UPSTAGING, CENTRALITY AND SURVIVAL IN EARLY STAGE NON-SMALL CELL LUNG CANCER VIDEO-ASSISTED SURGERY.

OBJECTIVES: Hiliar (pN1) and mediastinal lymph (pN2) nodal upstaging after surgery for early stage (

Lung sparing surgery by means of extended broncho-angioplastic (sleeve) lobectomies.

OBJECTIVE: To determine the morbidity, mortality and survival of sleeve lobectomy procedures compared to simple broncho-angioplasty procedures. PATIENTS AND METHODS: A total of 535 patients diagnosed with bronchogenic cancer between September 2005 and May 2010 who fulfilled the criteria of clinical, oncological and functional operability were treated in our unit. Unresectable central tumours (n=95) using simple lobectomy were scheduled for broncho-angioplasty techniques and a pneumonectomy in those where this was impossible. RESULTS: A total of 58 (11%) were performed, 46 simple broncho-angioplastic lobectomies (SBAL) and 12 extended broncho-angioplastic lobectomies (EBAL). In the SBAL group there were 32 bronchial (70%) and 7 (15%) bronchovascular reconstructions and only vascular (15%). In the EBAL group, 8 (66.7%) were bronchial and 4 (33.3%) were bronchovascular reconstructions. The most common type of resection was the right upper lobe (RUL)+segment 6 in five (41%) cases, followed by RUL+middle lobe. There were 2 (3%) deaths in the SBAL group. There was 34% morbidity in the SBAL and 33% in the EBAL group (P>0.05). Fifteen patients received neoadjuvant chemo-radiotherapy treatment, due to histologically confirmed cN2; however, the number of complications was not significantly higher. No risk factors were detected in any variable studied that would affect EBAL compared to the SBAL group (P>0.05). The patients in both groups with a higher morbidity were pN1, located in the left upper lobe and associated with vascular reconstruction (P<0.05). The overall survival at 5 years was 61.6%, SBAL (61%) and EBAL (68.9%) with no differences between groups (P>0.05). CONCLUSIONS: EBALs are technically more demanding procedures, but do not increase morbidity or mortality compared to simple broncho-angioplasty techniques, and with a similar survival.

Integrating concurrent navelbine and cisplatin to hyperfractionated radiotherapy in locally advanced non-small cell lung cancer patients treated with induction and consolidation chemotherapy: feasibility and activity results.

OBJECTIVES: The purpose of this study was to determine the effectiveness and toxicity of a new combination schedule based on concurrent navelbine, cisplatin and hyperfractionated radiotherapy in patients with locally advanced NSCLC treated with platinum and gemcitabine induction and consolidation chemotherapy. MATERIALS AND METHODS: The 37 patients with pathological confirmed advanced NSCLC (non-surgical stages IIIA and IIIB) were included in the study. All of them were assessable for survival and 32 for response. The treatment schedule consisted of cisplatin (100 mg/m2) or carboplatin (400 mg/m2) on day 1 with gemcitabine (1000 mg/m2) on days 1, 8 and 15. Treatment was given every 28 days for two courses, followed by concurrent administration of accelerated modified hyperfractionated radiotherapy, with concomitant boost, with a total dose of 61.64 Gy administered for 5 weeks, with cisplatin and navelbine, for two courses, finally followed by two courses of the same initial chemotherapy. RESULTS: Four patients achieved complete response (12.5%) and 14 (44%) partial response, for an overall objective response rate of 56.5%. After a minimum follow-up duration of 35.5 months, median progression free survival was 12.2 months. The median survival was 15.4 months with actuarial 1-, 2- and 3-year survival of 67, 21 and 15%, respectively. The main toxicity was hematological. There was esophagitis (grades III and IV) in 30% of the patients and there were two treatment-related deaths. CONCLUSION: Combined treatment with concurrent radiotherapy and chemotherapy in non-surgical NSCLC is an acceptable treatment modality. However, the toxicity was not negligible.

[Bronchial carcinoid tumor: a retrospective analysis of 62 surgically treated cases]. / Tumor carcinoide bronquial. Análisis retrospectivo de 62 casos tratados quirúrgicamente.

OBJECTIVE: To evaluate the results of surgical treatment for lung carcinoid tumor. PATIENTS AND METHOD: The medical records of 62 patients who underwent surgical intervention for lung carcinoid tumor between May 1985 and October 2000 were reviewed. RESULTS: Fifty-two patients had typical carcinoid tumors and 10 had atypical carcinoid tumors. Hilar or mediastinal lymph node metastases were present in 9 patients. Distant metastasis occurred in 5 patients and was significantly more frequent in those with the atypical carcinoid histological subtype. The overall survival rate at 15 years was 70%, with a mean survival rate of 138 (SD 11) months, calculated with the Kaplan-Meier method. We found no statistically significant correlation between smoking and the development of carcinoid tumors. CONCLUSIONS: Although carcinoid tumors behave like low-grade malignant tumors, they should be treated in the same way as other malignant lung tumors. Curative surgical resection is the technique of choice whenever possible.

[Video-assisted thoracoscopic sympathectomy for the treatment of facial flushing: ultrasonic scalpel versus diathermy]. / Simpatectomía torácica por videotoracoscopia para el tratemiento del rubor facial: bisturí ultrasónica frente a diaterma.

OBJECTIVE: To evaluate the advantages of the ultrasonic scalpel compared to electrocoagulation in patients undergoing video-assisted thoracoscopic sympatholysis or sympathectomy for uncontrolled facial blushing. METHODS: Two hundred bilateral video-assisted thoracoscopic procedures to interrupt transmission in the thoracic sympathetic nerve were performed in 100 patients with incapacitating facial blushing. In 2 cases, the video-assisted approach was chosen because of pleural symphysis. The mean age of patients was 34 years (range: 15 to 67). The sympathetic chain was interrupted from the lower portion of the first thoracic ganglion through the third. RESULTS: All patients were discharged within 24 hours with the exception of one on whom an emergency thoracotomy had been performed. No complications were reported in the group in which a harmonic scalpel was used. One case of temporary Horner syndrome (4 months) and 3 cases of persistent chest pain (more than 2 weeks) were reported in the diathermy group. There were 9 cases of partial and asymptomatic pneumothorax that resolved without treatment or prolonged hospital stays. CONCLUSION: Dissection of the sympathetic nerve is accomplished more reliably and with better visualization with the ultrasonic scalpel. Peripheral lesions in lung parenchyma and adjacent tissues (intercostal vessels and nerves) are avoided, as is Horner syndrome, which can be caused by dispersion of heat. Use of the ultrasonic scalpel would also lead to a lower incidence of postoperative neuralgia.

[Video-assisted lobectomy through the auscultatory triangle for the surgical treatment of bronchopulmonary carcinoma. Preliminary experience]. / Lobectomía videoasistida a través del triángulo auscultatorio en el tratamiento quirúrgico del carcinoma broncopulmonar. Experiencia preliminar.

OBJECTIVE: To describe a technique for video-assisted lobectomy through the auscultatory triangle (VALAT) and to assess early and medium-term outcome of the procedure in patients with non-small cell bronchopulmonary carcinoma in stage I. PATIENTS AND METHOD: Between April 1999 and May 2002 we performed 25 VALAT procedures (24 lobectomies and 1 bilobectomy) in 25 patients with a mean age of 63.6 years (range 39-80). RESULTS: No deaths occurred during or after surgery. Conversion to conventional thoracotomy was necessary in two cases. One patient was re-operated to resolve hemothorax and one developed a bronchopleural fistula that was treated by pleural drainage. The mean hospital stay was 6.3 days. Twenty-three patients have been disease-free throughout a mean follow-up period of 11.5 months (range 1-36). The two-year actuarial survival rate (Kaplan-Meier) was 93% 7%. CONCLUSIONS: VALAT is a safe procedure that nevertheless requires specific training. The rate of complications was low in our patient series and mortality was nil. The outcome for patients with stage I bronchogenic carcinoma over a two-year follow-up period has been comparable to results obtained with conventional thoracotomy.

Mediastinal metastasis of ovarian carcinoma.

Mediastinal metastasis of ovarian tumors are not rare as autopsy findings. Ovarian carcinomas usually spread by transcaelomic, lymphatic or haematogenous dissemination to peritoneum, pelvic and para-aortic lymph nodes, lung and pleura. A case of mediastinal metastasis of ovarian carcinoma is reported. A retrosternal mass was identified by CT scan and resected by VTC surgery.

Chest wall parachordoma.

A 21-year-old woman with a painful chest wall mass was found to have a parachordoma (PC). The tumor arose from the fifth intercostal space. A wide chest wall resection including the tumor and a 2.5 cm free margin and the subsequent reconstruction with a Gore-Tex soft tissue patch covered with a latissimus dorsi rotational flap was performed. To our knowledge, chest wall parachordoma has not been previously reported in the medical literature.

[Our experience in treating obstructive lesions of the main airway by Nd-Yag laser resection]. / Nuestra experiencia en el tratamiento de las lesiones obstructivas de la vía aérea principal mediante fotorresección con láser Yag-Nd.

We performed 164 laser resections with a neodymiumyttrium-aluminum-garnet (Nd-Yag) laser in 116 patients between January 1992 and December 1997. Seventy-eight patients had malignant neoplasms, 5 had neoplasms of intermediate malignancy and 33 had inflammatory tracheal lesions. Eighteen resections were emergency procedures. All resections were performed with the patient under general anesthesia and preferably breathing spontaneously. Immediate results varied according to the nature and location of the lesion. Treatment was palliative for tumors showing intraluminal proliferation, providing successful reopening of the airway as shown endoscopically in 70% of patients. Mean survival of the 44 patients with malignant lesions who could be followed was 29 weeks, with a median of 15.19 (range, 1-120). The tracheas of patients with inflammatory stenosis were reopened rapidly and emergency tracheostomy was avoided in all cases. One patient with malignant tracheal tumors died during the procedure due to asphyxia related to tracheal hemorrhage.

Outcome of patients after curative resection of pulmonary metastases.

BACKGROUND: Resective surgery can play a role in solitary pulmonary metastasis or in a few multiple metastases of the lungs. METHODS: We performed a retrospective analysis of the cure rate and survival in patients with pulmonary metastases after surgical resection. Inclusion criteria included no evidence of extrapulmonary metastases or local control of the primary neoplasia. Selective adjunctive therapy was added when applicable. RESULTS: Twenty-five out of 53 patients with resected pulmonary metastases are still alive and disease free. After a 5-year period of follow-up the cure rate obtained was 42%. CONCLUSIONS: In selected patients, resective surgery of solitary or limited multiple pulmonary metastases should be useful, offering the patients a high rate of curability and long term survival. These positive results suggest that adjunctive therapies should be added after resective surgery.

Endothelial dysfunction in pulmonary arteries of patients with mild COPD.

To investigate whether endothelial dysfunction of pulmonary arteries (PA) is present in patients with mild chronic obstructive pulmonary disease (COPD) and to what extent it is related to the morphological abnormalities of PA, we studied 41 patients who underwent lung resection. Patients were divided into the following groups: nonsmokers (n = 7), smokers with normal lung function (n = 13), and COPD (n = 21). Endothelium-dependent relaxation mediated by nitric oxide was evaluated in vitro in PA rings exposed to cumulative concentrations of acetylcholine (ACh) and ADP. Structural abnormalities of PA were assessed morphometrically. PA of COPD patients developed lower maximal relaxation in response to ADP than both nonsmokers and smokers (P < 0.05 each) and a trend to reduced relaxation in response to ACh (P = 0.08). Maximal relaxation to ADP correlated with the degree of airflow obstruction (r = 0.48, P < 0. 01). Morphometrical analysis of PA revealed thicker intimas, especially in small arteries, in both smokers and COPD compared with nonsmokers (P < 0.05 each). We conclude that endothelial dysfunction of PA is already present in patients with mild COPD. In these patients, as well as in smokers with normal lung function, small arteries show thickened intimas, suggesting that tobacco consumption may play a critical role in the pathogenesis of pulmonary vascular abnormalities in COPD.

Primary mediastinal leiomyoma: an angiographic study and embolisation of the feeding vessels to improve the surgical approach.

The case of a young woman suffering from superior vena caval syndrome secondary to a tumour mass of the anterosuperior mediastinum is presented. Angiography showed a highly vascularised mass. Surgical biopsy confirmed the diagnosis of leiomyoma of the mediastinum. Percutaneous embolisation before surgery was performed.

Surgical treatment of primary spontaneous pneumothorax with video-assisted thoracic surgery.

We report the results of our experience using video-assisted thoracoscopic surgery (VATS) to treat primary spontaneous pneumothorax (PSP) from January 1992 until December 1994 in a multicentered co-operative study. A total of 132 patients (110 males and 22 females, aged 13-38 yrs, mean age 26 yrs) were treated by VATS to deal with the PSP that they presented with. A standard VATS technique was used. Apical bullae were always removed, and mechanical pleural abrasion was performed, leaving a pleural drainage tube. In two cases (1.5%), a switch to thoracotomy was necessary. In eight cases (6%), air leakage persisted for 5 days after surgery, which resolved with pleural drainage. There were eight postoperative relapses (6%), which were treated with pleural drainage (n = 4), VATS (n = 3) or axillar thoracotomy (n = 1). The average postoperative stay was 5.6 days (range 2-15 days). We conclude that video-assisted thoracoscopic surgery is a viable alternative for the treatment of primary spontaneous pneumothorax. There is, however, a high relapse rate, and in a number of cases air leakage persists in the postoperative period.

Subglottic stenosis in an HIV positive patient: an exceptional form of clinical presentation in Kaposi's sarcoma.

The case of a 29-year-old HIV positive male patient suffering from a Kaposi's sarcoma exclusively located in the proximal third of the trachea and subglottic region is presented. The patient was found to have included an obstruction of the upper airway. A characteristic endoscopic appearance led to the final diagnosis. A combined treatment with Nd-YAG laser endoscopic resection and laringotracheal irradiation was performed. Pathological examination confirmed Kaposi's sarcoma.

[Traumatic pulmonary pseudocysts]. / Seudoquistes pulmonares traumáticos.

Two cases of traumatic pulmonary pseudocysts in young patients are presented. Blunt chest injuries resulting from traffic accidents were the causes in both cases. Air cavities were seen on chest films 12 hours and one hour, respectively, after trauma. In both cases, self-limited hemoptysis preceded the appearance of an air-fluid level on X-rays. The diagnoses of pulmonary pseudocyst were made after excluding other possible cause and the outcomes were satisfactory after treatment of symptoms and associated lesions.

Antibiotic prophylaxis in non-cardiac thoracic surgery: cefazolin versus placebo.

A total of 127 patients (57 given placebo and 70 given a single preoperative dose of 1 g cefazolin) undergoing thoracic surgery were included in a randomized double-blind trial. The two groups were similar in regard to mean age, sex ratio, in-hospital stay before surgery, underlying disease, risk factors, type of surgery, mean duration of surgical procedure, and mean duration of chest tube drainage. The relative risk of wound infection of the patients from the placebo group was 3.27 (range 1.5-11.5; 95% confidence interval). Cefazolin significantly reduced (p less than 0.01) the wound infection rate--1 case (1.5%) in the cefazolin group versus 8 cases (14%) in the placebo group--but not the incidence of postoperative pleural empyema--5 (7%) versus 8 cases (14%)--or nosocomial pneumonia--3 (4%) versus 5 cases (9%). Cultures were made from 3 out of 9 wound infections and Staphylococcus aureus or S. epidermidis was isolated in all 3. In addition, cultures were made from 6 out of 13 pleural cavity infections and S. aureus (1 case) or other microorganisms (5 cases) were isolated in all 6. Mortality was similar in both groups and all deaths unrelated to the infections. No adverse side effects of the drug were encountered. In conclusion, a single preoperative dose of 1 g cefazolin proved to be effective for reducing the wound infection rate in non-cardiac thoracic surgery.

Experimental reconstruction of the canine trachea with a free revascularized small bowel graft.

Extensive tracheal stenotic lesions caused by tracheomalacia or neoplasms represent a surgical challenge. Segmental tracheal substitution is sometimes required to obtain radical cure. We present an experimental study of 27 dogs undergoing replacement of the cervical trachea using a vascularized small bowel segment as a tubular graft. A silicone stent was placed in the lumen of the intestinal fragment and was removed the second week after operation. Endoscopic and histological examinations were performed between the first week and second month after operation, and rigidity of the graft was assessed in all cases. No evidence of anastomotic stricture or mucous formation was found. Microscopic examination showed the substitution of bowel mucosa by squamous epithelium as well as the development of connective tissue favoring the fixation of the skeletal muscular structures of the neck to the serous layer of the graft, thus avoiding collapse of the new airway.

Hepaticothoracic transdiaphragmatic echinococcosis.

Between 1970 and 1985, seven patients were referred to us for surgical treatment of simultaneous hydatid cysts in the liver and the chest. Their mean age was 45.4 years (age range, 23-73 years), and they represented 46% of patients with hydatid cysts in the liver and thorax. Three patients had hepaticopleural involvement, and 3 patients had symptoms of pulmonary origin. In a single patient, only the diaphragm was involved along with the liver. Liver scintigraphy and ultrasonography were equally helpful in delineating the extent of the disease, but computed tomographic scanning is now the method of choice. The operations were through a thoracolaparotomy in 3 patients and a thoracotomy alone in 3 patients. A single patient had a thoracotomy with a transdiaphragmatic laparotomy. Complete drainage or excision of hydatid cavities was accomplished in all patients. Hydrogen peroxide instilled into the cysts was satisfactory for control of spread potentially secondary to possible intraoperative spillage. There have been no postoperative deaths. Follow-up has ranged from 6 months to 8 years, and 2 patients had relapsing hydatid disease 3 years postoperatively. These results suggest that, when hydatid disease of the liver is complicated by transdiaphragmatic extension and simultaneous pleural or pulmonary cysts, early surgical repair is indicated. Complete drainage and cyst excision are recommended.