Neural cell adhesion molecule expression, neuroendocrine differentiation and prognosis in lung carcinoma.

We investigated the expression of the neural cell adhesion molecule (NCAM) in a series of surgically resected lung carcinomas of various histological subtypes by means of a panel of monoclonal antibodies recognising different N-CAM epitopes. In a subgroup of 56 tumours, the results of immunostaining with MAb 123C3--the antibody studied most extensively in our material--were compared to the ultrastructure, and in 231 radically resected non-small cell carcinomas, with histological tumour type and with clinical follow-up data. N-CAM expression was not limited to neuroendocrine tumours, as assessed ultrastructurally. Non-small cell lung carcinomas positive for MAb 123C3 showed post-operative overall and disease-free survival times significantly shorter than 123C3-negative non-small cell carcinomas.

Pneumothorax. Results of thoracoscopy and pleurodesis with talc poudrage and thoracotomy.

A retrospective study was performed of the evaluable data in 710 patients with a spontaneous pneumothorax. The male:female ratio was 3.4:1. A thoracoscopy was performed in 622 patients. The two main therapeutic strategies were pleurodesis with talc poudrage (n = 356) and thoracotomy (n = 248). The success rate of talc poudrage was 88 percent, and in the group failures who have undergone surgery afterwards, we found unexpected bullous structures in 20 of 37 patients. The success rate of operation (bullectomy, pleurectomy, or resection) was 97 percent. Our conclusion is that aggressive therapy in spontaneous pneumothorax is acceptable, with a high success rate with very few complications. The diagnostic thoracoscopic evaluation needs to be in experienced hands, especially to inspect the apical lobes with the Valsalva maneuver.

Bronchoscopic therapy in patients with intraluminal typical bronchial carcinoid.

OBJECTIVE: To study the efficacy of bronchoscopic therapy in patients with intraluminal typical bronchial carcinoid. DESIGN: Retrospective analysis of the data of patients with bronchial carcinoid, treated primarily with bronchoscopic techniques such as Nd-YAG laser in various hospitals in the Netherlands. SUBJECTS: Eleven patients with pulmonary complaints, ages 22 to 60 years, who were found to have intraluminal typical bronchial carcinoid. BRONCHOSCOPIC INTERVENTIONS: Six of the 11 patients received Nd-YAG laser treatments, one received Nd-YAG laser plus photodynamic therapy, and the other four had mechanical tumor removal. RESULTS: Six patients were surgically treated after bronchoscopic therapy. The resected specimens showed no residual carcinoid. Median follow-up has been 70 months (range, 9 to 170 months). Five patients were not surgically treated after bronchoscopic therapy. Follow-up has been 27 to 246 months (median, 47 months) without signs of recurrence. CONCLUSIONS: In 11 patients with typical, intraluminal, bronchial carcinoids, bronchoscopic treatment seemed to result in excellent local control, with surgical proof of cure in 6 of 11 patients. Bronchoscopic approach may provide a tissue-sparing alternative for bronchoplastic surgery in a subset of patients with typical intraluminal bronchial carcinoids.

A twenty-five-year follow-up of ninety-three resected typical carcinoid tumors of the lung.

From 1965 to 1990, 93 patients (57 women and 36 men) with typical bronchopulmonary carcinoids were operated upon. Patient ages ranged from 17 to 78 years, the mean age being 45.5 years. Central carcinoids were symptomatic in 80% of the patients. A correct preoperative diagnosis was made in 54 of 64 (84%) patients. Peripheral carcinoids were usually asymptomatic and a correct diagnosis was established in 4 of 29 patients (14%). The prognosis in the group of patients with bronchopulmonary carcinoids treated surgically was excellent. Seven patients died from nonrelated causes. The 5-, 10-, and 15-year survival rates for the remaining 86 patients are 100%. Only one patient died as a result of the tumor after 17 years and another patient is known to have had distant metastasis 9 years after resection. There was no hospital mortality. In the last decade a lung parenchyma-preserving attitude was adopted. Whenever possible, bronchoplastic surgery was applied for central carcinoids and resection of one segment or less was used for peripheral carcinoids. This approach was possible in 30 of 50 patients (60%). Nine patients were treated with preoperative endobronchial neodymium:yttrium-aluminum-garnet laser resection to facilitate a lung-preserving surgical resection. The prognosis of patients for whom a lung-preserving approach was adopted was as good as that of those with conventional resections. Involvement of regional lymph nodes (nine patients, 9.7%) or positive resection margins (two patients, 2.1%) had no influence on prognosis. We conclude that lung-preserving resections are often facilitated by preoperative neodymium:yttrium-aluminum-garnet laser treatment in central obstructing carcinoids.

Bullectomy for giant bullae in emphysema.

The results of changes in dyspnea and pulmonary function are reported in 27 emphysematous patients followed up for about 10 years after removal of giant bullae, which occupied at least 50% of a hemithorax. In 10 patients bilateral bullectomy was done. The spirographic improvement depends on the type of bulla. Resection of bullae at open communication with the bronchial tree resulted predominantly in improvement of forced expiratory volume as a percentage of vital capacity, whereas after closed bullae were resected, the increase in vital capacity was most apparent. Dyspnea lessened in all patients. Seven older patients died of ventilatory insufficiency. Preoperatively they were clinically and functionally severely disabled. They improved markedly after bullectomy, and their mean survival time was more than 7 years. In all 27 patients improvement of dyspnea and pulmonary function lasted several years and only gradually returned to preoperative values and beyond. No giant bullae recurred in the observation period; neither was there an accelerated progression of the emphysematous process. Our present selection criteria, based on previous experience, are as follows: giant bullae occupying at least 50% of a hemithorax, definite displacement of adjacent lung tissue, exclusion of the presence of vanishing lung syndrome, and absence of chronic purulent bronchitis.

Resection of more than 10 lung segments. A 30-year survey of 30 bronchiectatic patients.

A series of 30 bronchiectatic patients, treated by bilateral resection of 11, 12, or 13 lung segments, has been followed up for 30 years. The progress of the patients is analyzed and the results of treatment are evaluated. Ten patients required further resections for persisting collapse, kinking of the apical segment of a lower lobe, or because the previous resection had been too limited. The long-term results of these extensive bilateral resections in our group of patients are excellent. The quantitative function, more than 20 years after the last resection, lies markedly above the predicted value for the number of remaining segments. The qualitative function did not deteriorate over the years. It is clear that extensive bilateral bronchiectasis does not, per se, constitute a contraindication to resection, provided that at least six normal segments can be preserved.

Long-term survival after bronchial sleeve resection: univariate and multivariate analyses.

BACKGROUND: Long-term results after bronchial sleeve resection remain controversial, especially in relation to nodal involvement. In a previous report, there were no 10-year survivors among patients with N1 or N2 disease. METHODS: From 1960 to 1989, 145 patients underwent bronchial sleeve resection for a bronchogenic tumor. Follow-up was updated until the end of 1994, so the minimum follow-up was 5 years for surviving patients. A univariate analysis and a multivariate analysis were performed. RESULTS: For the whole group, 5-year, 10-year, and 15-year survival rates were 46%, 33%, and 22%, respectively. The median survival time was 53 months. Five-year and 10-year survival rates for the 71 patients with no disease were 62% and 51%, respectively; for the 58 patients with N1 disease, 31% and 10%; and for the 16 patients with N2 disease, 5-year and 7-year survival rates were 31% and 13%. There was a highly significant difference in survival between patients with no and N1 or N2 disease but not between those with N1 and N2 disease. Multivariate analysis showed only nodal stage and patient age to be significant factors in relation to survival. CONCLUSIONS: Long-term results after bronchial sleeve resection are influenced chiefly by nodal stage. A significantly lower survival is found in patients with N1 and N2 disease, and most of these patients die of distant metastases.

Adjuvant therapy with levamisole in resectable lung cancer.

In view of the discouraging results that have been obtained so far with the use of cytotoxic chemotherapy as an adjunct to surgery, a double-blind placebo-controlled evaluation of the adjuvant use of levamisole was conducted in 211 resectable lung cancer patients, following these patients for 2 years after their operation. Levamisole (or the placebo) was given for 3 days every 2 weeks and the dose level ranged 1.1--3.8 mg/kg per day (a fixed dose of 3 x 50 mg was given to all patients). It appeared that recurrences and carcinomatous deaths had occurred significantly less often in patients who had received a high dose (i.e., 2.1--3,8 mg/kg: patients weighing 70 kg or less) but not in the patients who received a lower dose. Patients who had more advanced cancers at the time of surgery seemed to have profited more from the treatment, but the results did not seem to depend upon the histologic type of the tumor or on the immune status of the patients as estimated from the skin test reactivity at the start. There was also suggestive evidence that levamisole may be more effective in preventing hematogenous dissemination than in inhibiting recurrences in the lung or the mediastinal tissues. Levamisole, if dosed adequately, appears to be a very suitable adjuvant treatment in resectable lung cancer patients as judged from its efficacy and its lack of troublesome side-effects.

Prophylactic cranial irradiation in limited disease small-cell lung cancer in complete remission: a retrospective analysis.

Recently a meta-analysis showed an improved survival probability of prophylactic cranial irradiation (PCI) in limited disease small-cell lung cancer (LD SCLC) in complete remission after chemotherapy. We evaluated treatment results of PCI+ and PCI- in these patients. Whether PCI (n = 65) or no PCI (n = 37) was administered did not depend either on patients or on tumour characteristics. After 2 years the incidence of brain metastases was 11% in PCI+ patients and 51% in PCI- patients. Both disease-free survival and overall survival were significantly longer after PCI. PCI reduces the incidence of brain metastases, prolongs brain metastases-free period, and overall survival in LD SCLC patients in complete remission after chemotherapy.

Extended use of diagnostic anterior mediastinotomy: intrapericardial exploration and evaluation of resectability of left-sided bronchogenic carcinoma.

From June 1987 to June 1990, an anterior mediastinotomy with opening of the pericardium was performed in 11 patients (mean age 67.8 years) to evaluate resectability of left-sided centrally located bronchogenic carcinoma. In 3 patients (27.3%), extensive intrapericardial involvement was found which precluded complete resection. Intrapericardial extension without complete invasion of the pulmonary vessels was present in 2 patients (18.2%) who subsequently underwent an intrapericardial pneumonectomy. In 6 patients (54.5%), no intrapericardial tumour was present. There was no perioperative mortality. One patient required redrainage of the pleural cavity because of a postoperative pneumothorax. In total, 4 patients (36.4%) underwent intrapericardial pneumonectomy, 6 (54.5%) were treated by radiotherapy and 1 (9.1%) by chemotherapy. In left-sided, centrally located tumours, opening the pericardium during anterior mediastinotomy yields additional information about the degree of tumour invasion and the feasibility of performing an intrapericardial pneumonectomy. In this way, an exploratory thoracotomy is avoided and the risk of irresectability is greatly reduced.

[ACTH-producing small-cell lung carcinoma]. / ACTH-producerend kleincellig longcarcinoom.

Small-cell lung cancer may be accompanied by hypercortisolism due to secretion of adrenal stimulating peptides. This occurs almost exclusively in case of extensive disease. The neuroendocrine cell, from which these tumours may originate, plays an important part in the production of these peptides. Four patients are described with small-cell lung cancer and clinical presentation of hypercortisolism, particularly manifesting itself with hypokalaemia.

[Tracheobronchial lesions after closed thoracic injuries]. / Les lésions trachéobronchiques lors des traumatismes fermés du thorax.

We report the clinical picture and the outcome after medical and surgical treatment of eleven patients who had a traumatic rupture of the tracheobronchial tree between 1971 and 1990. The lesions occurred after a blunt chest trauma. All patients but one had evidence of extrapulmonary air leak on admission; one patient complained of hemoptysis. Seven patients underwent a fibroscopy on admission, which confirmed the rupture. One of them was operated immediately for tracheal rupture; four presented a small lesion which was medically treated; two were operated later on for secondary stenosis. Four patients didn't undergo a fibroscopy at first examination, one of them being asymptomatic. All four were operated secondarily. Of the six patients operated for secondary stenosis, three were operated within one month after the accident. This reflects the importance of other priorities at the initial stage. Of the three patients operated later on two didn't have a fibroscopy and it is impossible to assess the importance of the primary lesion. For the last patient operation was delayed because of the peripheral location of the lesion. The long term evolution was satisfactory in all cases.

[Pleural talcage in patients with spontaneous pneumothorax (author's transl)]. / Le talcage pleural dans le pneumothorax spontané.

The insufflation of iodinised (1%) sterile talc in patients with spontaneous pneumothorax is presented as a safe and valuable method of treatment. A recidive pneumothorax occurs in 6.6% of the patients. This form of treatment should only be used in the forms of pneumothorax without bullous degeneration, which should be treated surgically. Pleural talcage can be performed under local anesthesia, without harmful repercussion on the patient or on the VC, FEV1, and diffusion capacity. In our experience, thoracoscopy provides the inestimable and necessary information for choosing the best way of treatment in patients with a spontaneous pneumothorax.

[Thorascopy under local anesthesia (author's transl)]. / Thorascopie sous anesthésie locale.

Thoracoscopy has proved to be a method of investigation which can give important diagnostic information in diseases of the pleura, the diaphragm, the mediastinum, the thoracic wall and in some peripheral pulmonary lesions. Th procedure can be accomplished safely under local anesthesia which has important advantages in the better recognition of certain abnormalities and avoids a general anesthesia in many patients in a poor cardiopulmonary conditions.

Complications of endobronchial neodymium-Yag (Nd:Yag) laser application.

Endobronchial Nd:Yag laser therapy is an excellent tool to reopen the central airway(s) in patients with severe respiratory symptoms caused by endobronchial tumor growth. Rigid bronchoscopy should be the method of choice. Usually general anesthesia is necessary. Complication rate depends on the condition of the patient, the localization of the tumor, patient selection criteria, method of endoscopy, method of anesthesia, method of laser energy application, and last but not least, the operator's skills and the treating team's cooperation. A very careful monitoring of the patient's condition during and after the operative procedure is mandatory. Only when all these conditions are fulfilled can endobronchial Nd:Yag laser therapy have a great benefit for the patient with a low grade, acceptable complication rate.