephalic SAH pattern in the setting of ruptured posterior fossa aneurysms, and to determine whether this clinical syndrome and pattern of bleeding could be reliably and definitely distinguished from that of aneurysmal SAH. METHODS: Twenty-eight patients with ruptured posterior circulation aneurysms and 44 with nonaneurysmal perimesencephalic SAH were selected from a series of 408 consecutive patients with spontaneous SAH admitted to the authors' institution. The admission unenhanced CT scans were evaluated by a neuroradiologist in a blinded fashion and classified as revealing a perimesencephalic SAH or a nonperimesencephalic pattern of bleeding. Of the 28 patients with posterior circulation aneurysms, five whose grade was I according to the World Federation of Neurosurgical Societies scale were classified as having a perimesencephalic SAH pattern on the initial CT scan. The data show that the likelihood of finding an aneurysm on angiographic studies obtained in a patient with a perimesencephalic SAH pattern is 8.9%. Conversely, ruptured aneurysms of the posterior circulation present with an early perimesencephalic SAH pattern in 16.6% of cases. CONCLUSIONS: This study supports the impression that there is no completely sensitive and specific CT pattern for a nonaneurysmal SAH. In addition, the authors believe that there is no specific clinical syndrome that can differentiate patients who have a perimesencephalic SAH pattern caused by an aneurysm from those without aneurysms. Digital subtraction angiography continues to be the gold standard for the diagnosis of cerebral aneurysms and should be performed even in patients who have the characteristic perimesencephalic SAH pattern on admission CT scans.

Benchmarking in thoracic surgery.

OBJECTIVE: Presentation of an experience in benchmarking in 13 university Spanish thoracic surgery services. METHODS: The minimum basic data set (MBDS) for hospitalization, corresponding to 2007, including all registered hospital discharges, was used. The performance of the hospitals was compared using an external reference pattern (SN) and internal average (BMG). Cases were chosen in which a major pulmonary resection (lobectomy or pneumonectomy) was done for bronchogenic carcinoma. Performance indicators were the complexity of the casuistry (average weight and relative weight). Performance results indicators included average length of stay (preoperative, postoperative, and global lengths of stay were analyzed separately for lobectomies as well as pneumonectomies), complications, mortality, and urgent readmissions. RESULTS: A total number of 4778 cases were analyzed, with major thoracic surgeries being prominent with 1779 (37.3%). For average weight, there was a dispersion between 2.5 and 5.68, with an average of 3.45 for the BMG and 3.43 for the SN. There were some very significant differences in morbidity, with groups having a gross rate of few complications (2.6%) up to many (16.1%). The mortality rate ranged between 1.6% and 6.6%. There were considerable differences in urgent readmissions, with gross rates between 2.6% and 7.3%, considering as points of reference 5.4% (BMG) and 4.7% (SN). Concerning the results of pulmonary resections for bronchogenic carcinoma, the index of pneumonectomies was between 8% and 29%. The average length of stay for lobectomy was between 6 and 9.5, with an average of 7 in BMG. In the case of pneumonectomies, it was between 6 and 26 days, with an average of 9 for BMG. Average preoperative stay also varied widely, between 0.2 and 2.4, while postoperative stay was between 7.5 and 12.1. The gross global rate of complications ranged from 2.7% to 36.7%, with points of reference of 15.6% (BMG) and 13.8% (SN). The complication rate ranged from 3% to 33%, with an average of 14.5% for lobectomies, with higher variability for pneumonectomies (0-58%). CONCLUSIONS: Benchmarking could be an effective method for improving clinical management. A considerable variability was detected in our study among the participating groups.

Role of surgery in pulmonary tuberculosis.

BACKGROUND: The purpose of our study was to analyze current indications for surgery in tuberculosis (TB). We present our experience with TB patients presenting with indications for surgery between 1990 and 1998. MATERIAL/METHODS: The indications for surgical intervention included 25 cases of pulmonary aspergilloma, 19 cases of pneumothorax, 16 cases of pulmonary nodes and masses without histological diagnosis, 15 cases of bronchiectasis, 12 cases of massive hemoptysis, 12 cases of pleural empyema, and 33 cases of other complications. No patients with multidrug-resistant tuberculosis required surgical intervention, although 56 were treated during this period. RESULTS: The techniques utilized included lobectomy in 45 cases, pleural drainage in 32 cases, segmented pulmonary resection in 32 cases, surgical procedures on the thoracic wall in 17 cases, pneumonectomy in 10 cases, pleuropulmonary decortication in 8 cases, mediastinoscopy in 6 cases, and thoracoscopy in 5 cases. In 25 cases two or more procedures were performed on the same patient. In 36 cases (27.3%) there were complications, of which persistent air leakage after pulmonary resection was the most frequent (n=10). There was a mortality rate of 5.3% (7 CONCLUSIONS: In our experience, surgery in the treatment of TB is indicated to resolve sequelae or complications, since cases of simple or multidrug-resistant TB can be managed pharmacologically. The morbidity and mortality rates in our series were acceptable.