Bronchoalveolar lavage and morphology of the airways after cessation of exposure in asthmatic subjects sensitized to toluene diisocyanate.

To evaluate the morphologic basis of the different outcomes of toluene diisocyanate (TDI) asthma after quitting occupational exposure, we examined ten patients with TDI asthma who showed, at diagnosis, a positive TDI challenge test and nonspecific bronchial hyperresponsiveness (NSBH) to methacholine. After diagnosis, all patients ceased work and a 4- to 40-month follow-up was obtained with three to eight determinations of the cumulative dose producing a 15 percent fall in FEV1 (PD15FEV1) methacholine in each patient. Bronchoalveolar lavage (BAL) and biopsy of bronchial muscosa were performed 3 to 39 months after cessation of work, in the absence of acute exacerbations of the disease. Total cell count in BAL fluid was moderately increased in four of ten patients, eosinophils were increased in five of ten patients, and neutrophils were increased in eight of ten patients. Mucosal biopsy specimens of main or lobar bronchi were available in eight of ten patients; epithelial damage and thickening of basement membrane was observed in almost all patients, as well as a mild-to-moderate inflammatory reaction in the submucosa, mainly represented by lymphocytes, eosinophils, and neutrophils. No relationship was observed between the cellularity of BAL and the degree of NSBH at the time of BAL; mean values of total cells and differential count were not different between patients with presence or absence of the different histologic findings. Mucosal biopsy and BAL were performed also in four subjects exposed to dusts without respiratory symptoms or NSBH; similar findings were obtained except for the absence of eosinophils in BAL and a lesser degree of basement membrane thickening and inflammatory reaction in the submucosa. The study of the changes in NSBH after quitting exposure showed that five of ten patients had a significant improvement in NSBH to methacholine, as evaluated by a positive significant linear regression between months of work cessation and PD15FEV1 methacholine; only one of these five patients had an increased number of eosinophils in BAL fluid. By contrast, four of the five patients with persistent NSBH after quitting exposure had an increased number of eosinophils in BAL. We suggest that persistent NSBH in TDI asthma after cessation of work may be related to an inflammatory reaction in which eosinophil infiltration seems to be a major determinant.

Surgery in the management of small cell lung cancer.

OBJECTIVE: We analyzed our experience in the period January 1975-December 1995 aiming to confirm the role of surgery in the multimodality treatment of small cell lung cancer (SCLC). METHODS: 127 patients (5.28% of the overall lung resections for carcinoma) underwent surgery for SCLC. The median age was 60 years (range 34-73). In 87 patients (68.5%) a pre-operative tissue diagnosis was effected and those patients underwent a complete staging procedure. Fifteen patients received up to six complete courses of neoadjuvant and adjuvant chemotherapy. The surgical procedures included: 50 pneumonectomies, 71 lobectomies and six wedge resections. Two patients experienced a local recurrence and a completion pneumonectomy was performed. RESULTS: The median follow-up is 66 months (range 6-214). The 5-year actuarial survival rate is 22.6% (median 18 months). Twenty-three patients are still alive, 21 of them being disease-free. Considering the most conspicuous group of patients (n = 92) treated by surgery and adjuvant chemotherapy, the survival data were 47.2, 14.8 and 14.4% for Stage I, II and III, respectively (P = 0.001). NO patients had a significantly better survival than N1 and N2 patients (P = 0.035). CONCLUSIONS: Surgery and adjuvant chemotherapy might represent an effective form of treatment of limited SCLC without lymph-node involvement. The role of surgery is yet to be verified as regards N1 and N2 status, where even neoadjuvant chemotherapy has not achieved the hoped-for results (no patient reaching a 2-year survival).

Treatment by VATS of giant bullous emphysema: results.

OBJECTIVE: In selected patients with giant bullous emphysema GBE and in those with specific complications, surgery may be the treatment of choice. METHODS: In the period January 1993-February 1996 we performed 34 VATS treatments in 29 patients affected by GBE. There were 22 (76%) males and 7 (24%) females, with a mean age of 54 years (range 24 74). In 23 cases, a pneumothorax (PNX) was present at admission, while 6 patients were treated by choice. Altogether. we performed 23 resections of sessile bullae (type 2 of Reid) by using a linear endoscopic stapling device (Endo-path 35 and 45 mm) and 11 ligatures of pedicled bullae (type 1 of Reid) by loop (Endo-loop 'PDS'). The mean number of charges for every treatment was 8 (range 4-21). The largest bullae were perforated and deprived of incarcerated air. They were then twisted on the axis perpendicular to the base in order to improve the manoeuvrability of the lesion and favour the correct placement of the Endo-path or Endo-loop. GBE was bilateral in 7 cases: one of these was treated bilaterally in the same surgical stage, other 4 were treated by staged operations. RESULTS: We experienced two conversions to open thoracotomy (one sessile giant bulla inside the fissura; 1 case of strong tuberculous pleural adhesions). Two patients, underwent a second operation by open thoracotomy because of a prolonged air leak. We have two peri-operative deaths, both to respiratory failure. Altogether, in 23 out of 29 (79%) cases VATS was effective and the mean hospital stay was 6 days (range 3-16). At a mean follow up of 16 months (range 1-36) no recurrence of PNX was observed. CONCLUSIONS: VATS may be considered as a suitable surgical technique to approach GBE and, in most cases, it is effective.

Tumor angiogenesis and biologic markers in resected stage I NSCLC.

OBJECTIVE: Microvessel count (MC), as a measure of tumor angiogenesis, has been shown to be significantly correlated with metastatic disease in cutaneous, mammary, prostatic, head and neck cancer. We have previously assessed the role of intensity of angiogenesis as predictor of metastasis in surgically resected T1N0M0 NSCLC. We needed to confirm its value, in a prospective larger study on Stage I NSCLC, before its utilization as a prognostic tool for further clinical investigations. METHODS: In the present report we prospectively investigated 227 patients (206 males, 21 females; median age 65 years) with Stage I NSCLC treated only by radical surgery between March 1991 and December 1994 with utmost care for some biological characteristics (proliferative activity, the blood vessel invasion, angiogenesis and the p53 protein expression). RESULTS: The operative procedures consisted of 62 pneumonectomies, 148 lobectomies and 17 segmentectomies or wedge resections. With a median follow-up of 36 months (range 15-60), eighty patients have already experienced a local (n = 22) or systemic (n = 58) relapse. Univariate analysis revealed that T factor (T1 versus T2)(P = 0.008) and angiogenesis count (< or = versus > median, 17) (P = 0.0006) were significant predictors of survival. The same variables were also significant predictors of long Disease Free Survival (P = 0.006 and P = 0.004, respectively). On multivariate analysis, however, only the microvessel count retained its level of prognostic significance as regards both overall (P < 0.01) and disease-free survival (P < 0.01). CONCLUSIONS: The present study corroborates the role of angiogenesis in the metastatic spread of NSCLC and emphasizes its value in the identification of patients in whom surgery should be supplemented by systemic treatment.

Results of en bloc resections for lung cancer.

The results of en bloc resection carried out in 33 patients with lung cancer involving the chest wall are described. Microscopic examination of the lung specimen revealed large cell anaplastic carcinoma in 14 cases, squamous carcinoma in 10, adenocarcinoma in 5, microcytoma and fibrosarcoma in 2 cases respectively. The 5 year survival, calculated according to the actuarial method, was 32%, only slightly lower than the 5 year overall survival observed in our survey. The long-term prognosis was essentially related to the presence of lymph node metastases, which were found to occur at a late stage of the clinical evolution.

[Diagnosis and treatment of pleuro-pericardial cysts. Role of videosurgery]. / Diagnosi e trattamento delle cisti pleuro-pericardiche. Ruolo della videochirurgia.

BACKGROUND: The pericardial cysts are benign "tumors" of the antero-inferior mediastinum, most often asymptomatic, which diagnosis is radiologic and incidental. When cysts are symptomatic and/or diagnosis is difficult, any resort to invasive diagnostic examinations and surgical ablation is suitable. METHODS: From January 1993 to January 1994 five patients with pericardial cyst have been treated. Three patients were symptomatic: two suffering from cardiac arrhythmia and one had cough with dyspnea. In three cases the lesion had a typical location and typical radiological patterns, and diagnosis was made by chest X-ray, confirmed by computed tomography (CT). In one case chest X-ray and CT didn't allow a sure diagnosis (differential diagnosis with Morgagni's diaphragmatic hernia), and in another case all examinations suggested a relapsing pleural effusion. RESULTS: All patients underwent ablation of the cyst by VATS; no complications were observed and patients left the hospital, on average, after 2 days (range 1-3). CONCLUSIONS: VATS, thanks to its low invasiveness, may be considered the method of choice for the diagnosis of atypical lesions and/or treatment of symptomatic cysts.

Endothoracic sonography with color Doppler availability during video assisted thoracic surgery (videothoracoscopic operative staging with ultrasound color Doppler) for lung cancer staging.

BACKGROUND: The preoperative staging of lung cancer can be problematical when we attempt to evaluate T factor (T2-T3 versus T4) and N factor (N0 versus N1-N2). In some cases, radiology tests (CT scan, magnetic resonance imaging) cannot entirely dispel the possibility that the mediastinal structures have been infiltrated. N factor is evaluated mainly by dimensional criteria. However, mediastinoscopy and mediastinotomy do not allow the full exploration of all mediastinal mode stations. METHOD: Starting in 1995, we submitted 10 consecutive patients to videothoracoscopic operative staging with ultrasound color Doppler (VOS-USCD). In five cases, preoperative staging showed possible infiltration of the pulmonary artery (T4). In nine cases, we found involvement of the mediastinal nodes, seven patients were N2, and two were N3. Videothoracoscopy was performed under general anesthesia using a double-lumen endotracheal tube. The videothoracoscope and sonographic probe were inserted via three thoracoports placed in the axillary triangle. RESULTS: Following the results of VOS-USCD, the staging and subsequently the therapeutic program were modified in seven of 10 cases (70%). CONCLUSIONS: Our preliminary experience indicates that VOS-USCD should be applied to the diagnosis of patients in stage IIIA (N2) and that it is particularly valuable for patients in stage IIIB.