Multidisciplinary consensus statement on the clinical management of patients with stage III non-small cell lung cancer.

Stage III non-small cell lung cancer (NSCLC) is a very heterogeneous disease that encompasses patients with resected, potentially resectable and unresectable tumours. To improve the prognostic capacity of the TNM classification, it has been agreed to divide stage III into sub-stages IIIA, IIIB and IIIC that have very different 5-year survival rates (36, 26 and 13%, respectively). Currently, it is considered that both staging and optimal treatment of stage III NSCLC requires the joint work of a multidisciplinary team of expert physicians within the tumour committee. To improve the care of patients with stage III NSCLC, different scientific societies involved in the diagnosis and treatment of this disease have agreed to issue a series of recommendations that can contribute to homogenise the management of this disease, and ultimately to improve patient care.

Injury patterns from major urban terrorist bombings in trains: the Madrid experience.

BACKGROUND: Terrorist urban mass casualty incidents (MCI) in the last 3 years have targeted commuter trains at rush hour, producing large numbers of casualties. Civilian care providers are usually not familiar with the types of blast injuries sustained by victims of these MCI. METHODS: We focus on the injury patterns sustained by casualties of the Madrid, 11 March 2004, terrorist bombings, at the seven hospitals that received most victims. Data were gathered of casualties who had injuries other than superficial bruises, transient hearing loss from barotrauma without eardrum perforation, and/or emotional shock. The degree of severity in critical patients was assessed with the ISS. RESULTS: The bombings resulted in 177 immediate fatalities, 9 early deaths, and 5 late deaths. Most survivors had noncritical injuries, but 72 (14%) of 512 casualties assessed had an Injury Severity Score (ISS) >15. The critical mortality rate was of 19.5%. The most frequently injured body regions were the head-neck and face. Almost 50% of casualties had ear-drum perforation, and 60% of them were bilateral. There were 43 documented cases of blast lung injury, with a survival rate of 88.3%. Maxillofacial and open long-bone fractures were most prevalent. Gustillo's grade III of severity predominated in tibia-fibular and humeral fractures. Upper thoracic fractures (D1-6 segment) represented 65% of all vertebral fractures and were associated with severe blast to the torso. Severe burns were uncommon. Eye injuries were frequent, although most were of a mild-to-moderate severity. Abdominal visceral lesions were present in 25 (5%) patients. A multidisciplinary approach was necessary in most operated patients, and orthopedic trauma procedures accounted for 50% of the caseload in the first 24 h. CONCLUSIONS: Ninety-three percent of the fatalities of the Madrid trains terrorist bombings were immediate, and most survivors had noncritical injuries. Closed doors increased the immediate fatality rate in the trains. Severely wounded casualties presented specific patterns of injuries, some of them life-threatening and unusual in other types of trauma mechanisms. Ear-lobe amputations and upper thoracic spine fractures were markers of critical injuries.

Recurrence pattern of esophageal cancer after esophagectomy with two-field lymphadenectomy.

AIM: To analyze the pattern of recurrence of esophageal carcinoma after a curative-intention surgical resection. PATIENTS: Ninety-two patients with non-metastatic esophageal carcinoma were included. Ninety percent of patients were male, and the mean age of this series was 61 years. The most frequent histologic subtype was squamous cell carcinoma. Fifty percent of tumors were at or above the tracheal bifurcation. All patients were submitted for transthoracic subtotal esophagectomy plus two-field radical lymphadenectomy, leaving no apparent residual disease. No adjuvant therapy was applied to any patient. RESULTS: Follow-up was complete for 76 out of 80 patients surviving the operation. Thirty-four tumoral recurrences were detected for a disease-free survival af 39% at 9 years after surgery. All recurrences were detected during the first two years after treatment. Tumoral relapse was related to the presence of T3 or T4 tumors, with positive lymph nodes, squamous cell carcinoma subtype and supracarinal location. Nine percent of patients had a distant relapse, 15% had a locorregional relapse and 12% a combination of both. Distant relapse presented significantly earlier. There was no statistical association between type of recurrence and clinico-pathological or surgical features. CONCLUSIONS: After radical surgery for carcinoma of the esophagus, half of the patients relapse in the following two years. Distant metastases happen to appear earlier in the follow-up, but the most frequent recurrence is the locorregional one.