Diffuse neoplasms of the pleural serosa.

This study describes the diffuse neoplastic conditions that may affect pleural membranes. These include mesothelioma, the most important and common malignancy of pleural origin, and metastatic involvement by carcinomas, lymphomas and thymomas. On the basis of diagnostic imaging, we identify the distinctive features of pleural involvement by each of these conditions and provide elements enabling accurate differential diagnosis. Finally, we discuss the best diagnostic approach in the case of suspected primary or secondary neoplastic involvement of pleural membranes.

Colorectal cancer pulmonary oligometastases: pooled analysis and construction of a clinical lung metastasectomy prognostic model.

BACKGROUND: Although resecting colorectal cancer (CRC) pulmonary metastasis is associated with long-term survival, identification of prognostic groups is needed for future randomized trials, and construction of a lung metastasectomy prognostic model (LMPM) is warranted. PATIENTS AND METHODS: We searched the PubMed database for retrospective studies evaluating prognostic factors following resecting CRC lung metastasis. Individual patient data were analyzed. Independent prognostic factors were used to construct an LMPM. RESULTS: Between 1983 and 2008, 1112 metastasectomies were carried out on 927 patients included in eight studies. Five-year survival rate was 54.3% following the first lung resection. Multivariate analysis identified three independently poor prognostic factors: pre-thoracotomy carcinoembryonic antigen ≥5 ng/ml, disease-free interval <36 months, and more than one metastatic lesion. Patients with good-, intermediate-, and high-risk groups according to the LMPM had a 5-year survival of 68.2%, 46.4%, and 26.1%, respectively (P < 0.001). Perioperative chemotherapy and previously resected liver metastasis had no influence on survival. CONCLUSIONS: The low- and intermediate-risk groups have a good chance of long-term survival following metastasectomy. However, more studies are needed to investigate whether surgery offers any advantage over systemic therapy for the poor-risk group.

XRCC1 and ERCC1 variants modify malignant mesothelioma risk: a case-control study.

Malignant pleural mesothelioma (MPM) is a rare aggressive tumor associated with asbestos exposure. The possible role of genetic factors has also been suggested and MPM has been associated with single nucleotide polymorphisms (SNPs) of xenobiotic and oxidative metabolism enzymes. We have identified an association of the DNA repair gene XRCC1 with MPM in the population of Casale Monferrato, a town exposed to high asbestos pollution. To extend this observation we examined 35 SNPs in 15 genes that could be involved in MPM carcinogenicity in 220 MPM patients and 296 controls from two case-control studies conducted in Casale (151 patients, 252 controls) and Turin (69 patients, 44 controls), respectively. Unconditional multivariate logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs). Two DNA repair genes were associated with MPM, i.e. XRCC1 and ERCC1. Considering asbestos-exposed only, the risk increased with the increasing number of XRCC1-399Q alleles (Casale: OR=1.44, 95%CI 1.02-2.03; Casale+Turin: OR=1.34, 95%CI 0.98-1.84) or XRCC1 -77T alleles (Casale+Turin: OR=1.33, 95%CI 0.97-1.81). The XRCC1-TGGGGGAACAGA haplotype was significantly associated with MPM (Casale: OR=1.76, 95%CI 1.04-2.96). Patients heterozygotes for ERCC1 N118N showed an increased OR in all subjects (OR=1.66, 95%CI 1.06-2.60) and in asbestos-exposed only (OR=1.59, 95%CI 1.01-2.50). When the dominant model was considered (i.e. ERCC1 heterozygotes CT plus homozygotes CC versus homozygotes TT) the risk was statistically significant both in all subjects (OR=1.61, 95%CI 1.06-2.47) and in asbestos-exposed only (OR=1.56, 95%CI 1.02-2.40). The combination of ERCC1 N118N and XRCC1 R399Q was statistically significant (Casale: OR=2.02, 95%CI 1.01-4.05; Casale+Turin: OR=2.39, 95%CI 1.29-4.43). The association of MPM with DNA repair genes support the hypothesis that an increased susceptibility to DNA damage may favour asbestos carcinogenicity.

Prognostic role of the PET parameter maximum standardized uptake value in non small cell lung cancer: analysis in tumour of diameter ≥ and <25 mm.

AIM: The aim of this study was to evaluate whether the primary tumour maximum standardized uptake value (SUV(max)) plays an independent prognostic role in patients with non small cell lung cancer (NSCLC) and whether this role is limited by partial volume effect (PVE) and motion artefacts. METHODS: One hundred and fifty-three consecutive patients underwent PET exam, surgery (R0 resection) and follow-up (mean 20.3; range 6-44.8 months). Correlation with Disease Free and Overall Survival (DFS, OS) was evaluated in the entire population for: SUV(max), clinical and histopathological features and pathological stage. To evaluate the PVE and motion artefacts' interferences on SUV calculation, the correlation between SUV(max) and DFS/OS was also calculated in the groups of patients with tumour diameter ≥ and < than 25 mm (group A and B, respectively). RESULTS: In the entire population only TNM and SUV(max) resulted correlated with DFS/OS. However, SUV(max) was significantly correlated with DFS/OS in group A but not in group B. Furthermore, only in the group of patients with primary tumour diameter ≥ 25 mm (group A), tumour diameter, tumour histotype, and tumour necrosis resulted significantly related with SUV(max) at both uni and multivariate analysis. CONCLUSION: TNM together with SUV(max) could be useful in giving a better prognostic stratification of patients with NSCLC; however technical limitations in the SUV calculation must be taken into account in patients with tumour diameter <25 mm.

Metallic staples line mimicking a retained surgical sponge.

The inadvertent loss of surgical sponges remains a dreadful hazard of surgery. We report the case of a patient with a medical history of myotonic dystrophy type 1 who had received a right upper lobectomy for the treatment of a stage IIA (pT1N1M0) well differentiated neuroendocrine carcinoma. In the early postoperative period, aspiration of gastric contents occurred and the patient underwent endotracheal intubation and mechanical ventilation. A follow-up multi-detector computed tomography (MDCT) scan of the chest showed a complex mass in interlobar position with an internal radiopaque serpiginous thread of metallic density which was assumed to represent a retained surgical sponge. Upon surgical exploration, no retained foreign body was found and a zone of recent hemorrhagic infarction, bordered by the line of the mechanical staples used to complete the minor fissure, was removed from the middle lobe. When evaluating patients suspected of having a retained surgical sponge, thoracic surgeons and radiologists should be aware of this potential source of confusion.

The pulmonary nodule: clinical and radiological characteristics affecting a diagnosis of malignancy.

The role of computed tomography (CT) in the diagnosis of the solitary pulmonary nodule (SPN) is constantly expanding. CT helps to detect a growing number of increasingly small lesions, but, as with chest radiography, the primary goal in the evaluation of small pulmonary nodules is to exclude malignancy. Despite the availability of numerous, variously invasive, diagnostic tests, diagnostic accuracy tends to decline as the size of the nodule decreases. The role of the radiologist is therefore to help the clinician determine the most appropriate management strategy by using all available modalities [CT, magnetic resonance (MR) imaging, positron emission tomography (PET)] and evaluating the patient's clinical history and the imaging features leading to a diagnosis of benignity or malignancy. Imaging features include nodule size, margins, calcifications and fatty component, internal features (cavitations, pseudocavitations, air bronchogram, halo sign), as well as advanced techniques for characterisation (growth rate, contrast enhancement) and management (computer-aided diagnosis, Bayesian analysis, neural networks). The aim of this paper is to summarise the approach to pulmonary nodules from the point of view of the radiologist, oncologist and thoracic surgeon.

Solitary fibrous tumor of the lung: three rare cases of intraparenchymal nodules.

Solitary fibrous tumor (SFT) of the pleura usually presents as a peripheral mass, in contact with the surface of the pleura. However, on occasion, it can occur separately from the pleura, in the lung parenchyma. We describe the radiological and imaging features of three SFTs of the lung, diagnosed in our department, with relevant clinical data. The diagnosis of SFT of the lung, although rare, should be considered in a slow-growing solitary lung parenchymal nodule.

Bronchogenic cysts in the adult: diagnostic criteria derived from the correct use of standard radiography and computed tomography.

PURPOSE: This study was undertaken to identify the radiographic and computed tomography patterns allowing a diagnosis of bronchogenic cyst. MATERIALS AND METHODS: We retrospectively reviewed chest radiographs and CT scans of 21 adults (ten men and 11 women, age range 18-74 years) with a histologically confirmed diagnosis of bronchogenic cyst. RESULTS: Sixteen cysts were located in the mediastinum and five in the lungs. On chest radiography, mediastinal cysts appeared as sharply marginated rounded areas of increased opacity; intrapulmonary cysts also exhibited an air-fluid interface. CT confirmed these morphological features in all cases. In addition, analysis of attenuation values allowed the subdivision of mediastinal cysts into three groups: fluid density (four cases), air density (two cases) and soft-tissue density (ten cases). CONCLUSIONS: All bronchogenic cysts were visualised on chest radiography, but the findings were nonspecific and required further characterisation by CT. The CT findings proved to be diagnostic when cystic attenuation values were evident. When soft-tissue attenuation values were demonstrated, a confident diagnosis was not possible, and other solid lesions had to be considered. In such cases, magnetic resonance imaging may be helpful to ascertain the cystic nature of the lesions.

CT features of solitary fibrous tumour of the pleura: experience in 26 patients.

PURPOSE: The purpose of this study was to identify the typical computed tomography (CT) features of solitary fibrous tumours of the pleura (SFTP) and determine which findings would allow confirmation of the pleural origin or benign behaviour of the tumour. MATERIALS AND METHODS: Twenty-six preoperative CT studies of the chest (23 enhanced and 14 unenhanced) were retrospectively reviewed. RESULTS: Up to 50% of SFTP were larger than 10 cm. At unenhanced CT, they showed homogeneous attenuation in 5 cases (35.7%) and inhomogeneous attenuation in 9 (64.3%). At contrast-enhanced CT, they were inhomogeneous in 21 cases (91.3%), with geographic pattern (61.9% of cases), serpiginous linear areas of enhancement (intralesional vessels) (23.8%), rounded (52.4%) or linear (33.3%) areas of low attenuation (necrosis). CONCLUSIONS: Depending on location, size and histological features, SFTP may produce a large spectrum of findings. Typical CT features of small SFTP were well-defined margins and smooth contours, homogeneous attenuation and right or obtuse angles with the pleura. Larger lesions were characterised by well-defined margins and lobulated contours, geographic pattern in enhanced CT scans, acute angles or smooth tapering margins with the pleura.

Multimodal management of stages III-IVa malignant thymoma.

PURPOSE: The optimal therapy for locally advanced malignant thymoma is controversial. We review our experience with a multimodal approach in 63 consecutive cases. PATIENTS AND METHODS: Forty-three patients had stage III and 20 stage IVa disease. Surgery with radical intent was initially performed in 30 cases, while 33 cases not amenable to radical surgery underwent neoadjuvant treatment (radiotherapy in 8 and chemotherapy in 25) before surgical reassessment. All patients, whether or not surgically resected, received radiation therapy. RESULTS: Radical resection (RR) was performed in 20 patients ab initio (all stage III) and in 12 patients after neoadjuvant treatment (eight stage III and four stage IVa). With the addition of patients radically operated with neoadjuvant treatment, the radical resection rate increased from 46 to 65% in stage III patients, and from 0 to 20% in those with stage IVa disease, respectively. Radical surgery was associated with longer progression free survival and overall survival according to both univariate analysis ( P< 0.001 and P<0.01, respectively) and multivariate analysis after adjustment for age, gender, histology and disease stage ( P<0.001 and <0.02, respectively). Progression free survival (median 56.9 months) was slightly lower in patients undergoing radical surgery after neoadjuvant approaches than in those radically resected ab initio (median not achieved), but overall survival (median not achieved) was similar in both groups. Subtotal surgical resection promoted complete response to subsequent radiation therapy. This condition significantly correlated with a better outcome. CONCLUSIONS: Complete surgical resection is an independent prognostic parameter in locally advanced thymoma treated with a multimodal approach. Preoperative treatment to increase the complete resection rate could improve the overall survival of these patients.

Epidermal growth factor receptor overexpression correlates with a poor prognosis in completely resected non-small-cell lung cancer.

BACKGROUND: We designed a prospective study to test epidermal growth factor receptor (EGFR) expression by immunohistochemistry (IHC) in resected stage I-IIIA non-small-cell lung cancer (NSCLC) and to correlate overexpression with survival. PATIENTS AND METHODS: EGFR expression was evaluated in 130 consecutive NSCLC patients after radical surgery (60 squamous cell carcinomas, 48 adenocarcinomas, 22 large cell carcinomas: stage I, 41 (31%); stage II, 37 (29%) and stage IIIA, 52 (40%). RESULTS: Overall, 101 of 130 (78%) specimens expressed EGFR, and with a cut-off value of 10% positive cells 48 cases (37%) were classified as positive. At univariate analysis, EGFR was significantly more expressed in stage III (50%) than stage I (20%) and stage II (25%) (P <0.03). No correlation with histotype was found. After a median follow-up of 84 months, both median survival time (18 versus 50 months), 2-year (43% versus 70%) and 5-year (31% versus 46%) survival rates of positive cases were significantly lower than negative ones [P <0.001; hazard ratio 1.96; 95% confidence interval (CI) 1.16-3.30]. At the multivariate analysis, EGFR overexpression and stage emerged as independent factors for cancer-related mortality. CONCLUSION: In patients with radically resected stage I-IIIA NSCLC, EGFR overexpression predicts shorter survival, thus representing a valuable prognostic factor.

Primary chemotherapy with adriamycin, cisplatin, vincristine and cyclophosphamide in locally advanced thymomas: a single institution experience.

From 1990 to 1997, 16 consecutive patients with stage III and IVa invasive thymoma were treated in a single institution with primary chemotherapy consisting in adriamycin (40 mg m(-2)), cisplatin (50 mg m(-2)) administered intravenously on day 1, vincristine (0.6 mg m(-2)) on day 2 and cyclophosphamide (700 mg m(-2)) on day 4 (ADOC). The courses were repeated every 3 weeks. The aim was to evaluate the impact of this cytotoxic regimen with respect to response rate, per cent of patients radically resected, time to progression and overall survival. Two complete responses (one clinical and one pathological) and 11 partial responses were observed (overall response rate 81.2%); two patients had stable disease and one progressed. Toxicity was mild as only two patients developed grade III/IV neutropenia and one patient grade III nausea/vomiting. Nine patients were radically resected (five out of ten with stage III, and four out of six with stage IVa). Median time to progression and overall survival was 33.2 and 47.5 months respectively. Three patients were alive and disease free after more than 5 years. The ADOC scheme is highly active and manageable in the treatment of locally advanced thymoma. As a preoperative approach it should be offered to patients not amenable to surgery or to those surgically resectable but with a great deal of morbidity.

Post-intubation tracheal rupture. A report on ten cases.

OBJECTIVE: We wanted to evaluate the role of surgical and conservative therapy in the treatment of post-intubation tracheal rupture. METHODS: A retrospective study was performed on 10 consecutive patients (9 women and 1 man) treated over a 7-year period. RESULTS: A tracheal rupture following double-lumen intubation was recognized and repaired at the time of lobectomy for lung cancer. Five patients with rents ranging from 2.5 cm to 5 cm underwent primary repair through a cervical collar incision (n = 3) or right posterolateral thoracotomy (n = 2). Three patients had small tears (about 1 cm in length) and were treated conservatively. Tracheostomy was performed in one patient with a 1.5-cm long laceration and extensive subcutaneous emphysema. Results were uniformly good. CONCLUSIONS: Early surgical repair is the preferred treatment for most patients with post-intubation tracheal ruptures. Conservative treatment may be a viable alternative for patients with small rents, in the absence of gross air leak, or for those judged unsuitable for surgery. The role of tracheostomy is limited by its potential for late sequelae.

Postoperative bronchopleural fistula: endoscopic closure in 12 patients.

Twelve consecutive patients with postresectional bronchopleural fistula were treated with endoscopic application of tissue glue adhesive (methyl-2-cyanoacrylate). Eight patients had associated empyema. Endoscopic gluing was successfully accomplished in 10 cases (success rate of 83%). The two failures both had fistulas of 0.5 cm or larger. Bronchopleural fistulas developed in 8 patients early after the intervention (< 15 days): of the 4 patients without associated empyema, 3 had their fistula definitely closed after endoscopic treatment. Similarly, 3 of the 4 patients with early bronchopleural fistulas and empyema were cured after endoscopic closure of the fistula and appropriate management of the empyema. Four bronchopleural fistulas occurred late after the operation (> 15 days) and all had associated empyema. Successful endoscopic closure of the fistula was accomplished in all. Resolution of the empyema occurred in 1. We conclude that endoscopic application of tissue adhesive may be a valid therapeutic measure in selected patients with postresectional bronchopleural fistula. In late bronchopleural fistula with empyema, the closure of the fistula can be achieved, but empyema may persist and require additional surgical procedures.

[The use of metal vascular prosthesis in the palliative treatment of neoplastic esophago-gastric stenosis]. / Impiego di protesi metalliche vascolari nel trattamento palliativo delle stenosi neoplastiche esofago-gastriche.

The paper reports the authors' experience regarding the use of expandable metal prostheses designed for vascular stenoses but adapted for unoperable esophago-gastric stenoses. Their first impressions are very positive so much so that they affirm that these prostheses are close to being ideal since they are flexible and have an insertion diameter of 3 mm which does not therefore require dilatation. As a result: 1) they involve limited trauma to the patient; 2) reduce the risk of perforation to virtually zero. Moreover: 3) they can be inserted in twisted and angled stenoses and in esophaguses with difficult access due to axial deviations and restriction of the upper cervical aperture; 4) they function well even in notoriously "difficult" sections such as the cardia and esophago-jejunal anastomoses; 5) the unfastening system is easy and rapid. On the strength of these characteristics the authors suggest that these prostheses should be used in an outpatient setting, as occurred in the case of the last of the 10 patients treated, and even at a preoperative stage in preparation for resective surgery so as to preserve normal oral feeding. The structure of these prostheses renders them contraindicated for use in stenoses associated with fistulas in air paths and requires an evaluation of long-term results to verify the incidence with which the following occur: 1) tumoral growth between the mesh; 2) food obstruction; 3) hemorrhage due to compressive necrosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Pleural abrasion in the treatment of recurrent or persistent spontaneous pneumothorax. Results of 94 consecutive cases.

In the ten-year period 1982 to 1991, 94 patients underwent pleural abrasion as definite treatment for spontaneous pneumothorax. Surgical indications included: 1) third recurrence of homolateral pneumothorax, 2) second recurrence of homolateral pneumothorax in the presence of alternating pneumothorax, and 3) persistent air leak with incomplete lung re-expansion in the presence of spontaneous pneumothorax treated with pleural drainage for more than 10 days. No deaths were observed in the present series. Post-operative complications were minimal and all reversible, including two cases of pleural effusion, one case of hemothorax, and one case of Horner's syndrome. Eighty cases were followed up from 7 to 91 months. No recurrences occurred during the follow-up period. Clinical, radiological and functional results appear satisfactory. Pleural abrasion seems to represent a valid surgical option in the treatment of recurrent or persistent spontaneous pneumothorax.

Autopsy indicators of exposure to asbestos and lung cancer.

In many instances, only post-mortem examination can provide probative data about (i) the presence of lung cancer and (ii) its relationship to exposure to asbestos. Moreover, the results of an autopsy may suggest that a thorough investigation of occupational history should be carried out, since such information is rarely recorded in clinical records. We considered pathological indicators for selecting subjects who had a high likelihood of previous occupational exposure to asbestos. The positive predictive value of pleural plaques ranged from 20 to 75%, depending on their size and on the concentrations of asbestos bodies and uncoated mineral fibres in the lung. The probability of no exposure was greater than 90% if neither asbestos bodies nor uncoated mineral fibres were found. Another purpose of our work on lung cancer and exposure to asbestos was to investigate the relationships between exposure and the occurrence of specific cell types of lung cancer in an autopsied population. Both work history and asbestos body count were considered. The matched analysis showed some tendency towards an association between the occurrence of adenocarcinoma and the presence of indicators of exposure to asbestos.

Asbestos exposure and histologic cell types of lung cancer in surgical and autopsy series.

A case-control study was carried out on 41 surgical and 106 autopsy histological tissue samples of lung cancer in men, in order to investigate the relationships between asbestos exposure and cell type of pulmonary carcinoma. Both occupational history (obtained by interviews of surgical patients or of the next-of-kin for deceased subjects) and lung asbestos body content (determined by optical count after hypochlorite digestion and membrane filtration of lung tissues) were considered as asbestos exposure indicators. No significant relationships were found in the surgical series after adjustment for smoking. The autopsy series showed a trend towards an association between lung adenocarcinoma and asbestos exposure indicators and a markedly higher agreement between the 2 kinds of indicators than that observed in the surgical series.

Tracheal stenosis. A study of 100 cases.

A series of 100 cases of tracheal stenoses, 66 non-neoplastic and 34 neoplastic, are reviewed; tracheal resection was performed in 28 inflammatory stenoses and in five tumours. A T-tube stent was used in 12 patients. Results were good in 81% of resections for non-neoplastic stenoses; two out of three resections for adenoid cystic carcinoma are alive after ten years and the third died after two years with metastases; two patients who received a tracheal resection for epidermoid carcinomas died after three and four years with metastases. Inflammatory tracheal stenoses treated using T-tube achieved good results only in one third of cases. Pre-operative preparation is the most important factor to obtain good results: end-to-end anastomosis requires a healthy mucosa without infection or ulcers.