Anterior mediastinal tracheostomy as salvage operation.

BACKGROUND: This study aimed to assess early and long-term results after anterior mediastinal tracheostomy (AMT) as a salvage operation for recurrent neck malignancies. METHODS: Between October 2006 and February 2013, 12 patients (mean age, 57 years) underwent AMT. All patients had experienced stomal recurrence, with or without esophageal involvement, after laryngectomy. All patients had undergone previous radiotherapy (50.3 ± 6.2 [43-60] Gy) and previous surgical treatment: total laryngectomy (n = 11) and thyroidectomy (n = 2). RESULTS: The mean length of resected trachea was 3.7 ± 2.7 (2.5-6) cm. Resection was complete in 10 patients. All patients required relocation of the remaining trachea below the innominate artery and myocutaneous flap for coverage/stoma construction. AMT was associated with esophagectomy (n = 4) and supraaortic trunk resection (innominate artery, n = 2; carotid artery, n = 3). Seven patients required resection of the pharyngoesophageal region, and 4 patients underwent reconstruction, including primary closure of a pharyngeal remnant (n = 1) and gastric pull-up (n = 3). There was 1 operative death (8.3%) resulting from an infectious process leading to bypass fistulization. Major complications were partial tracheal necrosis (n = 3), pharyngeal fistula (n = 1), pneumonia (n = 4), and flap dehiscence (n = 2). Length of hospital stay was 30 ± 22.8 (13-86) days. Actuarial overall 5-year survival was 58.3%, and median estimated disease-free survival was 53 (31-75) months. CONCLUSIONS: Our experience with AMT as salvage therapy has shown acceptable long-term results if complete resection is achieved. This procedure is not risk free, and very careful patient selection is required because of a tortuous postoperative course, especially in combined pharyngeal-esophageal and vascular reconstruction.

Lung incarceration after anterior mediastinal tracheostomy.

A 63-year-old man underwent anterior mediastinal tracheostomy for postradiotherapy stoma ulceration exposing the left anterolateral tracheal side, cervical vessels, and pharynx. An anterior chest wall defect (hemiclaviculectomy, manubriectomy, and resection of anterior third of first and second ribs bilaterally) was covered by a myocutaneous pectoral flap, and a new tracheostoma was constructed in the middle of the skin island. At postoperative day 7, a protrusion of the right upper lobe outside the thoracic cavity through the anterior chest wall defect was detected. Surgical repair by a right thoracotomy to reposition the lung and defect repair using an expanded polytetrafluoroethylene (Gore-Tex) internal prosthesis were successful. The patient was discharged home at 63 days after the first operation.

[Surgical treatment of solitary adrenal metastases in patients with lung cancer]. / Tratamiento quirúrgico de la metástasis adrenal única en pacientes con cáncer de pulmón.

BACKGROUND AND OBJECTIVE: Lung cancer (LC) can metastasize the adrenal gland. The objective of this study is to describe our experience in patients undergoing surgery for solitary adrenal metastasis of lung cancer in the past 11 years. PATIENTS AND METHODS: It is a retrospective study of patients who underwent the surgical resection of the lung primary tumor and the adrenal metastases. RESULTS: We included 7 patients with a median age of 64 years. Five patients underwent lobectomy, and 2, pneumonectomy with adjuvant therapy according to protocol. The single adrenal metastasis appeared synchronously in 3 patients and metachronously in 4, between 10 and 39 months (median 25 months). Two patients are alive and with good quality of life. The mean survival of patients was 41 months (95% confidence interval [95% CI] 7-74) and median survival was 20 months (95% CI 7-32). CONCLUSIONS: We conclude that surgery adrenal metastases from lung cancer increases life expectancy in selected patients according to the available literature.

Single nucleotide polymorphisms in tobacco metabolism and DNA repair genes and prognosis in resected non-small-cell lung cancer.

BACKGROUND: If tobacco-related carcinogens are not inactivated or extruded from the cell, they can damage the DNA. Single nucleotide polymorphisms (SNPs) in genes involved in tobacco metabolism, DNA repair, and multidrug resistance have been related to lung cancer susceptibility. We examined 13 SNPs in 10 of these genes and correlated the results with time to progression (TTP) and overall survival (OS) in 71 smoker or former smoker patients with resected non-small-cell lung cancer (NSCLC). MATERIALS AND METHODS: DNA was obtained from paraffin-embedded tumor. SNP analysis of the candidate genes was performed by allelic discrimination assay. Log-rank test, Kaplan-Meier plots, and Cox multivariate analysis were used to evaluate the association of TTP and survival with the SNPs evaluated. RESULTS: Patients with wild-type (wt) XPC rs2228001, wt CYP2C8 rs10509681, or non-wt NAT2 rs1799930 had a longer TTP. Patients with wt ERCC1 showed a nonsignificant trend towards longer TTP. No other relation between SNPs and TTP were observed. Patients harboring at least two unfavorable genotypes in these four genes had a shorter TTP and OS than patients with either one or no unfavorable genotypes. In the multivariate analysis, non-wt XPC rs2228001 and the presence of at least two unfavorable genotypes emerged as independent markers for shorter TTP. CONCLUSIONS: SNPs in tobacco metabolism and DNA repair genes may influence the clinical outcome of resected NSCLC.

Determining the appropriate sleeve lobectomy versus pneumonectomy ratio in central non-small cell lung cancer patients: an audit of an aggressive policy of pneumonectomy avoidance.

OBJECTIVE: To study the outcomes of broncho ± angioplastic sleeve lobectomy (SL) versus pneumonectomy (PN), and the PN:SL ratio after an aggressive policy of parenchyma-sparing surgery to improve postoperative complications rate and long-term quality of life (QoL). METHODS: A prospective study was conducted in 490 patients with non-small cell lung cancer between 2005 and 2009. All patients not suitable for standard lobectomy were scheduled for SL, if possible, or for PN; eight patients with functional impairment were directly scheduled for SL. RESULTS: Of 76 procedures, 21 (4%) were PN and 55 (11%) SL (29 bronchoplastic, seven bronchovascular, seven angioplastic; 11 extended to more than one lobe). There were no surgical, oncological or physiological preoperative differences between the groups. The 5-year PN:SL ratio was 1:2.6 (2005: 1:2.1; 2006: 1:2.6; 2007: 1:3.6; 2008: 1:3; 2009: 1:3.5). SL and PN mortality were 2 (3.6%) and 1 (5%), respectively. Postoperative complications occurred in 18 (32%) SL and 7 (33%) PN patients. pN1 (p = 0.04), vascular reconstruction and upper-left SL were risk factors for postoperative complications of SL (p = 0.03) but were not detected as a mortality risk. Overall 5-year survival was 61% for SL and 31% for PN. Survival at 5 years was significantly higher for SL (p = 0.03, Kaplan-Meier). Age <70 years and SL were positive factors for long-term survival. In multivariate modelling, both remained positive factors. Surviving PN patients experienced significantly greater loss of respiratory function and lower QoL than those who avoided this surgery (preoperative score, PN vs SL: 52 vs 51; 3 months, 41 vs 43; and 6 months, 42 vs 51, p = 0.04). The adjuvant treatment complement was higher in SL at 34 (62%) than at PN 10 (47%). The side effects of this treatment were more frequent in patients with more extirpated parenchyma (p = 0.04). CONCLUSIONS: Parenchyma-sparing procedures can reduce the PN rate to less than 10%. A PN:SL index lower than 1:1.5 as a quality standard in a specialised thoracic unit should encourage the use of broncho-angioplastic procedures and improve patient outcomes. Long-term survival, QoL, postoperative lung function test and tolerance of adjuvant therapies are significantly better after SL than PN intervention.

Cryopreserved arterial allograft reconstruction after excision of thoracic malignancies.

BACKGROUND: The purpose of this study was to evaluate the long-term clinical and immunologic outcome of cryopreserved arterial allograft (CAA) revascularization of intrathoracic vessels invaded by malignancies. METHODS: Since January 2002, consecutive patients whose intrathoracic vessels were invaded by malignancies were operated on and revascularizion made using human lymphocyte antigen (HLA)- and ABO-mismatched CAAs. Immunologic studies were performed preoperatively, and 1, 3, 6, 12, and 24 months postoperatively. Postoperative oral anticoagulation therapy was not given. RESULTS: Twenty-six patients aged 53.1 +/- 15 years with a nonsmall-cell lung cancer (n = 10), invasive mediastinal tumors (n = 7), pulmonary artery sarcoma (n = 3), laryngeal (n = 2), or other rare lung neoplasms (n = 4) underwent operation. Cardiopulmonary bypass was used in 10 cases (38%), and all resections were pathologically complete. Revascularization was either for venous (n = 12) or arterial (n = 14) vessels, and a total of 30 allografts revascularized the superior vena cava (n = 6), pulmonary artery (n = 7), innominate vein (n = 3) or artery (n = 2), ascendent (n = 4) or descending (n = 1) aorta, and subclavian vein (n = 3) or artery (n = 4). Hospital morbidity and mortality were 50% (n = 13) and 3.8% (n = 1), respectively, all CAA unrelated. With a median follow-up of 18 months (range, 3 to 60+), 5-year survival and allograft patency were 84% and 95%, respectively. Preoperative anti-HLA antibodies were detected in 2 patients (7.7%) and a postoperative anti-HLA antibody response, clinically irrelevant, in 1 of 24 patients (4%). CONCLUSIONS: Revascularization of intrathoracic venous and arterial vessels in patients with malignancies using HLA- and ABO-mismatched CAA is technically feasible and clinically attractive because of no infection risk and postoperative anticoagulation, and excellent long-term survival, patency, and nonimmunogeneicity.

Technique to avoid innominate artery ligation and perform an anterior mediastinal tracheostomy for residual trachea of less than 5 cm.

A 47-year-old man was admitted with recurrent autolimited bleeding arising from a cervical tracheostoma made 2 years earlier during a total laryngectomy. Stomal recurrence of the past laryngeal cancer invading the neighboring innominate artery was diagnosed by angiographic computer tomography and bronchoscopic biopsies. The malignant tracheostoma-innominate fistula was approached through an extended transversal supraclavicular incision, bilateral hemiclaviculectomy, and manubriectomy. It was treated with an anterior mediastinal tracheostomy with omental major transposition, right latissimus dorsi myocutaneous flap for tissue coverage, and brachiocephalic artery rerouting with cadaveric homograft. The patient was discharged on postoperative day 14 after an uneventful postoperative course.

Cyclooxygenase-2 is up-regulated in lung parenchyma of chronic obstructive pulmonary disease and down-regulated in idiopathic pulmonary fibrosis.

BACKGROUND AND AIM OF THE WORK: In vitro studies have suggested that fibroblasts from idiopathic pulmonary fibrosis (IPF) may have an impaired induction of cyclooxygenase (Cox)-2. We have investigated Cox-1 and Cox-2 expression in lung tissue from IPF. METHODS: Cox-1 and Cox-2 expression were determined using RT-competitive PCR and immunohistochemistry in pulmonary biopsies from IPF (n = 22), chronic obstructive pulmonary disease (COPD) (n = 13), and lung tissue from subjects undergoing pleurodesis for spontaneous pneumothorax (control group, n = 17). RESULTS: Immunohistochemical analysis showed that the score of Cox-2 positive cells was higher in COPD (1 +/- 0) with respect to fibrosis (0.37 +/- 0.1, p < 0.05) and controls (0.57 +/- 0.2). There were no differences between fibrosis and controls in Cox-2 positive cells. The expression of Cox-2 mRNA was significantly higher in COPD (3.26 +/- 0.72 x 10(6) molecules cDNA/microg total RNA) in comparison to IPF (0.57 +/- 0.17) and controls (0.54 +/- 0.16) (p < 0.001). After IL-1beta stimulation (1-10 ng/ml) Cox-2 mRNA basal expression increased significantly in controls (from 35 +/- 12 to 94 +/- 4 x10(6) molecules cDNA/microg total RNA, p < 0.01) and in COPD (from 38 +/- 8 to 92 +/- 3, p < 0.01). In contrast, no significant changes in Cox-2 mRNA expression were found in IPF (from 30 +/- 12 to 43 +/- 16). CONCLUSIONS: Our results suggest that differences in Cox-2 expression may play a role in the regulation of inflammatory responses in lung diseases. Excessive activity is associated with the development of chronic obstructive lung disease, while a limited activation following pro-inflammatory stimulation might contribute to fibrogenic responses.

Improvement in performance status after erythropoietin treatment in lung cancer patients undergoing concurrent chemoradiotherapy.

PURPOSE: A prospective Phase II trial was carried out to evaluate the effectiveness of erythropoietin in improving or maintaining performance status as determined by the Karnofsky performance status (KPS) score and hemoglobin (Hb) levels in lung cancer patients treated with concurrent chemoradiation (CH-RT). METHODS AND MATERIALS: A total of 51 patients with lung cancer (11 with small-cell, limited stage and 40 with non-small-cell disease, 17 with Stage IIIA and 23 with Stage IIIB), who underwent three different concurrent CH-RT protocols were enrolled. Baseline Hb and KPS values were recorded, as were the nadir Hb and KPS values before concurrent CH-RT. The final Hb and KPS values were recorded the last week of concurrent CH-RT. An Hb level of