Trapdoor anterior thoracotomy for cervicothoracic and apical thoracic neuroblastoma in children.

PURPOSE: Cervicothoracic and apical thoracic neuroblastoma pose unique surgical challenges. We report our experience with the trapdoor anterior thoracotomy (TAT) approach to overcome these difficulties. METHODS: Retrospective review of our centre's neuroblastoma database was conducted. Patients who underwent TAT at our centre were included, their demographic data and clinical reports were analyzed. RESULTS: A total of 21 patients underwent TAT for neuroblastoma, mean age at surgery of 3.5 (0.3-7.9) years, male to female ratio was 11:10. Fifteen patients had cervicothoracic tumors while 6 had apical thoracic tumors. All except 2 were primary tumors. They were stage M (n = 12), MS (n = 1), and L2 (n = 8). At pre-operative assessment, 19 patients had image-defined risk factor (IDRF), including dual compartmental involvement (n = 15), trachea/bronchus compression (n = 4), encasement of carotid (n = 5), subclavian (n = 11), and vertebral arteries (n = 6). Four underwent upfront surgery while 17 received pre-operative chemotherapy of 2-8 (mean 3.9) cycles. All patients accomplished gross total resection. None had MYCN amplification. The postoperative complications included Horner's syndrome (n = 21), Klumpke's palsy (n = 1), winged scapula (n = 1), phrenic nerve palsy (n = 1), and bronchomalacia (n = 2). CONCLUSION: Gross total resection of cervicothoracic and apical thoracic neuroblastoma can be accomplished by TAT with minimal morbidity.

Video-assisted thoracoscopic surgery and open chest surgery in infectious lung diseases.

Video-assisted thoracoscopic surgery (VATS) for infection or inflammatory conditions is uncommon as compared to lung cancer. In most developed countries less than 5% of all VATS procedures are for infective/inflammatory conditions. However VATS is technically more challenging in this situation and are more prone to postoperative complications. Principles of VATS for infectious diseases involve complete safe surgical removal of the diseased infected lung and prevention of major complications by minimally invasive technique.

Chest wall secondary chondrosarcoma arising from enchondroma in a young Asian female.

INTRODUCTION: Enchondromas are benign tumours derived from cartilaginous tissue and they rarely undergo malignant transformation unless they occur in multiple sites such as in the case of Ollier disease. PRESENTATION OF CASE: We report a rare case of a 36-year-old Chinese female, without any past medical history, who had a right chest wall tumour which was initially diagnosed to be benign, for which she was loss to follow up. The mass had been stable in size for the past 7 years until recently, when it gradually grew bigger. computed tomography (CT) scan of the thorax revealed that the mass had invaded the right chest wall suggestive of malignant change. She subsequently underwent an elective open right chest wall resection of the mass and chest wall reconstruction with mesh. A 3cm by 3cm tumour arising from the anterior aspect of the 4th rib was found intra-operatively. Post-operative course was uneventful. Histologically, the mass was confirmed to be chrondrosarcoma and resection margins were negative. The patient was discharged on 4th post-operative day and her latest CT thorax during follow up 2 years after operation did not show any tumour recurrence. DISCUSSION: The aim of chest wall reconstruction is to avoid instability and prevent thoracic organs from being exposed if the defect size is ≥10cm or at least three ribs are resected. Polypropylene mesh may be relatively weak in terms of mechanical support for the chest wall, however, in this case, the defect is not too large and the laterally reflected pectoral muscle can provide enough support together with the mesh. CONCLUSION: Secondary chondrosarcoma in a young Asian female arising from a benign solitary enchondroma in the absence of multiple enchondromatosis, such as Ollier disease or Maffucci syndrome, is extremely rare. Regular follow up including physical assessment and radiological imaging can result in earlier detection of malignant transformation obviating the need for aggressive surgical treatment involving multiple rib resections.

Giant bronchial artery aneurysm presenting as a right hilar mass.

We describe a case of bronchial artery aneurysm presenting as a solitary lung mass (4 × 5 cm) in a 53-year-old man with symptoms of cough for 3 months. The aneurysm was only detected at surgery, and resected by performing a middle lobectomy.

Single-stage posterior midline approach for dumbbell tumors of the thoracic spine, with intraoperative CT guidance.

BACKGROUND: Several different procedures have been advocated for thoracic spine dumbbell tumor resection, combining thoracic and neurosurgical approaches, in single and multiple stages, using various incisions and positions. These have led to controversies in the ideal management. The authors report their analysis of a series of 11 patients successfully treated through a one-step midline approach for complete resection and instrumentation when indicated under intraoperative CT (ICT) guidance. METHODS: The patients' clinical presentations, imaging results, operative findings and follow-up were reviewed in 11 patients (age ranged from 11 to 62 years), over the period from August 2007 to May 2010. A single-stage, posterior midline incision approach with laminectomy, facetectomy, costotransversectomy, for complete resection of intraspinal and paraspinal components of tumor was used. Spinal instrumentation under ICT guidance was also carried out in relevant (six) cases with tumors involving junctional spinal regions such the cervico-thoracic or thoraco-lumbar region. RESULTS: The initial clinical presenting symptom was pain in eight patients and paresthesia in one, while two patients were detected incidentally on routine chest X-rays. Total excision was achieved in 10 patients (9 schwanommas, 1 neurofibroma) with the exception of one patient who had a recurrent malignant peripheral nerve sheath tumor adherent to the vertebral artery. No significant postoperative complications occurred and an early mobilization/discharge was achieved in all patients with an average hospital stay of 5 days. CONCLUSIONS: A one-step approach through a posterior midline incision is feasible, safe and efficient for complete excision of thoracic dumbbell tumors. This approach facilitates laminectomy, facetectomy, costotransversectomy and instrumentation under ICT guidance, while limiting muscle damage, blood loss, operative time, postoperative pain, thus enabling early mobilization with a reduced hospital stay.

Differences between small-cell lung cancer and non-small-cell lung cancer among tobacco smokers.

It is known that smoking increases the risk for all histological subtypes of lung cancer. To date, the factors that determine why some patients develop small-cell lung cancer (SCLC) while others develop non-small-cell lung cancer (NSCLC) remain unknown. We compared the characteristics of 774 smokers with SCLC and NSCLC diagnosed during the period January 1999 till December 2002. Multivariate logistic regression was used to estimate the odds ratio (OR) with 95% CI. Testing of linear trend across categories of pack-years was also conducted. Six hundred and sixty-five NSCLC were compared to 109 SCLC. Among SCLC, there were significantly more females (20.2% versus 12.8%), current-smokers (81.7% versus 71.9%) as well as smokers who had smoked more than 40 pack-years (75.6% versus 50.3%). Comparing SCLC with NSCLC among the men only, having smoked more than 40 pack-years was associated with a significantly elevated odds ratio (OR) of 3.71 of developing SCLC (95% CI, 1.05-13.1; p=0.041). There was a decreasing trend in OR with increasing smoking cessation period. When comparing SCLC with adenocarcinoma, the women had a higher OR of 2.37 of developing SCLC (95% CI, 1.05-5.31; p=0.037) compared to the men. Our findings suggest that cumulative smoking exposure in terms of pack-years smoked is an important determining factor for the preferred development of SCLC among smokers.

Never-smokers with lung cancer: epidemiologic evidence of a distinct disease entity.

PURPOSE: Tobacco smoke is a definite causative agent for lung cancer. It is increasingly being recognized that never-smokers can be afflicted with non-small-cell lung cancer (NSCLC). We aim to assess survival differences between smokers and never-smokers with NSCLC. PATIENTS AND METHODS: We analyzed 975 NSCLC patients who presented from January 1999 to December 2002. Clinical characteristics among current-, former- and never-smokers were tested using chi2 or Kruskal-Wallis test. The hazard ratio (HR) for death and its 95% CI were calculated by Cox regression. RESULTS: Of 975 patients, 59 had no smoking history and 33 had no quit time recorded. Of 883 patients analyzed, 286 patients (32.4%) were never-smokers. One hundred ninety-six never-smokers (68.5%) were females compared with 12% among current- and 13% among former-smokers (P < .001). There was a significant difference in histologic subtype between never-smokers and smokers: 69.9% with adenocarcinoma versus 39.9% (current-smokers) versus 47.3% (former-smokers); 5.9% with squamous cell carcinoma versus 35.7% (current-smokers) versus 28% (former-smokers; P < .001). Smokers had significantly poorer performance status (P = .002) and higher median age at diagnosis (P < .001) while more never-smokers presented with advanced disease (P = .002). Eight hundred and five patients (82.6%) died by May 30, 2005. The HR for smokers was significantly higher on both univariate and multivariate analysis (HR, 1.297; 95% CI, 1.040 to 1.619). CONCLUSION: Never-smokers comprised a high proportion of NSCLC patients in Singapore. Definite epidemiologic differences exist between never-smokers and smokers. Differences in survival outcome further suggest that the biology underlying the pathogenesis and behavior of the disease may be different for never-smokers.

Tracheobronchial obstruction as a result of mediastinal mass.

A 21-year-old woman presented with almost complete extrinsic airway obstruction due to a massive mediastinal tumor. Venovenous extracorporeal membrane oxygenation support for 3 days with concurrent chemotherapy allowed time for tumor shrinkage, ventilation via the endotracheal route, and subsequent successful extubation on the fifth day.

Novel management of a large chronic bronchocutaneous fistula after lobectomy.

We describe the successful use of silicone stent for the treatment of chronic bronchocutaneous fistula in a patient with a large stump opening of 20 mm in diameter. A literature review of bronchoscopic treatment of bronchopleural fistula (BPF) is also discussed here.

The effects of remifentanil and thoracic epidural on oxygenation and pulmonary shunt fraction during one-lung ventilation.

OBJECTIVE: To compare the effects of remifentanil and thoracic epidural analgesia on the hemodynamic changes and pulmonary shunt fraction during one-lung ventilation (OLV) for thoracotomy. DESIGN: Prospective, single crossover design. SETTING: Tertiary care hospital. PARTICIPANTS: Thirty-four patients undergoing OLV for thoracic surgery. INTERVENTIONS: During general anesthesia with 2-lung ventilation, one-lung ventilation with remifentanil infusion, and one-lung ventilation with thoracic epidural anesthesia (TEA), hemodynamic parameters and arterial and mixed venous blood gases were taken from the radial and pulmonary artery catheters. During these 3 study periods, cardiac index (CI) was measured using thermodilution technique while shunt fraction (Qs/Qt), alveolar arterial oxygen gradient (A-a O(2)), and systemic (SVRI) and pulmonary vascular resistances indices (PVRI) were calculated. A p value <0.05 was taken to be statistically significant. MEASUREMENTS AND MAIN RESULTS: When OLV was instituted, there was a significant decrease in mean arterial blood pressure. Arterial oxygenation decreased, whereas CI and Qs/Qt increased during OLV, but there was no significant difference between remifentanil infusion and thoracic epidural analgesia. CONCLUSIONS: Both remifentanil infusion and TEA are suitable for analgesia during thoracic surgery when OLV is used. There was no significant difference in PaO(2) and Qs/Qt during each administration.