Role of Adjuvant Chemotherapy in Pulmonary Carcinoids: An NCDB Analysis.

BACKGROUND/AIM: Typical carcinoids (TC) and atypical carcinoids (AC) are rare diseases. A paucity of randomized studies and disagreements among various guidelines makes the management challenging. PATIENTS AND METHODS: Using codes for TC (8240) and AC (8249) in the National Cancer Database (NCDB), all surgically resected cases from 2004-2014 were included to evaluate the need for adjuvant chemotherapy. RESULTS: A total of 6,673 cases were included, 88% were TCs and 12% were ACs. From 2004 to 2014, the proportion of TCs went up from 1.3% to 1.8% and ACs from 0.1% to 0.3% of all lung malignancies. TC patients did well with surgery alone in all stages. AC patients with stage I [5-year overall survival (OS) - 84% vs. 52%; S vs. S+CT] and stage II disease (5-year OS - 81% vs. 55%; S vs. S+CT) showed better OS trend with surgery alone, while stage III patients showed some benefit with the use of adjuvant chemotherapy (5-year OS - 46% vs. 54%; S vs. S+CT). These results supported the National Comprehensive Cancer Network (NCCN) guidelines. CONCLUSION: No benefit was seen from adjuvant chemotherapy in TCs. While the adjuvant therapy may add benefit in stage III AC, the numbers are small and did not reach statistical significance.

Ultrasound-guided continuous thoracic paravertebral block provides comparable analgesia and fewer episodes of hypotension than continuous epidural block after lung surgery.

PURPOSE: Both paravertebral block (PVB) and thoracic epidural block (TEB) are recommended for postoperative pain relief after lung surgery. The addition of fentanyl to the anesthetic solution became popular for TEB because of the stronger effects; however, there have been few comparable trials about the addition of fentanyl to PVB. The purpose of this study was thus to compare postoperative analgesia, side effects, and complications between ultrasound-guided PVB (USG-PVB) and TEB with the addition of fentanyl to ropivacaine after lung surgery. METHODS: We examined 90 consecutive patients (age 18-75 years) scheduled for video-assisted thoracic surgery (VATS). In both groups, all blocks (four blocks in USG-PVB and one block in TEB) and one catheter insertion were performed preoperatively. Continuous postoperative infusion (0.1% ropivacaine plus fentanyl at 0.4 mg/day) was undertaken for 36 h in both groups. The recorded data included the verbal rating scale (VRS) for pain, blood pressure, side effects, complications for 2 days, and overall satisfaction score. RESULTS: There was no difference in the frequency of taking supplemental analgesics (twice or more frequently), or in VRS. Hypotension occurred significantly more frequently in TEB (n = 7/33) than in PVB (n = 1/36) (P = 0.02); on the other hand, the incidences of PONV and pruritus, as well as overall satisfaction score, were similar. There were no complications in both groups; however, the catheters migrated intrathoracically in four patients in PVB. CONCLUSION: USG-PVB achieved similar pain relief and lowered the incidence of hypotension compared with TEB. We conclude that both blocks with the same concentration of ropivacaine and fentanyl can provide adequate postoperative analgesia for VATS.

A modified Brompton technique for the treatment of giant bulla in patients with diffuse emphysema.

Four patients with diffuse emphysema and a giant bulla were treated by a modified Brompton technique using a mushroom catheter and low suction. There was no mortality although one patient developed a troublesome pulmonary infection. All the patients had significant symptomatic improvement with a mean dyspnoea index changing from 3.5 before operation to 2.25 afterwards. We concluded that the modified Brompton technique is a safe and simple alternative in treating a giant bulla associated with diffuse emphysema.

Sleeve resections for the treatment of non-small cell lung cancer.

Parenchyma-sparing sleeve lobectomies were originally developed as a surgical strategy for patients not fit for a pneumonectomy, because of impaired pulmonary function. As promising short- and long-term results were demonstrated, sleeve lobectomy was accepted as an alternative surgical procedure to pneumonectomy. Nowadays, sleeve resections are associated with prolonged long-term survival and better quality of life, compared to pneumonectomy. Therefore, sleeve resections should be performed for centrally located non-small cell lung cancer (NSCLC) whenever technically, anatomically and oncologically possible. In this review, we discuss the current status of sleeve resections in the management of NSCLC.

The impact of preoperative micronutrient supplementation in lung surgery. A prospective randomized trial of oral supplementation of combined alpha-ketoglutaric acid and 5-hydroxymethylfurfural.

OBJECTIVE: Preoperative micronutrient supplementation in fast-track surgery programs have shown to reduce complications, shorten recovery, and thereby lower costs. In a prospective randomized study, the metabolic effects of a combination of alpha-ketoglutaric acid (alpha-KG) and 5-hydroxymethylfurfural (5-HMF) were evaluated concerning their impact on improvement of exercise capacity and reduction of oxidative stress in lung surgery. METHODS: Thirty-two consecutive patients admitted for lung resection due to NSCLC were randomized to the study protocol. All patients received preoperative nutritional guidelines according to general recommendations. In 16 (study group), a supplementation of 7.2g alpha-KG and 720 mg 5-HMF/day (SANOPAL) was administered from days 1 to 10. Spiroergometric evaluation was carried out at baseline and day 10 after micronutrient supplementation. Blood samples for the determination of oxidative stress, i.e. carbonyl proteins (CPs) and isoprostanes (IPs) were taken on at baseline, in the operating room just before resection treatment, and 25 min after single lung ventilation (SLV). RESULTS: Spiroergometric re-evaluation showed a significant increase of VO2max (p=0.0108) and Watt's (p=0.011) in favor of the study group. Determination of oxidative stress showed a significant reduction of CPs before (p=0.048) and after SLV (p=0.0001) for the study group compared to the control group. The same is true for IPs before (p=0.003) and after SLV (p=0.02). Hospitalization and intensive care unit (ICU) of the study group showed a significant reduction compared to the control group (p=0.03 and p=0.02, respectively). CONCLUSIONS: Simple oral supplementation using a combination of alpha-KG and 5-HMF of preoperative micronutrition may therefore be one further step in a multimodality approach of fast-track surgery programs also in lung surgery.

[Surgical treatment of bronchial asthma]. / Khirurgicheskoe lechenie bronkhial'noi astmy.

Methods of surgical treatment of bronchial asthma (BA) are classified as first generation (glomectomy, gangliectomy, vagotomy, pulmonary roots denervation), second generation (implantation of neurostimulators of sinocarotid, diaphragmal nerves, vagus, sympathic trunks), third generation (implants of programmed microchips). 7-year experience of surgical treatment with second generation methods in 125 patients with BA and experience of third generation methods use are summarized. Methods of second and third generations are most promising, permit to prevent and to cure asphyxia attack without drugs--with electrostimulation of vegetative system structures by impulse current (30-150 Hz, 0.01-0.1 ms, 0.5-2.0 V). New methods increase remission period more than 2 times, reduce drug daily requirement not less than 2 times. New methods can be used with traditional drug therapy and don't lead to dangerous for life complications. From first generation methods of BA's surgical treatment, only glomectomy and pulmonary roots denervation can be performed on serious demand.