Chronic oral etoposide in non-small cell lung carcinoma.

25 consecutive inoperable or extended non-small cell lung cancer (NSCLC) patients (19 non-chemotherapy pretreated, 6 non-heavily pretreated) were given oral etoposide, 50 mg/m2/day for 21 successive days, every 4 weeks. 5 partial responses (PR), 9 disease stabilizations were achieved; the overall response rate of 20% (95% confidence interval, 4% to 36%) or 26% in non-pretreated patients. Median survival and PR duration probabilities were 6.7 months and 6.3 months, respectively. Alopecia excepted (96% of patients), non-haematological toxicity was mild. Haematological toxicity WHO grade II+III mainly consisted of leukopenia (28%).

Experimental reconstruction of the canine trachea with a free revascularized small bowel graft.

Extensive tracheal stenotic lesions caused by tracheomalacia or neoplasms represent a surgical challenge. Segmental tracheal substitution is sometimes required to obtain radical cure. We present an experimental study of 27 dogs undergoing replacement of the cervical trachea using a vascularized small bowel segment as a tubular graft. A silicone stent was placed in the lumen of the intestinal fragment and was removed the second week after operation. Endoscopic and histological examinations were performed between the first week and second month after operation, and rigidity of the graft was assessed in all cases. No evidence of anastomotic stricture or mucous formation was found. Microscopic examination showed the substitution of bowel mucosa by squamous epithelium as well as the development of connective tissue favoring the fixation of the skeletal muscular structures of the neck to the serous layer of the graft, thus avoiding collapse of the new airway.

Hepaticothoracic transdiaphragmatic echinococcosis.

Between 1970 and 1985, seven patients were referred to us for surgical treatment of simultaneous hydatid cysts in the liver and the chest. Their mean age was 45.4 years (age range, 23-73 years), and they represented 46% of patients with hydatid cysts in the liver and thorax. Three patients had hepaticopleural involvement, and 3 patients had symptoms of pulmonary origin. In a single patient, only the diaphragm was involved along with the liver. Liver scintigraphy and ultrasonography were equally helpful in delineating the extent of the disease, but computed tomographic scanning is now the method of choice. The operations were through a thoracolaparotomy in 3 patients and a thoracotomy alone in 3 patients. A single patient had a thoracotomy with a transdiaphragmatic laparotomy. Complete drainage or excision of hydatid cavities was accomplished in all patients. Hydrogen peroxide instilled into the cysts was satisfactory for control of spread potentially secondary to possible intraoperative spillage. There have been no postoperative deaths. Follow-up has ranged from 6 months to 8 years, and 2 patients had relapsing hydatid disease 3 years postoperatively. These results suggest that, when hydatid disease of the liver is complicated by transdiaphragmatic extension and simultaneous pleural or pulmonary cysts, early surgical repair is indicated. Complete drainage and cyst excision are recommended.

Candida albicans costochondritis in heroin addicts.

The dramatic increase in the number of heroin addicts has led to an increase in the number of infective complications seen, especially those due to Pseudomonas aeruginosa and Candida albicans. In this report we describe our current experience in the surgical treatment of Candida albicans costochondritis. The clinical picture, diagnostic techniques, and surgical therapy receive comment, and a brief review of the literature is given.

Congenital bronchoesophageal fistula in adults. Report of three cases.

Persistence of congenital bronchoesophageal fistulae into adulthood is rare. Three patients, one male and two female, of 52, 27 and 63 years of age, respectively, are reported. All three presented with chronic respiratory symptoms and coughing spells associated with ingestion. The barium swallow confirmed diagnoses. Treatment was surgical and consisted of excision of the fistulous tract, suture of the oesophageal and bronchial orifices and the interposition of a parietal pleura flap in two cases, and of biological glue in one. All three patients recovered and are free of symptoms.

Antibiotic prophylaxis in non-cardiac thoracic surgery: cefazolin versus placebo.

A total of 127 patients (57 given placebo and 70 given a single preoperative dose of 1 g cefazolin) undergoing thoracic surgery were included in a randomized double-blind trial. The two groups were similar in regard to mean age, sex ratio, in-hospital stay before surgery, underlying disease, risk factors, type of surgery, mean duration of surgical procedure, and mean duration of chest tube drainage. The relative risk of wound infection of the patients from the placebo group was 3.27 (range 1.5-11.5; 95% confidence interval). Cefazolin significantly reduced (p less than 0.01) the wound infection rate--1 case (1.5%) in the cefazolin group versus 8 cases (14%) in the placebo group--but not the incidence of postoperative pleural empyema--5 (7%) versus 8 cases (14%)--or nosocomial pneumonia--3 (4%) versus 5 cases (9%). Cultures were made from 3 out of 9 wound infections and Staphylococcus aureus or S. epidermidis was isolated in all 3. In addition, cultures were made from 6 out of 13 pleural cavity infections and S. aureus (1 case) or other microorganisms (5 cases) were isolated in all 6. Mortality was similar in both groups and all deaths unrelated to the infections. No adverse side effects of the drug were encountered. In conclusion, a single preoperative dose of 1 g cefazolin proved to be effective for reducing the wound infection rate in non-cardiac thoracic surgery.

Outcome of patients after curative resection of pulmonary metastases.

BACKGROUND: Resective surgery can play a role in solitary pulmonary metastasis or in a few multiple metastases of the lungs. METHODS: We performed a retrospective analysis of the cure rate and survival in patients with pulmonary metastases after surgical resection. Inclusion criteria included no evidence of extrapulmonary metastases or local control of the primary neoplasia. Selective adjunctive therapy was added when applicable. RESULTS: Twenty-five out of 53 patients with resected pulmonary metastases are still alive and disease free. After a 5-year period of follow-up the cure rate obtained was 42%. CONCLUSIONS: In selected patients, resective surgery of solitary or limited multiple pulmonary metastases should be useful, offering the patients a high rate of curability and long term survival. These positive results suggest that adjunctive therapies should be added after resective surgery.

[Traumatic pulmonary pseudocysts]. / Seudoquistes pulmonares traumáticos.

Two cases of traumatic pulmonary pseudocysts in young patients are presented. Blunt chest injuries resulting from traffic accidents were the causes in both cases. Air cavities were seen on chest films 12 hours and one hour, respectively, after trauma. In both cases, self-limited hemoptysis preceded the appearance of an air-fluid level on X-rays. The diagnoses of pulmonary pseudocyst were made after excluding other possible cause and the outcomes were satisfactory after treatment of symptoms and associated lesions.

Mediastinoscopy as an emergency diagnostic procedure in superior vena cava syndrome.

Seven men and one woman (aged 20-70 years) with superior vena cava syndrome underwent diagnostic mediastinoscopy to elucidate the cause, which other, lesser procedures had not identified. Intraoperative frozen-section studies of the biopsy specimens revealed small-cell carcinoma (4 cases), large-cell carcinoma (1), squamous-cell carcinoma (1), large-cell lymphoma (1) and Hodgkin's lymphoma (1). Radiotherapy or chemotherapy was initiated within the following 24 hours in six cases. One of the tumors intraoperatively diagnosed as small-cell carcinoma was subsequently reclassified as lymphocytic lymphoma. Complicating hemorrhage from the right carotid artery required median sternotomy in one case and wound infection occurred in another. There was no mediastinoscopy-related mortality. Mediastinoscopy is useful and reliable in the diagnostic emergency posed by the superior vena cava syndrome.

Traumatic intrapericardial diaphragmatic rupture.

A case of traumatic intrapericardial diaphragmatic rupture in a 72-year-old patient is presented. The evaluation and treatment of this lesion and associate pathology in the acute phase is presented, the pathophysiology is commented on, and a thorough review of the literature is presented. To our knowledge, only 29 cases have been previously reported.

VP-16 plus cyclophosphamide in the treatment of advanced lung cancer.

Ninety previously untreated patients with histologically documented lung cancer were treated with VP-16 and cyclophosphamide either alone (protocol I) or with methotrexate (protocol II) or Adriamycin (protocol III), with 30 patients in each protocol. The rates of objective response were 57,37, and 27%, respectively, protocol I being significantly better than protocol III (P less than 0.05). Protocol I was significantly less toxic than protocols II(P less than 0.01) and III (P less than 0.001). The overall rate of objective responses was 66% in small cell (SCC) and 22% in non-small cell carcinoma (nSCC). Median survival was 37 weeks in SCC and 21 weeks in nSCC. Median survival of responders both in SCC and in nSCC was significantly longer than in nonresponders. We conclude that VP-16 plus cyclophosphamide is a well tolerated regimen with positive effect in advanced lung cancer. The association of methotrexate or Adriamycin didn't offer any improvement over the basic combination in this study.

Spontaneous pneumothorax in cryptogenic fibrosing alveolitis.

The prevalence of spontaneous pneumothorax was studied in 82 patients with cryptogenic fibrosing alveolitis. In 46 patients the disease affected only the lung ('lone' fibrosing alveolitis); in the remaining 36 patients the interstitial lung disease was associated with several systemic diseases ('associated' fibrosing alveolitis). 3 patients with the 'lone' form had a spontaneous pneumothorax. This figure represents a prevalence of 3.6%. We did not observe this complication in any patient with the associated form. Suction drainage was ineffective in the 3 patients. One of them died as a consequence of pleural infection. In the other 2 subjects thoracotomy, resection of blebs and pleurectomy were required.

Lung structure and gas exchange in mild chronic obstructive pulmonary disease.

To investigate the influence of pulmonary emphysema and small airways abnormalities on ventilation-perfusion (VA/Q) mismatching in mild chronic obstructive pulmonary disease (COPD), we studied 23 patients (mean predicted FEV1, 76 +/- 15%) before lung resection because of a localized neoplasm. Respiratory gas exchange and VA/Q distributions were measured while the patients breathed room air and 100% O2. Breathing room air, the AaPO2 was moderately increased (25 +/- 12 mm Hg) as was VA/Q mismatching, indicated by the dispersion (log SD) of both blood flow (Q) and ventilation (V) distributions (log SD Q, 0.78 +/- 0.3; and log SD V, 0.66 +/- 0.28, respectively) (normal range, 0.3-0.6). AaPO2, log SD Q, and log SD V all significantly correlated with the emphysema severity assessed morphologically from the resected lung specimens (r = 0.57, r = 0.62, and r = 0.45, respectively). Log SD V also significantly correlated with the severity of the inflammatory infiltrate of membranous bronchioles (r = 0.62). During 100% O2 breathing there was an increase in VA/Q mismatching (log SD Q rose to 1.12 +/- 0.08, p less than 0.001), suggesting release of hypoxic pulmonary vasoconstriction. This increase in VA/Q inequality was not significantly related to the severity of lung pathologic findings. We conclude that, in mild COPD, both pulmonary emphysema and small airways abnormalities contribute to VA/Q mismatch, the severity of emphysema being the major morphologic correlate of the increase in AaPO2.