Single-centre 20-year experience with surgical treatment of thymic tumours.

BACKGROUND: Large single-centre institutional series on thymic tumours are rare. Complete resection remains the mainstay of successful treatment. Characteristics and survival were reviewed in all patients treated between 1993-2013. METHODS: Hospital databases revealed 134 patients with pathologically-proven thymic tumour. Follow-up (median 63 months) was through patient notes and telephone contact with general practitioner. RESULTS: Patients were classified in Masaoka-Koga stages: I: 50 (37%); IIa: 14 (10%); IIb: 14 (10%); III: 27 (20%); IVa: 19 (14%); IVb: 4 (3%); unknown: 6 (5%). According to WHO classification, pathological subtypes were A: 19 (14%); AB: 25 (19%); B1: 21 (16%); B2: 31 (23%); B3: 15 (11%); thymic carcinoma: 23 (17%). Parathymic syndromes were diagnosed in 45 patients : myasthenia gravis (84%); pure red-cell aplasia (4%); hypogammaglobulinemia (2%); and others. 124 patients (93%) underwent surgery with complete resection in 104 (84%). Surgical approach was: sternotomy: 79; thoracotomy: 35; cervicotomy: 2; other/unknown: 8. In 73 patients (59%) no biopsy was taken prior to surgical resection, 25 were treated with induction chemotherapy, 36 received adjuvant radiotherapy. Hospital mortality was 0.81%. 35 patients died during follow-up (13 of tumour or treatment-related causes). Overall and recurrence-free survival at 5, 10, and 15 years were 86%; 64%; 47% and 67%; 49%; and 31%, respectively and were significantly (p < 0.01) different according to Masaoka-Koga stage. There was a significant association between WHO classification and Masaoka-Koga stages I-IIa-IIb versus III-IVa-IVb (p < 0.01). CONCLUSIONS: Operability and complete resectability of thymic tumours in our experience is high resulting in prolonged overall and recurrence-free survival. Masaoka-Koga stage is an important predictor for survival and shows a significant association with WHO classification.

Single-Centre 20-Year Experience with Surgical Treatment of Thymic Tumours.

BACKGROUND: Large single-centre institutional series on thymic tumours are rare. Complete resection remains the mainstay of successful treatment. Characteristics and survival were reviewed in all patients treated between 19932013. METHODS: Hospital databases revealed 134 patients with pathologically-proven thymic tumour. Follow-up (median 63 months) was through patient notes and telephone contact with general practitioner. RESULTS: Patients were classified in Masaoka-Koga stages: I: 50 (37%); Ila: 14 (10%); lib: 14 (10%); III: 27 (20%); IVa: 19 (14%); IVb: 4 (3%); unknown: 6 (5%). According to WHO classification, pathological subtypes were A: 19 (14%); AB: 25 (19%); B1: 21 (16%); B2: 31 (23%); B3: 15 (11%); thymic carcinoma: 23 (17%). Parathymic syndromes were diagnosed in 45 patients: myasthenia gravis (84%); pure red-cell aplasia (4%); hypogammaglobulinemia (2%); and others. 124 patients (93%) underwent surgery with complete resection in 104 (84%). Surgical approach was: sternotomy: 79; thoracotomy: 35; cervicotomy: 2; other/unknown: 8. In 73 patients (59%) no biopsy was taken prior to surgical resection, 25 were treated with induction chemotherapy, 36 received adjuvant radiotherapy. Hospital mortality was 0.81%. 35 patients died during follow-up (13 of tumour or treatment-related causes). Overall and recurrence-free survival at 5, 10, and 15 years were 86%; 64%; 47% and 67%; 49%; and 31%, respectively and were significantly (p < 0.01) different according to Masaoka-Koga stage. There was a significant association between WHO classification and Masaoka-Koga stages I-IIa-IIb versus III-IVa-IVb (p < 0.01). CONCLUSIONS: Operability and complete resectability of thymic tumours in our experience is high resulting in prolonged overall and recurrence-free survival. Masaoka-Koga stage is an important predictor for survival and shows a significant association with WHO classification.

Diaphragm plication for unilateral diaphragm paralysis: a case report and review of the literature.

Unilateral diaphragm paralysis is an often not recognised cause of dyspnoea. We present a patient with a unilateral phrenic nerve paralysis treated with diaphragmatic plication. Patient presented with life-style limiting dyspnoea and pulmonary function showed a decrease in FVC when lying down. Since there was no improvement after respiratory muscle training, plication of the hemidiaphragm was performed by a small thoracotomy. The patient improved with regard to respiratory complaints and lung function. Furthermore, we also demonstrate for the first time a significant improvement in exercise capacity with accompanying striking amelioration of quality of life. The patient is now in follow up up for more than 2 years and the impressive improvement in exercise capacity remains present. Surgical treatment of unilateral diaphragm paralysis has been described in case reports and in small series since 1985. Although comparison of the available data is difficult a diaphragm plication seems an effective and safe procedure for patients with symptomatic, acquired unilateral diaphragm paralysis. Improvement of dyspnoea is present in the majority of patients and we even observed an impressive amelioration in exercise capacity. Consequently, it seems appropriate to propose plication to patients with clear symptoms from the moment spontaneous recovery seems unlikely; yet, prospective randomised controlled studies are needed to prove this.

Cervical videomediastinoscopy.

Cervical mediastinoscopy is a frequently used technique to assess the mediastinum, in particular the mediastinal lymph nodes in patients presenting with non-small cell lung cancer (NSCLC). The senior author of this article is credited for developing in 1989 the concept of what is now called videomediastinoscopy. The introduction of videomediastinoscopy has proven to be superior to conventional mediastinoscopy and has made teaching of this operation much easier. However, imaging modalities, in particular positron emission tomography, have substantially decreased the need for mediastinoscopy in early stage NSCLC, while in more advanced stages the indication for primary staging and/or restaging after induction therapy is now challenged by the increasing experience with endobronchial ultrasound, endoesophageal ultrasound, and fine-needle aspiration. This article discusses the current deployment of videomediastinoscopy in the diagnosis and management of NSCLC.

Morbidity and mortality after induction chemotherapy followed by surgery in IIIa-N2 non small cell lung cancer.

OBJECTIVE: To evaluate the frequency and risk of postoperative complications and mortality in patients with IIIa-N2 non small cell lung cancer after induction chemotherapy and surgery. METHODS: In a surgical database records from ninety two patients, operated between January 1, 2000 and December 31, 2006 were reviewed. Univariate analysis was used to identify predictors of postoperative complications and in-hospital mortality. RESULTS: All cases were histologically confirmed stage IIIa-N2. All patients received preoperative platinum based chemotherapy without radiotherapy. Pneumonectomy was performed in 20 cases (23.5%), from which 9 right sided. (Bi)lobectomy was performed in 53 cases (62.4%) and sleeve lobectomy in 11 cases (17.2%). One wedge resection was performed (1.2%). In 7 cases (7.6%) only an exploration was done. Complications developed in 35 patients (38%). Major complications in 15 patients (16%). No bronchopleural fistulae were observed. Analysis identified increased age and high physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) as a risk factor to develop complications, and a high simplified comorbidity score as a risk factor to develop a major complication. Higher age, Charlson comorbidity index, simplified comorbidity score and POSSUM were a risk factor for developing pneumonia. CONCLUSION: Although surgery after induction therapy for IIIa-N2 NSCLC can be done with a morbidity and mortality comparable to surgery alone, it remains a high risk operation. It should therefore be performed in a center with experience. Bronchial stump protection should be used whenever there is an increased risk for developing a bronchopleural fistula. In deciding whether to do surgery or radiotherapy one should keep in mind the feasibility of performing a complete resection together with a preoperative assessment to predict complications and mortality. For the preoperative assessment several scoring systems can be used from which we find the simplified comorbidity score most useful.

Quality in the surgical treatment of cancer of the esophagus and gastroesophageal junction.

Surgical treatment of cancer of the esophagus and gastroesophageal junction (GEJ) remains a complex and challenging task. Quality of care may be improved by concentrating these patients in high volume centres in order to decrease post-operative mortality. However, it appears that hospital mortality is a poor tool to measure the quality. More likely specialisation as well as appropriate hospital environment supporting a dedicated multidisciplinary team are key elements in improving both the short term and long term results. The dedicated specialist surgeon has a key role in improving these results through surgical quality. The most important goal in the surgical treatment of these cancers is to perform a complete resection (R0). Data from literature seem to indicate that R0 resection combined with extensive lymphadenectomy are resulting in improved disease free survival and possibly in improved 5 year survival, often reported to exceed 35% after such interventions. These results suggest that there is a great need for standardisation of surgery. Such a standardisation and the resulting improved quality most likely will result in a significant improvement of outcome of esophagectomy for cancer of the esophagus and GEJ. These improvements in outcome should become the gold standard to which all other therapeutic regimens should be compared. Poor surgical quality and related poor results should not be a justification for multimodality regimen.