A multitaxonomic assessment of Natura 2000 effectiveness across European biogeographic regions.

The Natura 2000 (N2K) protected area (PA) network is a crucial tool to limit biodiversity loss in Europe. Despite covering 18% of the European Union's (EU) land area, its effectiveness at conserving biodiversity across taxa and biogeographic regions remains uncertain. Testing this effectiveness is, however, difficult because it requires considering the nonrandom location of PAs, and many possible confounding factors. We used propensity score matching and accounted for the confounding effects of biogeographic regions, terrain ruggedness, and land cover to assess the effectiveness of N2K PAs on the distribution of 1769 species of conservation priority in the EU's Birds and Habitats Directives, including mammals, birds, amphibians, reptiles, arthropods, fishes, mollusks, and vascular and nonvascular plants. We compared alpha, beta, and gamma diversity between matched selections of protected and unprotected areas across EU's biogeographic regions with generalized linear models, generalized mixed models, and nonparametric tests for paired samples, respectively, for each taxonomic group and for the entire set of species. PAs in N2K hosted significantly more priority species than unprotected land, but this difference was not consistent across biogeographic regions or taxa. Total alpha diversity and alpha diversity of amphibians, arthropods, birds, mammals, and vascular plants were significantly higher inside PAs than outside, except in the Boreal biogeographical region. Beta diversity was in general significantly higher inside N2K PAs than outside. Similarly, gamma diversity had the highest values inside PAs, with some exceptions in Boreal and Atlantic regions. The planned expansion of the N2K network, as dictated by the European Biodiversity Strategy for 2030, should therefore target areas in the southern part of the Boreal region where species diversity of amphibians, arthropods, birds, mammals, and vascular plants is high and species are currently underrepresented in N2K.

Análisis multitaxonómico de la efectividad de Natura 2000 en las regiones biogeográficas de Europa Resumen La red de áreas protegidas (AP) de Natura 2000 (N2K) es una herramienta importante para reducir la pérdida de biodiversidad en Europa. A pesar de que cubre el 18% del área terrestre de la UE, todavía es incierta la efectividad que tiene para conservar la biodiversidad en los taxones y las regiones biogeográficas. Sin embargo, es complicado analizar esta efectividad porque requiere considerar la ubicación no azarosa de las AP y la posibilidad de muchos factores confusos. Usamos el pareamiento por puntaje de propensión y consideramos los efectos confusos de las regiones biogeográficas, lo accidentado del terreno y la cobertura del suelo para analizar la efectividad de las AP de N2K en la distribución de 1,769 especies (mamíferos, aves, anfibios, reptiles, artrópodos, peces, moluscos y plantas vasculares y no vasculares) con prioridad de conservación en las Directivas de Aves y Hábitats de la UE. Comparamos la diversidad alfa, beta y gamma entre las selecciones pareadas de las áreas protegidas y no protegidas en las regiones biogeográficas de la UE con los modelos generalizados lineales, mixtos y pruebas no paramétricas de las muestras pareadas, respectivamente, para cada grupo taxonómico y para el conjunto completo de especies. Las áreas protegidas en N2K tuvieron una mayoría significativa de especies prioritarias en comparación con el suelo no protegido, pero esta diferencia no fue coherente entre los taxones y las regiones biogeográficas. La diversidad alfa total y la diversidad alfa de anfibios, artrópodos, aves, mamíferos y plantas vasculares fue significativamente mayor dentro de las AP que fuera de ellas, excepto en la región biogeográfica boreal. La diversidad beta fue significativamente más alta dentro de las AP de N2K que fuera de ellas. De forma similar, la diversidad gamma tuvo los valores más altos dentro de las AP, salvo algunas excepciones en las regiones boreal y atlántica. Por lo tanto, la expansión planeada de la red N2K, como dicta la Estrategia de la UE sobre Biodiversidad para 2030, debería enfocarse en las áreas del sur de la región boreal, donde es alta la diversidad de especies de anfibios, artrópodos, aves, mamíferos y plantas vasculares y cuyas especies están poco representadas dentro de N2K.

Prognostic Impact of Node-Spreading Pattern in Surgically Treated Small-Cell Lung Cancer: A Multicentric Analysis.

OBJECTIVE: Although surgery in selected small-cell lung cancer (SCLC) patients has been proposed as a part of multimodality therapy, so far, the prognostic impact of node-spreading pattern has not been fully elucidated. To investigate this issue, a retrospective analysis was performed. METHODS: From 01/1996 to 12/2012, clinico-pathological, surgical, and oncological features were retrospectively reviewed in a multicentric cohort of 154 surgically treated SCLC patients. A multivariate Cox proportional hazard model was developed using stepwise regression, in order to identify independent outcome predictors. Overall (OS), cancer-specific (CSS), and Relapse-free survival (RFS) were calculated by Kaplan-Meier method. RESULTS: Overall, median OS, CSS, and RFS were 29 (95 % CI 18-39), 48 (95 % CI 19-78), and 22 (95 % CI 17-27) months, respectively. Lymphadenectomy was performed in 140 (90.9 %) patients (median number of harvested nodes: 11.5). Sixty-seven (47.9 %) pN0-cases experienced the best long-term survival (CSS: 71, RFS: 62 months; p < 0.0001). Among node-positive patients, no prognostic differences were found between pN1 and pN2 involvement (CSS: 22 vs. 15, and RFS: 14 vs. 10 months, respectively; p = 0.99). By splitting node-positive SCLC according to concurrent N1-invasion, N0N2-patients showed a worse CSS compared to those cases with combined N1N2-involvement (N0N2: 8 months vs. N1N2: 22 months; p = 0.04). On the other hand, the number of metastatic stations (p = 0.80) and the specific node-level (p = 0.85) did not affect CSS. At multivariate analysis, pN+ (HR: 3.05, 95 % CI 1.21-7.67, p = 0.02) and ratio between metastatic and resected lymph-nodes (RL, HR: 1.02, 95 % CI 1.00-1.04, p = 0.03) were independent predictors of CSS. Moreover, node-positive patients (HR: 3.60, 95 % CI 1.95-6.63, p < 0.0001) with tumor size ≥5 cm (HR: 1.85, 95 % CI 0.88-3.88, p = 0.10) experienced a worse RFS. CONCLUSIONS: In selected surgically treated SCLC, the long-term survival may be stratified according to the node-spreading pattern.

Thoracic Endometriosis Syndrome: Association With Pelvic Endometriosis and Fertility Status.

STUDY OBJECTIVE: To evaluate associations among catamenial pneumothorax, pelvic endometriosis, and fertility status. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: Departments of Thoracic Surgery and Obstetrics and Gynecology, San Raffaele Hospital, Milan, Italy. PATIENTS: Sixteen females referred to the Department of Thoracic Surgery for treatment of spontaneous pneumothorax between January 2001 and January 2014 and referred to the outpatient clinic for gynecologic follow-up. INTERVENTIONS: Thoracoscopy for catamenial pneumothorax and laparoscopy for pelvic endometriosis. MEASUREMENTS AND MAIN RESULTS: Characteristics of the patients, the presence of endometriosis, and their fertility status were statistically analyzed. Pelvic endometriosis was diagnosed in 9 patients (56.3%), but 6 patients did not undergo a laparoscopic procedure to confirm or exclude the disease. Seven of the affected patients (77.8%) had stage III-IV endometriosis. Two-thirds of the patients with pelvic endometriosis who attempted conception conceived spontaneously, as did all of the patients without histopathological confirmation of endometriosis. CONCLUSION: Thoracic endometriosis syndrome, characterized mainly by catamenial pneumothorax, is a relevant condition in patients affected by endometriosis. However, few previous studies have analyzed this condition from a gynecologic standpoint, in terms of characteristics of endometriosis and fertility status of affected women. Our findings support the presence of a strong association between catamenial pneumothorax and pelvic endometriosis, as well as a minimal effect of catamenial pneumothorax on fertility status, even in the presence of pelvic endometriosis.

Metabolomic Study of Dactylis glomerata Growing on Aeolian Archipelago (Italy).

The Aeolian Islands (Italy) are a volcanic archipelago in the Tyrrhenian Sea comprising seven main islands, among which are two active volcanoes. The peculiar geological features and the wide variety of environments and soils have an important impact on native plants, and in particular, the Aeolian populations of Dactylis glomerata (a perennial cool-season bunchgrass) exhibit remarkable phenotypic variability. Considering that environmental drivers also strongly affect the production of plant metabolites, this work aimed at comparing the metabolomic profiles of D. glomerata (leaves) harvested at different altitudes on four islands of the Aeolian archipelago, namely: Lipari, Vulcano, Stromboli and Panarea. Samples were analyzed by 1H NMR profiling, and data were treated by PCA. Samples collected on Stromboli were very different from each other and from the samples collected in the other islands. Through an Orthogonal Partial Least Squares (OPLS) model, using altitude as the y variable, it emerged that the concentration of proline, glycine betaine, sucrose, glucose and chlorogenic acid of D. glomerata growing on Stromboli decreased at increasing altitude. Conversely, increasing altitude was associated with an increment in valine, asparagine, fumaric acid and phenylalanine.

Conservative and surgical treatment of acute posttraumatic tracheobronchial injuries.

BACKGROUND: Acute posttraumatic tracheobronchial lesions are rare events associated with significant morbidity and mortality. They are caused by blunt and penetrating trauma, or they are iatrogenic, appearing after intubation or tracheotomy. Although surgery has traditionally been considered the treatment of choice for these injuries, recent reports show that conservative treatment can be effective in selected patients. The aim of this study was to evaluate the role of surgical and conservative management of these lesions, differentiated on the basis of clinical and endoscopic criteria. METHODS: From January 1993 to October 2010, a total of 50 patients with acute posttraumatic tracheobronchial lesions were referred for treatment to our department. In all, 36 patients had iatrogenic injuries of the airway, and 14 had lesions resulting from blunt or penetrating trauma. RESULTS: Of the 30 patients who underwent surgery, the lesion was repaired with interrupted absorbable sutures in 29; the remaining patient, with an associated tracheoesophageal fistula, underwent single-stage tracheal resection and reconstruction and closure of the fistula. In all, 20 patients were treated conservatively: clinical observation in 5 patients, airway decompression with a mini-tracheotomy cannula in 4 spontaneously breathing patients, and tracheotomy with the cuff positioned distal to the lesion in 11 mechanically ventilated patients. One surgical and one conservatively-managed patient died after treatment (4% overall mortality). Complete recovery and healing were achieved in all the remaining patients. CONCLUSIONS: Surgery remains the treatment of choice for posttraumatic lesions of the airway. However, conservative treatment based on strict clinical and endoscopic criteria-stable vital signs; effective ventilation; no esophageal injuries, signs of sepsis, or evidence of major communication with the mediastinal space-enables favorable results to be achieved in selected patients.

Diversity of European habitat types is correlated with geography more than climate and human pressure.

Habitat richness, that is, the diversity of ecosystem types, is a complex, spatially explicit aspect of biodiversity, which is affected by bioclimatic, geographic, and anthropogenic variables. The distribution of habitat types is a key component for understanding broad-scale biodiversity and for developing conservation strategies. We used data on the distribution of European Union (EU) habitats to answer the following questions: (i) how do bioclimatic, geographic, and anthropogenic variables affect habitat richness? (ii) Which of those factors is the most important? (iii) How do interactions among these variables influence habitat richness and which combinations produce the strongest interactions? The distribution maps of 222 terrestrial habitat types as defined by the Natura 2000 network were used to calculate habitat richness for the 10 km × 10 km EU grid map. We then investigated how environmental variables affect habitat richness, using generalized linear models, generalized additive models, and boosted regression trees. The main factors associated with habitat richness were geographic variables, with negative relationships observed for both latitude and longitude, and a positive relationship for terrain ruggedness. Bioclimatic variables played a secondary role, with habitat richness increasing slightly with annual mean temperature and overall annual precipitation. We also found an interaction between anthropogenic variables, with the combination of increased landscape fragmentation and increased population density strongly decreasing habitat richness. This is the first attempt to disentangle spatial patterns of habitat richness at the continental scale, as a key tool for protecting biodiversity. The number of European habitats is related to geography more than climate and human pressure, reflecting a major component of biogeographical patterns similar to the drivers observed at the species level. The interaction between anthropogenic variables highlights the need for coordinated, continental-scale management plans for biodiversity conservation.

rasterdiv-An Information Theory tailored R package for measuring ecosystem heterogeneity from space: To the origin and back.

Ecosystem heterogeneity has been widely recognized as a key ecological indicator of several ecological functions, diversity patterns and change, metapopulation dynamics, population connectivity or gene flow.In this paper, we present a new R package-rasterdiv-to calculate heterogeneity indices based on remotely sensed data. We also provide an ecological application at the landscape scale and demonstrate its power in revealing potentially hidden heterogeneity patterns.The rasterdiv package allows calculating multiple indices, robustly rooted in Information Theory, and based on reproducible open-source algorithms.

A grid-based map for the Biogeographical Regions of Europe.

BACKGROUND: Biogeographical units are widely adopted in ecological research and nature conservation management, even though biogeographical regionalisation is still under scientific debate. The European Environment Agency provided an official map of the European Biogeographical Regions (EBRs), which contains the official boundaries used in the Habitats and Birds Directives. However, these boundaries bisect cells in the official EU 10 km × 10 km grid used for many purposes, including reporting species and habitat data, meaning that 6881 cells overlap two or more regions. Therefore, superimposing the EBRs vector map over the grid creates ambiguities in associating some cells with European Biogeographical Regions. NEW INFORMATION: To provide an operational tool to unambiguously define the boundaries of the eleven European Biogeographical Regions, we provide a specifically developed raster map of Grid-Based European Biogeographical Regions (GB-EBRs). In this new map, the borders of the EBRs are reshaped to coherently match the standard European 10 km × 10 km grid imposed for reporting tasks by Article 17 of the Habitats Directive and used for many other datasets. We assign each cell to the EBR with the largest area within the cell.

Prognostic factors and analysis of S100a4 protein in resected pulmonary metastases from renal cell carcinoma.

BACKGROUND: This study analyzes our experience with pulmonary resection for metastases from renal cell carcinoma. The goals were to search for factors influencing prognosis and to investigate the presence and the prognostic value of S100A4 protein in lung metastases and corresponding primary renal tumors. METHODS: Sixty-five patients underwent surgical resection for renal and pulmonary lesions between 1992 and 2007. S100A4 protein expression was immunohistochemically examined in the peritumoral infiltrate of 64 lesions (32 metastases and the 32 corresponding primary carcinomas). RESULTS: Overall 3-, 5-, and 10-year survival rates were 58, 46, and 25%, respectively. Univariate analysis revealed that surgical radicality (p = 0.0039) and stratification into groups according to the International Registry of Lung Metastases classification (p = 0.0137) were prognostic factors. Multivariate analysis confirmed that this classification was a significant prognostic factor (p = 0.01). All metastases and the corresponding primary carcinomas expressed S100A4 protein. Twenty-one metastases (66%) had weak expression and 11 (34%) had strong expression. Twelve (37.5%) primary lesions had weak expression and 20 (62.5%) had strong expression. The 5-year survival rate for patients with strong expression in primary carcinoma was 41%, significantly lower than that of patients with weak expression (78%; p = 0.05). CONCLUSIONS: Pulmonary resection in metastatic renal cell carcinoma results in long-term survival. Complete resection and stratification into groups according to the International Registry of Lung Metastases classification were prognostic factors. Overexpression of S100A4 protein in primary tumors was correlated with a poor prognosis. If confirmed in larger studies this finding could be used to schedule adjuvant treatments in patients undergoing nephrectomy for renal cell carcinoma.

Early surgical repair of isolated traumatic sternal fractures using a cervical plate system.

BACKGROUND: We reviewed our experience of the surgical management and follow-up of patients admitted with an isolated traumatic sternal fracture (TSF) to a Thoracic Surgical Unit through the Emergency Department. METHODS: During a 5-year period, six patients were surgically treated for an isolated TSF. Presence of physical deformity or acute and persistent pain were considered indications for surgical repair. Surgical repair was performed within 1 week from the trauma by means of a titanium cervical plate system currently in use in spine surgery. RESULTS: There were no postoperative complications. Mean hospital stay was 3 days. All patients showed regular sternal healing at 6 to 8 weeks. In one patient the plate was removed after 3 years because of persistent chest discomfort. CONCLUSIONS: Early surgical repair of isolated TSF is advocated in cases of physical deformity or acute and persistent pain. The titanium cervical plate system provides effective repair of the fracture with satisfactory long-term results.

Prognostic role of liver X receptor-alpha in resected stage II and III non-small-cell lung cancer.

INTRODUCTION: In the search of new therapeutical strategies against non-small-cell lung cancer (NSCLC), the identification of new prognostic factors is crucial. OBJECTIVES: In this study, we analyzed the prognostic value of the liver X receptor-alpha (LXR-alpha), a nuclear receptor of a family of cholesterol derivatives called oxysterols, in patients with radically resected NSCLC. METHODS: We retrospectively reviewed 140 stage II and III surgically treated NSCLC patients that were grouped by percentage of LXR-alpha-positive cells value above or below its median value. Tumor-related survival was evaluated as primary end point. RESULTS: The 5-year overall and tumor-related survival rates were 40% and 46%, respectively. The median percentage of LXR-alpha-positive cells was 20%. Patients with stage II NSCLC had higher LXR-alpha values than those with stage III (P = .04). Univariate analysis demonstrated that both TNM stage and LXR-alpha were significantly related to tumor-related survival (P = .006 and P = .004, respectively). The 5-year tumor-related survival rates in stage II and III NSCLC were 56% and 34%, respectively. The 5-year tumor-related survival rates in high and low LXR-alpha value were 57% and 32%, respectively. The multivariate analysis showed that both TNM stage and LXR-alpha were independent prognostic factors (P = .01 and P = .007, respectively) with hazard ratio of 1.92 and 0.49, respectively. CONCLUSION: LXR-alpha seems to be an independent prognostic factor indicating a better survival in completely resected stage II and III NSCLC patients.

Multidisciplinary management of a giant cervico-mediastinal liposarcoma: A case report and literature review.

Liposarcomas are rare mesenchymal tumors that usually develop in lower extremities or retroperitoneum; cervico-mediastinal presentation is quite uncommon. These neoplasms are commonly diagnosed at a late stage because they remain asymptomatic until nearby structures are compressed. This makes radical excision particularly challenging. To date, alternative chemoradiotherapy protocols have not yet been standardized. We report a case of a 55-year-old man with a right laterocervical mass and without substantial symptoms. Fine-needle aspiration cytology results were compatible with a well-differentiated liposarcoma. Contrast-enhanced magnetic resonance imaging revealed the magnitude of the mass, which was expanding into the mediastinum; displacing the trachea, esophagus, cervical neurovascular bundle, and thoracic aorta; and encasing the brachiocephalic artery. Compression of the left brachiocephalic vein resulted in a focal enhancement spot in the fourth liver segment, the expression of superior vena cava compression, which can promote the development of collateral venous pathways, such as the caval-mammary-phrenic-hepatic capsule-portal venous pathway. The mass was successfully excised by a team of surgical subspecialists (otorhinolaryngologists and thoracic, cardiac, and vascular surgeons). Adjuvant tomotherapy was administered to increase local disease control. The patient remained disease-free 38 months postoperatively. This case underlines the importance of accurate preoperative radiologic evaluation in patients presenting with neck masses but without substantial symptoms. Because of the involvement of many critical structures, the cooperation of many surgical subspecialties is mandatory to achieve a satisfying oncologic outcome.

First Evaluation of PET-Based Human Biodistribution and Dosimetry of 18F-FAZA, a Tracer for Imaging Tumor Hypoxia.

18F-labeled fluoroazomycinarabinoside (18F-FAZA) is a PET biomarker for noninvasive identification of regional tumor hypoxia. The aim of the present phase I study was to evaluate the biodistribution and dosimetry of 18F-FAZA in non-small cell lung cancer patients. Methods: Five patients awaiting surgical resection of histologically proven or radiologically suspected non-small cell lung cancer were prospectively enrolled in the study. The patients underwent PET/CT after injection of 371 ± 32 MBq of 18F-FAZA. The protocol consisted of a 10-min dynamic acquisition of the heart to calculate the activity in blood, followed by 4 whole-body PET/CT scans, from the vertex to the mid thigh, at 10, 60, 120, and 240 min after injection. Urine samples were collected after each imaging session and at 360 min after injection. Volumes of interest were drawn around visually identifiable source organs to generate time-activity curves. Residence times were determined from time-activity curves, and effective doses to individual organs and the whole body were calculated using OLINDA/EXM 1.2 for the standard male and female phantoms. Results: Blood clearance was characterized by a rapid distribution followed by first-order elimination. The highest uptake was in muscle and liver, with respective percentage injected activity (%IA) peaks of 42.7 ± 5.3 %IA and 5.5 ± 0.6 %IA. The total urinary excretion was 15 %IA. The critical organ, with the highest absorbed radiation doses, was the urinary bladder wall, at 0.047 ± 0.008 and 0.067 ± 0.007 mGy/MBq for the 2- and 4-h voiding intervals, respectively. The effective doses for the standard male and female phantoms were 0.013 ± 0.004 and 0.014 ± 0.004 mSv/MBq, respectively, depending on the voiding schedule. Conclusion: With respect to the available literature, the biodistribution of 18F-FAZA in humans appeared to be slightly different from that in mice, with a low clearance in humans. Therefore, use of animal data may moderately underestimate radiation doses to organs in humans. Our dosimetry data showed that a 370-MBq injection of 18F-FAZA is safe for clinical use, similar to other widely used PET ligands. In particular, the effective dose is not appreciably different from those obtained with other hypoxia tracers, such as 18F-fluoromisonidazole.

Video-assisted thoracoscopic treatment of primary spontaneous pneumothorax in older children and adolescents.

BACKGROUND: Primary spontaneous pneumothorax (PSP) is a relatively rare condition in the pediatric population lacking of specific recommendations regarding the management. Video-assisted thoracoscopic surgery (VATS) has gained widespread consensus during the last 10 years. We retrospectively reviewed our experience of VATS in the treatment of pediatric patients affected by PSP in terms of timing of surgery, operative technique, and postoperative outcome. METHODS: Between 1998 and 2014, 58 pediatric patients were treated for PSP. Treatment consisted in pulmonary apicectomy in all patients and pleurodesis. Patients received either apical pleurectomy and mechanical pleurodesis or mechanical pleurodesis alone. RESULTS: Mean age was 16.6 ± 1.6 years (range 10-18) with a male/female ratio of 5:1. Seventeen patients underwent surgery after the first episode of PSP. Apical pleurectomy and mechanical pleurodesis was performed in 30 patients while others received mechanical pleurodesis alone. Conversion to open surgery was needed in four procedures (6.9%). Postoperative complications occurred in 1.7% of cases. Sixteen patients received more than one procedure for contralateral pneumothorax (15 cases) and postoperative recurrence (1 case). The mean follow-up was 95 ± 63 months. Recurrence rate was 12.1%. Univariate analysis showed that recurrence was significantly correlated with younger age (P = 0.044) and postoperative chest tube (P = 0.027). Both univariate and multivariate analysis showed that apical pleurectomy did not prevent recurrences. CONCLUSIONS: VATS is an effective procedure for PSP in pediatric patients. Apical pleurectomy does not seem to prevent recurrence. Due to the increased risk of recurrence of PSP in younger patients, indication to VATS after the first episode might be considered. Pediatr Pulmonol. 2016;51:713-716. © 2016 Wiley Periodicals, Inc.

Patients with known or suspected lung cancer: evaluation of clinical management changes due to 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) study.

AIM: To determine prospectively from the referring physician's point of view the impact of F-fluorodeoxyglucose positron emission tomography (F-FDG PET) results on the management decisions in patients with known or suspected lung cancer. METHODS: Seventy-five consecutive patients (58 men, 17 women; age range, 33-82 years; mean age, 64 years) with a diagnosis of a pulmonary lesion, obtained by means of morphological imaging studies and/or cytological sampling, were included in the study. The patient population consisted of three groups: (A) patients (n=18) with a solitary lung nodule; (B) patients (n=37) with untreated lung cancer; and (C) patients (n=20) with treated lung cancer. All were referred for whole-body F-FDG PET within 15 days (mean, 11 days) of lung lesion detection. To determine whether and how PET findings could modify the treatment strategy, a questionnaire was sent to the referring physician before and after the PET results. With regard to the treatment strategy, four major options were recognized: (1) further diagnostic investigations; (2) medical therapy; (3) surgical treatment; (4) wait-and-see. For data analysis, intermodality changes, defined as changes between treatment strategies related to PET findings, were considered. RESULTS: Before the PET study, the planned management for the overall patient population was as follows: further diagnostic investigations in 44 cases (58%), medical therapy in 17 (23%), surgical treatment in nine (12%) and wait-and-see in five (7%). After the PET study, further diagnostic tools were indicated in 27 cases (36%), medical therapy in 17 (23%), surgical treatment in 28 (37%) and wait-and-see in three (4%). Relative to the initially planned strategy, changes in patient management after PET imaging occurred in 34 (45%) cases. Overall, the most relevant variation after PET concerned the surgical treatment strategy. The highest percentage (67%) of changes in management after PET was found in patients with a solitary pulmonary nodule; the percentages of changes of the three patient groups were significantly different (chi-squared test; P=0.021). CONCLUSIONS: In patients with known or suspected lung cancer, F-FDG PET results determined significant variations in major clinical management decisions.

Prognostic significance of cancer-testis gene expression in resected non-small cell lung cancer patients.

MAGE, BAGE and GAGE genes encode T cell-defined tumor-associated antigens (TAA), which are expressed by various human tumors and are silent in normal tissues. Because of their expression pattern these TAA have received attention as potential targets for active immunotherapy and as molecular tumor markers. Both of these features are potentially useful in improving treatment of non-small cell lung cancer (NSCLC). We analyzed the expression of some members of the MAGE, BAGE and GAGE gene families by reverse transcription polymerase chain reaction (RT-PCR) in a cohort of 46 NSCLC patients who underwent complete resection and were followed-up for a median period of 41 months. A substantial proportion (range, 25-41%) of NSCLC expressed MAGE-A1, -A2, -A3, GAGE-1, -2, -8 and MAGE-B2 genes. On the contrary, BAGE and MAGE-B1 were expressed less frequently (17% and 11%, respectively). Overall, 59% of NSCLC patients expressed at least one gene and therefore could be eligible for tumor-specific immunotherapy protocols. Moreover, while MAGE-A, BAGE and MAGE-B genes did not provide any prognostic information, GAGE expression was associated with a worse survival (p=0.05). Multivariate analysis confirmed this association, which is independent of TNM stage and other clinicopathologic variables. In conclusion, the detection of GAGE gene expression by RT-PCR appears to be an independent survival predictor in completely resected NSCLC patients.

Lung resection for cancer in patients with coronary arterial disease: analysis of short-term results.

OBJECTIVE: Patients with lung cancer may present concomitant coronary arterial disease. Feasibility of lung resection is dependent on the severity of the cardiac impairment since it can increase operative morbidity and mortality. The aim of this study was to analyze the results of lung resection in patients with coronary arterial disease in terms of operative complications and hospital stay. METHODS: Between January 1993 and March 2001, 50 patients with coronary arterial disease underwent lung resection for cancer at our department. Nineteen patients with a curable left-main or multiple-vessel disease first underwent surgical (six patients) or transluminal (13 patients) myocardial revascularization. Twenty-two of the 31 patients who did not require myocardial revascularization presented a medium-high cardiac risk. Univariate analysis determined the impact of coronary disease on operative complications and hospital stay. RESULTS: Surgery consisted in 40 lobectomies, three pneumonectomies and seven wedge resections. The overall mortality and morbidity rates were 4% and 28%, respectively. Ten patients (22%) experienced postoperative cardiac complications such as arrhythmia and there was one intraoperative death, three suffered secretion retention and one patient died as a consequence of a stroke. Occurrence of postoperative complications was influenced by age (P=0.02) and the presence of medium-high cardiac risk (P=0.03). Hospital stay was longer for patients who did not have prior myocardial revascularization (11.7+/-4 vs. 8.1+/-3 days) and underwent more extensive pulmonary resection (10.6+/-5 vs. 7.4+/-2 days). CONCLUSIONS: Lung resection in patients with coronary arterial disease is justified in selected cases. Previous myocardial revascularization and limited resections can decrease operative complications and hospital stay. Careful preoperative evaluation can identify patients who might benefit from myocardial revascularization prior to surgery.

Therapeutic strategy in patients with non-small cell lung cancer associated to satellite pulmonary nodules.

OBJECTIVES: In patients with non-small cell lung cancer (NSCLC) the presence of satellite metastatic nodules may be considered a contraindication to surgical treatment. The use of spiral computed tomography (CT) scan has improved the accuracy of the diagnostic assessment of pulmonary diseases, but has also led to the detection of a consistent number of indeterminate satellite lesions. Obtaining a differential diagnosis of these lesions is extremely important in defining the therapeutic strategy. The aim of the study was to assess the characteristics of satellite nodules in patients with NSCLC and to examine the diagnostic and therapeutic approach used in the presence of indeterminate satellite lesions. METHODS: From November 1995 to February 2001, 29 patients (mean age 64 years) who underwent surgery for NSCLC had indeterminate satellite pulmonary lesions at the preoperative spiral CT scan. A differential diagnosis of the nodules was obtained by histological examination in 27 patients and by follow-up (62 and 64 months, respectively) in two patients. Positron emission tomography (PET) scan was selectively performed in the preoperative evaluation. RESULTS: Thirty-two satellite nodules were analyzed in the group of 29 patients. The size of the lesions varied from 2 to 15 mm (mean 8mm). The nodules were ipsilateral to the primary tumor in 25 patients and contralateral in four. They were benign in 22 cases and malignant in ten (metastases from NSCLC in seven patients and second primary lung cancer in three). Nodules with a size equal to or less than 5mm were more frequently benign. Patients with stage III tumors had a higher incidence of malignant satellite nodules in comparison to earlier stages, although the data did not reach statistical significance. PET scan correctly differentiated benign and malignant satellite nodules in six patients. CONCLUSIONS: Obtaining a differential diagnosis of indeterminate pulmonary nodules associated to NSCLC is of great importance in defining the therapeutic strategy. The results of this study show that indeterminate satellite lesions may be benign or represent a second primary lung cancer, and should not therefore be considered a contraindication to surgical exploration when a preliminary differential diagnosis by other means cannot be obtained.

Video-assisted thoracoscopic surgery for pulmonary nodules: rationale for preoperative computed tomography-guided hookwire localization.

OBJECTIVES: Video-assisted thoracic surgery (VATS) provides a minimally invasive means to resect pulmonary nodules (PN). Deep localization of PN may jeopardize VATS lung resection. The aim of this study was to establish the utility of preoperative computed tomography (CT)-guided hookwire localization of PN. METHODS: Between January 1993 and September 2001, we performed 151 VATS resections for PN. Preoperative CT-guided hookwire localization was not performed in 98 patients (group I); it was done just before surgery in 53 patients (group II) when, at CT scan, the distance of PN from the lung surface was >15 and/or when the size was <10 mm. RESULTS: Pneumothorax occurred in four patients (7.5%). Hookwire dislodged in four patients, but the hematoma left on the visceral pleura made thoracoscopic localization possible in three of these. Seventeen patients (17%) in group I and 4 (7.5%) in group II required conversion to thoracotomy (P< or =0.05). The most common reason for conversion was impossibility to localize PN in group I (nine cases) and deep localization requiring local enucleation in group II (two cases). In 31 group II patients (58%) hookwire positioning led to successful VATS resection that would otherwise have been impossible because PN were neither visible nor palpable. CONCLUSIONS: Preoperative CT-guided hookwire localization for pulmonary nodules is an effective technique which allows VATS resection of PN <10 mm located >15 mm from the pleural surface. Even when PN are subpleural but <10 mm, hookwire localization makes VATS resection faster. Apical and diaphragmatic localization of PN are limitations to the procedure.

Solitary fibrous tumour of the pleura presenting as a spontaneous massive haemothorax.

Solitary fibrous tumours of the pleura are rare neoplasms. These tumours are generally asymptomatic and incidentally diagnosed. Symptoms, if present, are nonspecific such as cough, dyspnea, and chest pain. This report describes the case of a 38-year-old woman admitted to our department after the onset of a right massive spontaneous haemothorax requiring emergency surgical treatment. Intraoperatively a bleeding pleural mass was found to be the cause of the haemothorax. The tumour was successfully resected and the patient made an uneventful recovery. Histological examination revealed the mass to be a solitary fibrous tumour of the pleura.