High serum YKL-40 level is associated with poor prognosis in patients with lung cancer.

INTRODUCTION: YKL-40 is a glycoprotein that plays role in inflammation and malignant processes. High serum YKL-40 levels are associated with short survive in cancer and chronic obstructive pulmonary disease (COPD) is another reason to increase its' level. However, limited knowledges are known in YKL-40 along with lung cancer and COPD. MATERIALS AND METHODS: One hundred patients were involved to study with lung cancer (84 men, 16 women, and median age 62). Results were compared with 30 healthy volunteers. Thirteen patients were small cell lung cancer (SCLC), 87 patients were non-small cell lung cancer (NSCLC). 62% of patients were inoperable. RESULT: Median YKL-40 level was 222.7 ± 114.1 ng/mL in patients and was 144.5 ± 105.7 ng/mL in controls (p< 0.001). Stage, tumour size, lymph node involvement and distant metastasis weren't associated with serum YKL-40 level. Above all cut-off values (133.159 and 162 ng/mL) survival was shorter (p> 0.05). Patients with COPD had worse survive above all cut-off values (p< 0.05), especially according to 133 ng/mL (p= 0.01). CONCLUSIONS: YKL-40 level is useful in lung cancer however it's not related to cell type and prognosis. It is associated with poor prognosis in lung cancer patients with COPD.

Prognostic significance of serum vascular endothelial growth factor and Angiopoietin-2 in patients with lung cancer.

INTRODUCTION: Vascular endothelial growth factor (VEGF) and Angiopoietin-2 (Ang-2) are major angiogenic mediators in neovascularization process. In current literature both biomarkers are discussed separately and only for non-small cell lung cancer (NSCLC). So in this study we aimed to examine them together for both cell types NSCLC and small cell lung cancer (SCLC). PATIENTS AND METHODS: 100 patients with lung cancer were enrolled to this single center study. 87 of patients were diagnosed with NSCLC including 28 adenocarcinomas and 59 squamous cell cancers and 13 were SCLC. Results were compared with 30 healthy volunteers. Pre-treatment serum VEGF and Ang-2 levels were measured by using ELISA method. RESULTS: While serum Ang-2 levels were higher in patients than healthy controls (23395 pg/mL vs. 4025 pg/mL, p< 0.001), VEGF levels didn't differ (2308 pg/mL vs. 2433 pg/mL, p> 0.05). There was no difference between cases with SCLC and NSCLC in terms of Ang-2. But serum VEGF values were significantly lower in SCLC than NSCLC and control groups. None of these mediators were correlated with cell type, tumor size, TNM staging, performance status and operability. VEGF levels were higher in patients with chronic obstructive pulmonary disease (COPD), but it was not significant. Three cut of values were determined according to sensitivity and specificity by using youden index. They were 8515.73 pg/mL (sensitivity 78%, specificity 76%), 7097 pg/mL (sensitivity 80%, specificity 70%) and 11063.48 pg/mL (sensitivity 76%, specificity 70%). Patients with SCLC had shorter survival time above cut-off values (p> 0.05). VEGF and Ang-2 showed a weak positive correlation (p= 0.1 and r= 0.638). CONCLUSION: In conclusion, serum VEGF wasn't useful to predict lung cancer, prognosis or cell type. Albeit Ang-2 was higher in patients with lung cancer without any effect on survival. Due to the heterogeneity of the studies done with serum measurement Ang-2 on tumor tissue should be more meaningful.

Pulmonary artery sarcoma mimicking pulmonary thromboembolism.

A 30 years old male patient was referred to our hospital with a diagnosis of pulmonary thromboembolism due to thorax-computerized tomography (CT) angiography, revealing a thrombus totally occluding left main pulmonary artery. The lesion was evaluated as tumoural mass. Positron emission tomography (PET)-CT revealed pathologic uptake at pulmonary artery mass. Due to localization of tumour, left pneumonectomy was performed. The pathological diagnosis revealed to be pulmonary artery sarcoma. The patient was presented because pulmonary artery sarcomas are very rare tumors and can mimick pulmonary thromboembolism. The true prevalence is underestimated as many pulmonary artery sarcomas are misdiagnosed as pulmonary thromboembolism. PET-CT may help to make a differential diagnosis.

The management of postoperative COVID-19 pneumonia in a case with right pneumonectomy.

A 61-year-old male patient was hospitalized for the evaluation of a lung mass. The patient underwent right pneumonectomy. Although reverse-transcription polymerase chain reaction tests were negative for COVID-19, the diagnosis was supported by thoracic computed tomography. The patient responded to COVID-19 treatment, as evidenced by thoracic computed tomography. This case report highlights the importance of prompt diagnosis and treatment of COVID-19 in a patient who underwent pneumonectomy, which has high mortality and morbidity rates.

Primary pulmonary paraganglioma: Two cases.

Paraganglioma is a rare tumor originating from extra-adrenal chromaffin cells. Primary pulmonary paraganglioma can also be seen in pediatric patients. Due to its endobronchial localization, morphological features, and neuroendocrine immunohistochemical profile, primary pulmonary paraganglioma can be confused with carcinoid tumor. Primary pulmonary paraganglioma should be considered in the differential diagnosis of endobronchial tumors and necessary precautions should be taken, considering that it may be functioning. In appropriate cases, bronchial sleeve resection provides curative treatment. In this article, we present two cases: First was a functioning primary pulmonary paraganglioma that underwent lobectomy and second was an entirely endobronchial tumor without any extra-bronchial spread that underwent bronchial sleeve resection.

Sublobar resections in early-stage non-small cell lung cancer.

BACKGROUND: This study aims to evaluate the outcomes of sublobar resections in patients with early-stage non-small cell lung cancer and to investigate the factors affecting survival. METHODS: Medical files of a total of 63 patients (52 males, 11 females; mean age 64 years; range, 39 to 81 years) who underwent sublobar resection for suspected or known early-stage non-small cell lung cancer between January 2001 and August 2013 were retrospectively reviewed. Data including demographic characteristics of the patients, comorbid conditions, smoking status, surgical margin, visceral pleura invasion, distance from surgical margin to tumor, tumor size, pathological N status, cell type, tumor localization, and recurrences were recorded. RESULTS: Survival was significantly longer in the patients with negative surgical margin for tumor (R0) than in those with positive margin (R1) (94.1 months vs. 32.2 months, p<0.01). Survival was also significantly longer in the patients without lymphatic invasion (p<0.01). CONCLUSION: In early-stage lung tumors, sublobar resection can be performed, if complete resection is performed. Lymphatic invasion is a negative prognostic factor for survival following sublobar resection.

Parenchyma-preserving surgery in the management of pulmonary hydatid cysts.

Pulmonary hydatid cysts remain a significant health problem in endemic regions like Turkey. Here, we present our surgical experience in patients with pulmonary hydatid cysts. Between January 1985 and January 2001, 1118 operations were performed in 1032 patients (528 males, 504 females; mean age 32.7 years; range 1-87 years) with pulmonary hydatid cysts in our department. Posterolateral thoracotomy was performed in 1015 (98.3%), two-stage thoracotomy in 34 (3.3%), and median sternotomy in 17 (1.7%) patients. We preferred conservative surgical procedures. As a surgical procedure, cystotomy and capitonnage was performed in 626 (56%), cystotomy alone in 368 (33%), wedge resection in 81 (7%), enucleation in 29 (3%), and decortication in 11 (1%) patients. None of our patients were treated with anatomic resection. During surgery, 949 patients (92%) had unruptured and 83 patients (8%) had ruptured hydatid cyst. The morbidity ratio was 6.7%. Major complications were wound infection (2.3%), prolonged air leak (1.9%), atelectasis (1.2%), pleural effusion (0.8%), postoperative hemothorax (0.6%), and empyema (0.3%). Two patients (0.2%) died within the first month postoperatively. Mean follow-up was 31.2 months. Recurrence was detected in only 35 patients (3.3%). Treatment of pulmonary hydatid cyst is primarily surgical. Medical treatment is indicated for recurrent and multiple hydatid cysts postoperatively. Cystotomy alone, or cystotomy and capitonnage, as parenchyma-preserving surgery, is preferred. Radical surgery including pneumonectomy, lobectomy, and segmentectomy should be avoided.

Resection of esophageal carcinoma during pregnancy.

Esophageal carcinoma diagnosed during pregnancy is a rare occurrence. A 26-year-old pregnant patient was referred to our hospital with dysphagia. A thorough examination showed a tumor in the esophagus. Laparotomy, thoracotomy, and cervical exploration were performed. There are only 2 cases reported in the literature about esophageal carcinoma diagnosed during pregnancy and treated surgically. However, ethical dilemmas arise in managing such situations. Here we report a case of esophageal squamous cell carcinoma diagnosed at 27 weeks of gestation in which surgical resection was performed successfully.

Single-stage transthoracic approach for right lung and liver hydatid disease.

OBJECTIVE: Human echinococcosis remains a serious health problem for the Mediterranean countries. Synchronous pulmonary and hepatic hydatid disease may occur in 4% to 25% of cases. Our experience on simultaneous surgical treatment of right lung and liver hydatid disease in patients was reviewed. METHODS: Between 1990 and 2000, 48 patients (33 female patients and 15 male patients) with synchronous right lung and liver dome hydatid cysts were operated with a 1-stage procedure. RESULTS: Six patients had previous surgical treatment of hepatic (n = 2) or pulmonary (n = 4) hydatid cyst. The pulmonary cysts were diagnosed with radiography in 18 patients and thoracic computed tomography scan in 30. The pulmonary cysts of 9 patients were bilateral. Seventy-five pulmonary cysts were seen in radiological examinations. The diagnosis of hepatic cysts was established with ultrasonography in 18 patients and upper abdominal computed tomography in 30. The total number of hepatic cysts was 48. In cases with pulmonary cysts, cystotomy and capitonnage were performed in 32 patients, only cystotomy was done in 14 patients, and wedge resection was performed in 2. Liver cysts were approached to transdiaphragmatically after the lung cysts had been dealt with and were managed with evacuation of the cysts. In the remaining cases, marsupialization (n = 2), pericystectomy (n = 1), and enucleation (n = 1) were performed. Major postoperative complications were hemorrhage (n = 1) and biliocutaneous fistula (n = 1). Hepatic recurrence was seen in 3 patients (6.2%) and pulmonary recurrence in 1 (2.1%). CONCLUSION: Transthoracic approach is a useful and a safe surgical management of both pulmonary and upper surface of hepatic hydatid cysts.

Prognostic value of tumor size in non-small cell lung cancer larger than five centimeters in diameter.

OBJECTIVES: The tumor size is an important prognostic factor in non-small cell lung cancer (NSCLC). However, a criterion for tumor size has remained unchanged for the last 25 years in TNM classification. The purpose of this study was to determine the relationship between tumor size and survival in patients with non-small cell lung cancer. METHOD: Of 550 consecutive patients who underwent operation for NSCLC between 1994 and 1998, we reviewed the medical record of 509 patients. There were 470 men and 39 women. Survivals were compared according to groups of tumor size (Group I: < or = 3 cm, Group II: 3.1-4 cm, Group III: 4.1-5 cm, Group IV: >5 cm, Group A (II + III): 3.1-5 cm, and Group B (IV): >5 cm). The Cox proportional hazard model was used with same variables. RESULTS: The univariate analysis showed that poor pulmonary function test (P < 0.05), pneumonectomy (P < 0.05), limited resection (P < 0.001), tumor size larger than 5 cm (P = 0.006), T factor (P < 0.05), N status (P < 0.001), and advanced staged of disease (P < 0.001) were all significant prognostic factors. Further comparison of survival between tumor size groups demonstrated a significantly poor prognosis for larger tumors. There was a statistically significant difference between Group A (3.1-5 cm) and Group B (> 5 cm), with 5 years survivals of 45.9% and 31.4%, respectively (P = 0.005). CONCLUSION: We emphasize that tumor size is an important prognostic factor in NSCLC. The 5 years survival with tumors larger than 5 cm (31.4%), is significantly less than the tumors 3.1-5 cm (45.9%) (P = 0.005). These initial results should strongly encourage additional studies in different countries on the interaction between tumor size and lung cancer characteristics to better clarity. In future revisions of the TNM classification, 5 cm may be a new threshold.

Surgical treatment of peripheral lung cancer adherent to the parietal pleura.

OBJECTIVES: The objective of this paper is to assess the results of surgical treatment retrospectively in a consecutive series of 85 patients with peripheral non-small cell lung cancer (NSCLC) invading parietal pleura and chest wall. METHODS: From 1994 to 1998, of the 572 patients having pulmonary resection for NSCLC, 29 patients with neoplasm involving the parietal pleura (group I) and 56 with that invading the chest wall (group II) underwent resection. RESULTS: The operative mortality rate was 3.4% in group I and 1.8% in group II. In groups I and II, pathologic N status was N0 in 20 (69%) cases, N1 in five (17%), N2 in four (13.8%) and 44 (78.6%), seven (12.5%), five (8.9%), respectively. An incomplete resection (R1) was performed in two (6.9%) patients in group I and seven (12.5%) in group II. Postoperative radiotherapy was carried out in 18 patients in group I and 46 in group II. Systemic chemotherapy was also administered in seven patients in group I and eight in group II. There was a significant difference in adjuvant therapy between the groups (P<0.05). Two patients (R1) in group I (7.4%) and 12 patients (seven patients R1+5 R0) in group II (24%) had local recurrence. There was no significant difference in local recurrence between the groups (P=12). Follow-up was completed in 79 cases (28 in group I and 51 in group II). Median survival for groups I and II were 27+/-6 and 16+/-4.6 months, respectively. Five-year survival was longer in group I than in group II (33 vs. 14%), but there was no significant difference (P=13). CONCLUSIONS: We found similar survival rates for extrapleural resection in limited parietal pleura invasion and chest wall resection in exceeded-beyond-parietal pleura invasion. The completeness of resection is important in both groups.

Surgical treatment in bronchiectasis: analysis of 166 patients.

BACKGROUND: Bronchiectasis is usually caused by pulmonary infections and bronchial obstruction. It is still a serious problem in developing countries as our country. We reviewed the morbidity and mortality rates and outcome of surgical treatment for bronchiectasis. PATIENTS AND METHODS: Between 1990 and 2000, 166 patients (92 female and 74 male patients) underwent pulmonary resection for bronchiectasis. The mean age was 34.1 years (range, 7-70 years). Mean duration of symptoms was 5.7 years. RESULTS: Symptoms were copious amount of purulent sputum in 135 patients, expectoration of foul-smelling sputum in 109, hemoptysis in 35 and cough in all patients. The indication for pulmonary resection was failure of medical therapy in 158 patients, massive hemoptysis in five and lung abscess in three. The disease was bilateral in six patients and mainly confined to the lower lobe in 127. One hundred and twenty patients had a lobectomy, 13 had a pneumonectomy, 21 had a segmentectomy and a combination of these approaches in 18. Operative morbidity and mortality were seen in 18 (10.5%) and in three (1.7%) patients, respectively. Follow-up was complete in 148 patients with a mean of 4.2 years. Overall, 111 patients were asymptomatic after surgical treatment, symptoms were improved in 31, and unchanged or worse in six. CONCLUSIONS: Surgical treatment of bronchiectasis is more effective in patient with localized disease. It is satisfactory with acceptable ratio of morbidity and mortality.

[Gene therapy in malignant mesothelioma]. / Malign mezotelyomada gen tedavisi.

Malignant mesothelioma which arises from pleural mesothelial cells is a rare and deadly disease. Environmental factors, especially the exposure of asbestos, are accepted as etiological factors. There is not any accepted treatment of malignant mesothelioma. Nowadays four main forms of therapy and the combination of these forms are put in the practise for the treatment of malignant mesothelioma. These are surgical therapy, chemotherapy protocols, radiotherapy protocols and recently immunologic therapy which is based on direct antiproliferative effect of interferon. Gene therapy has been studying experimentally for recent years. The main principles of the gene therapy is sensitizing to antiviral drugs by infecting and changing the gene structure of the malign cells. The most used gene is herpes simplex virus (HSV) tk gene. In malignant mesothelioma, there is no standard treatment protocol and the main cause of death is local spread of tumor and the pathological effects of its mass rather than metastasis and the diagnosis and treatment results are evaluated from the same localization (pleural space). According of these factors, gene therapy could be an appropriate treatment for malignant mesothelioma.

[The importance of exercise testing for the functional assessment of lung resectional candidates]. / Akciger rezeksiyonu yapilacak hastalarin fonksiyonel degerlendirmesi için egzersiz testinin önemi.

UNLABELLED: Although there are a lot of physiologic tests to evaluate the preoperative cardio-pulmonary reserve in the patients who candidate lung resection, there is no a single gold standard test to suggest the postoperative pulmonary complications. In this study, we researched the importance of the exercise testing in the evaluation preoperative cardio-pulmonary reserve. We analyzed a series of 26 consecutive patients with a resectable lung disease [26 male patients, mean age 51.5 +/- 15.8 (13-78 years), 22 non-small cell lung carcinoma (NSCLC), 2 bronchectasis, 1 hydatid cyst, 1 empyema]. Patients were evaluated by pulmonary function testing (PFT), diffusing capacity of lung for carbonmonoxide (DLCO), and symptom-limited exercise testing. After the functional examination, 26 patients underwent pulmonary resections with standard thoracotomy: 4 segmental or wedge resection, 11 lobectomies, 5 pneumonectomies, and 1 cystotomia. The mean stay in the ICU was 2.6 days (+/- 3.5), the mean hospital stay was 11.9 days (+/- 8.0). Postoperative complications (within 30 days) occurred in 9 (34.6%) patients of whom one died (overall mortality rate was 3.8%). There was no relationship between the presence of complication and physiologic tests (PFT, DLCO). The patients were divided three groups according to peak oxygen consumption (VO(2)/kg peak) (mL/kg/min) (< 10, 10-20, > 20 mL/kg/min). There was no significantly difference among these groups and complication rates (p= 0.056), but the complication rate was higher in the group of VO(2)/kg peak < 10 mL/kg/min (75%). On the other hand, there was a significantly relationship between the presence of only pulmonary complication and VO2/kg peak (p= 0.034). CONCLUSION: We think that the preoperative functional evaluation in the patients with lung resection candidate is prominent to reduce the postoperative mortality and morbidity and especially cardiopulmonary exercise testing has an important role to suggest the postoperative pulmonary complications as a major complication.

Segmental bronchial sleeve resection: preserving all lung parenchyma for benign/low-grade neoplasms.

BACKGROUND: Bronchoplastic techniques are used commonly for the surgical treatment of benign or low-grade malignant neoplasms as a means of sparing healthy lung parenchyma. Because of technical difficulties, however, standard lobectomy or segmentectomy procedures are performed for the neoplasms localized in distally located tumors. We present the clinical and surgical data of 12 patients who underwent a unique surgical procedure, called by the authors of this article "segmental bronchial sleeve resection," without any pulmonary resection. METHODS: Twelve patients with benign or low-grade malignant neoplasms who underwent segmental bronchial sleeve resection to totally preserve lung parenchyma between the years 1979 and 2008 were included in the study. Data were gathered from patient records retrospectively. RESULTS: The postoperative course was uneventful for 10 patients. One of the remaining 2 patients underwent rethoracotomy because of hemorrhage, and tracheostomy was performed for the other patient because of persistent atelectasis. There was no mortality for any of the patients. CONCLUSIONS: Segmental bronchial sleeve resection is complex in technique and may have an increased risk of complications compared to a standard sleeve resection, but it is an effective and safe bronchoplastic technique for selected patients with benign or low-grade malignant bronchial tumors when performed carefully by an experienced surgeon.

Management of recurrent malignant pleural effusion with chemical pleurodesis.

PURPOSE: Malignant pleural effusion is a common complication of primary and metastatic pleural malignancies. It is usually managed by drainage and pleurodesis, but there is no consensus as to the best method of pleurodesis. We compared the effectiveness, side effects, and cost of different chemical pleurodesis agents used in patients with malignant pleural effusion. METHODS: Between January 1990 and December 2001, 108 patients with malignant pleural effusion underwent chemical pleurodesis in our department. Thoracoscopy was performed in 64 patients (59%), a minithoracotomy in 18 (17%), tube thoracostomy in 11 (10%), and a small-bore catheter was inserted in 15 (14%). Talc was used in 68 (63%) patients, tetracycline in 26 (24%), and bleomycin in 14 (13%). Talc was instilled by insufflation during surgery after drainage, whereas tetracycline and bleomycin were instilled via tube or catheter for pleural analgesia. RESULTS: Talc resulted in significantly earlier tube and catheter removal, after an average 4.1 days versus 5.1 days after tetracyline, and 6.3 days after bleomycin (P = 0.026, P = 0.001, respectively). A significantly lower reaccumulation ratio in 90 days was achieved by the talc group, with nine (13.2%) patients, representing an 86.8% success rate, than in the tetracyline and bleomycin groups, with seven (26.7%) and five (35.7%) patients, respectively, representing 73.8% and 64.3% success rates (P = 0.04). CONCLUSIONS: Talc resulted in the earliest expansion, minimal drainage, and the earliest tube and catheter removal.