Synchronous pleuro - renal solitary fibrous tumors: a new clinical-pathological finding.

Solitary fibrous tumors of the pleura (SFTP) are rare mesenchymal neoplasms usually originating from the visceral pleura, but sometimes found in other sites like the orbit, dura, paranasal sinus, upper respiratory tract, thyroid, sublingual gland, lung, periosteum, cauda equina, ovary, scrotum and testicular tunica vaginalis. Solitary fibrous tumor of the kidney is extremely rare with fewer than 15 reported cases in modern English literature. To the best of our knowledge, this report describes the first known case of synchronous SFTP in the left parietal pleura and left kidney. The SFTP of the pleura, widely compressing and displacing the left lower lung lobe, was resected via left thoracotomy, whereas the renal SFTP, diagnosed by echo-guided histological biopsy, was closely monitored by computed tomography scan and ultrasound. After a one-year follow-up no recurrence was detected in the left hemithorax and the renal lesion remained stable.

Pneumocephalus after Pancoast's tumor surgery: to be or not to be conservative?

We report a case of a 62-year-old man affected by Pancoast's tumor who developed pneumocephalus 17 days after right upper lobectomy with en bloc resection of the first three ribs and C8-D1 branches of the brachial plexus. The patient complained of aphasia, disorientation and sphincterial release. A chest and brain-CT scan showed a right apical pneumothorax associated with a massive pneumocephalus of the ventricles and of the subarachnoidal spaces. A pneumoperitoneum was also seen. The patient was treated using pleural drainages, Trendelenburg's position and antibiotic therapy. Clinical and radiological remission was achieved after 12 days of additional hospital stay.

A safe and effective method for an immediate bronchopleural fistula repair.

Bronchopleural fistula (BPF) is a well recognized and potentially fatal complication of major thoracic surgery and several strategies regarding its prevention and subsequent management have been described. An immediate BPF occurring intraoperatively after bronchial closure is a rare event and is usually treated by bronchial stump reamputation and/or hand-suture reinforcement by mattress suture, or myoplasty. We report a simple and successful technique, using azygous vein flaps, to repair an intraoperative BPF associated to a small bronchial dehiscence occurred after a right pneumonectomy in a 70-year-old diabetic man receiving induction chemotherapy treatment.

[Technique, results and impact of induction chemotherapy in sleeve lobectomy for lung cancer]. / Tecnica, risultati e ruolo della chemioterapia di induzione nella lobectomia con resezione/anastomosi bronchiale (sleeve).

AIM: The aim of this study was to evaluate the safety of continuous nonabsorbable (3/0 polypropylene) sutures for sleeve lobectomy, and the influence of induction chemotherapy on postoperative outcome in patients with lung malignancies. METHODS: A review of a prospective database of a single surgeon identified 41 consecutive patients who underwent sleeve lobectomy from May 1998 to July 2003. Bronchial reconstruction was done placing two 3/0 polypropylene sutures at the far side of the cartilaginous wall and subsequently fixed. Afterwards, two running sutures were performed in order to obtain a telescopic anastomosis. RESULTS: Twenty-four patients (59%) underwent induction chemotherapy. There were 31 right upper, 3 left lower ''reverse'', and 7 left upper sleeve lobectomies with radical lymph node dissection. Eight patients underwent reconstruction of the pulmonary artery. There were 34 non-small cell lung cancers, 3 limited small cell lung cancers, 1 neuroendocrine large cell carcinoma, and 3 bronchial carcinoid tumors. N2, N1, and N0 diseases were found in 13, 12 and 16 patients, respectively. Post-operative morbidity and mortality were 14.5% (n=6) and 4.8% (n=2) (1 patient, 4%, after induction chemotherapy). The rate of postoperative anastomotic complications was 2.4% (n=1). Late bronchial stenosis developed in 3 cases, but all were successfully medically treated. Twenty-nine patients are still alive, 27 without evidence of disease. The overall 2-year probability of survival (Kaplan-Meier) was 59%. Induction chemotherapy did not influence postoperative morbidity/mortality (chi2 test: P=0.64/P=0.56). CONCLUSIONS: Continuous nonabsorbable suture for sleeve lobectomy is quick and technical easy to perform, with low postoperative morbidity/mortality; induction chemotherapy does not influence postoperative outcome in these patients.

Extended redo sleeve resection for postoperative dehiscence after right upper bronchoplasty.

Complete anastomotic dehiscence after sleeve resection is a dramatic and often fatal event requiring an extremely aggressive and risky treatment; completion pneumonectomy represents the sole effective therapeutic option to rescue the patient, but postoperative mortality after this procedure is high. We report a case successfully treated by extended redo carinal sleeve resection after full bronchial dehiscence. This option should be taken into account in such a complication, mainly in patient with compromised respiratory function.

Assessment and Optimisation of Lung Cancer Patients for Treatment with Curative Intent.

Over the past decade the field of lung cancer management has seen many developments. Coupled with an ageing population and increasing rates of comorbid illness, the work-up for treatments with curative intent has become more complex and detailed. As well as improvements in imaging and staging techniques, developments in both surgery and radiotherapy may now allow patients who would previously have been considered unfit or not appropriate for treatment with curative intent to undergo radical therapies. This overview will highlight published studies relating to investigation and staging techniques, together with assessments of fitness, with the aim of helping clinicians to determine the most appropriate treatments for each patient. We also highlight areas where further research may be required.

Methodology for the assessment of lung protection. Human pulmonary artery endothelial cell preservation using haemaccel.

This investigation was designed to show an original methodology for the assessment of lung preservation and to analyze the efficacy of a low potassium polygelin solution (haemaccel [HM]) on isolated human pulmonary artery endothelial cells. The effects of HM were compared with those of low potassium dextran (LPD), Belzer (University of Wisconsin [UWS]), and Euro-Collins solutions. The viability of the endothelial cultures was assessed by means of both total protein content and recovery of metabolic cellular function expressed as the protein synthesis rate after 6 hr and 16 hr of incubation at 10 degrees C. Our results failed to show any significant difference in the total protein content for HM, LPD, and UWS, both after 6 and 16 hr of incubation; however, the Euro-Collins-preserved sample revealed a significant drop in this parameter as early as 6 hr after the start. This finding was regarded as a clear indication of cellular cytotoxicity. In contrast, the metabolism recovery capacity of the cells varied significantly between HM and UWS at 6 hr and among HM, LPD, and UWS at 16 hr; at 6 hr, however, no significant difference was observed between HM and LPD. In conclusion, HM appears to exert a more significant effect on human pulmonary artery endothelial cell metabolism recovery than do the other fluids, thus suggesting its suitability as a long-term pulmonary perfusate.

An effective solution for prolonged preservation of cultured human pulmonary artery endothelial cells.

Pulmonary endothelium is considered the compartment most susceptible to preservation damage. This investigation was designed to analyze the efficacy of an original, University of Parma low-potassium-albumin solution (SPAL UP) on cultured human pulmonary artery endothelial cells (HPAEC) and to compare its effects with those of University of Wisconsin solution (UW) and Euro-Collins solution (EC). Cryopreserved HPAEC tertiary cultures were inoculated at the density of 5000 cells/cm2 in 9-cm2 well-plates; subcultures were then incubated at 10 degrees C for 6 hr and 16 hr in 2 ml/well of SPAL UP, UW, and EC. The HPAEC viability after incubation was assessed by evaluating the total protein content and the expression of cytotoxicity, and by analyzing the rate of protein synthesis and expression of cellular functionality after stress. Results after 6 hr of preservation showed that SPAL UP had a less significant cytotoxic effect than EC, exerted a less depressing effect on cellular metabolism, and enhanced functional recovery of endothelial cells compared with UW. At the second time interval (16 hr), SPAL UP provided a less cytotoxic effect than UW; besides, SPAL UP-induced cytotoxicity was similar to that of warm control. In conclusion, in vitro preliminary data regarding the use of SPAL UP in HPAEC preservation suggest its suitability as solution for prolonged lung protection.

Fluorodeoxyglucose positron emission tomography improves preoperative staging of resectable lung metastasis.

OBJECTIVE: F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) is now a procedure of proven clinical value in the staging of primary lung cancer. This study evaluated the role of PET in the preoperative assessment of resectable lung metastases. METHODS: Eighty-six patients with previously treated malignancy and proven or suspected lung metastases, deemed resectable at computed tomography scan, were investigated with 89 preoperative PET procedures. Primary tumor sites were: gastrointestinal in 32 cases, sarcoma in 13, urologic in 14, breast in 8, head and neck in 7, gynecologic in 5, thymus in 5, other in 5. Seventy lung resections were performed in 68 patients of whom only 54 proved to be lung metastasis, 7 were primary lung tumors, and 9 were benign lesions. RESULTS: In 19 cases (21%) lung surgery was excluded on the basis of PET scan results due to extrapulmonary metastases (11 cases), primary site recurrence (2), mediastinal adenopathy (2), or benign disease (4). All mediastinal node metastases (7 cases) were detected by PET with a sensitivity, accuracy, and negative predictive value for mediastinal staging of 100%, 96%, and 100%, respectively, versus 71%, 92%, and 95% of the computed tomography scan. In the group of patients who underwent lung resection, PET sensitivity for detection of lung metastasis was 87%. CONCLUSIONS: PET scan proved to be a valuable staging procedure in patients with clinically resectable lung metastasis and changed the therapeutic management in a high proportion of cases.

Cisplatin and vinorelbine as second-line chemotherapy in patients with advanced non-small cell lung cancer (NSCLC) resistant to taxol plus gemcitabine.

The aim of the study was to evaluate the activity of cisplatin (CDDP) plus vinorelbine (VNR) in patients with advanced non-small cell lung cancer (NSCLC) progressing after paclitaxel plus gemcitabine. Treatment consisted of CDDP 80 mg/m(2) administered on day 1 and VNR 25 mg/m(2) administered on day 1 and 8, repeated every 3 weeks. Nine patients who relapsed after partial response and eight patients refractory to prior CT received a minimum of two treatment cycles: three patients achieved a PR (18%; 95% CI: 4-43%), four had stable disease and 10 had disease progression. All responses were observed among the nine patients responsive to prior treatment. Median survival was 35 weeks. No patients required dose-reduction, treatment discontinuation or delay because of toxicity. Our results indicate a reasonable antitumor efficacy and no relevant toxicity of a second-line CDDP-based chemotherapy in patients with advanced NSCLC. We recommend the use of this regimen for patients not refractory to primary treatment.

Low morbidity of bronchoplastic procedures after chemotherapy for lung cancer.

OBJECTIVE: To evaluate if induction chemotherapy, with or without irradiation, represents an additional risk factor for early and late morbidity and perioperative mortality in bronchoplastic procedures for lung cancers. METHODS: From January 1998 to January 2001, 27 patients underwent a bronchial sleeve resection after induction treatment at the European Institute of Oncology in Milan. They represent 7% of lung cancer resections (387) and 27% of those performed after neoadjuvant treatment (100 cases). Histology was: 17 epidermoid carcinoma, 8 adenocarcinoma and 2 SCLC. Twenty-four patients (89%) received a preoperative cisplatin based polichemotherapy, and three cases (11%) a chemo-radiation therapy. A right sleeve lobectomy or bilobectomy was undertaken in 21 patients (78%) and a left lobectomy in 6 (22%). A resection of tracheal carina was associated in three cases and a vascular resection in 10 (five vena cava and five pulmonary artery). Twelve patients (44%) received adjuvant mediastinal irradiation. Perioperative morbidity of the study group (group 1) was compared with that of patients submitted to sleeve resection without neoadjuvant treatment (group 2), or standard pneumonectomy after induction treatment (group 3). RESULTS: There were no postoperative deaths. A major perioperative complication occurred in two patients (7%) of group 1, one patient of group 2 (3.5%), and four in group 3 (17%). Among patients of the study group, no anastomotic dehiscence or pleural empyema were observed. Only one late anastomotic stricture occurred after postoperative radiation treatment. No significant difference in early and late complication rate was found between the three groups of patients. High rate of complete resection was achieved (93%) in patients of the study group and extent of nodal dissection was similar between sleeve resections and pneumonectomy patients. CONCLUSIONS: Preoperative chemotherapy or combination of chemo-radio therapy is not associated with an additional risk of anastomotic complications in bronco and angioplastic procedures. Parenchyma sparing resection is a valid option for selected patients with locally advanced lung cancer after induction treatment. A longer follow up is necessary to evaluate efficacy of the procedure in term of survival and local control.

Pneumonectomy for lung metastases: indications, risks, and outcome.

BACKGROUND: Resection of pulmonary metastases (PM) by pneumonectomy is infrequently performed and benefits are uncertain. METHODS: From 1985 to 1995, 42 patients underwent pneumonectomy for PM. Twenty-nine patients had PM from sarcomas, 12 patients from carcinomas, and 1 patient from melanoma. The indications for pneumonectomy were pulmonary recurrences in 12 patients, PM centrally located in 26 patients, and high number of PM in 4 patients. There were 11 intrapericardial and 6 extended pneumonectomies. The average number of PM resected was 3. Twenty-two patients (52%) had lymph nodes involvement. RESULTS: There were 2 postoperative deaths (4.8%) related to pneumonectomy and one death within 30 days for rapidly evolving disease; 4 patients (9.5%) had major postoperative complications that were medically treated. Five patients (12%) were operated on for recurrences on the residual lung. At the completion of the study, 12 patients were still alive, 8 without recurrences. The median survival was 6.5 months (range, 1 to 144 months); the 5-year survival was 16.8%. CONCLUSIONS: Pneumonectomy should not be considered an absolute contraindication in patients with PM, but the poor outcome of our series suggests strict criteria of selection.

GSTM1, P53 and K-ras molecular detection in resectable non-small cell lung cancer by denaturing gradient gel electrophoresis-bronchoalveolar lavage fluid analysis.

BACKGROUND: Understanding molecular abnormalities could potentially lead to novel investigational approaches in the molecular epidemiology of lung cancer. These might include the identification of patients at high risk for primary NSCLC and the surveillance of patients with known NSCLC who are being treated using lung-sparing surgical strategies. MATERIALS AND METHODS: The PCR-Denaturing Gradient Gel Electrophoresis (DGGE) strategy was used for primary tumors and corresponding bronchalveolare lavage (BAL) samples. RESULTS: We recruited 36 consecutive patients with NSCLC, 28 (77.7%) males and 8 females (22.3%). DGGE showed a good rate of accuracy in the genetic screening of K-ras and p53 mutations in BAL specimens. Specific mutations were more often detected in BAL fluid from patients with not peripheral tumors than parenchymal or peripheral tumors (p53: 85.7%, p=0.0004; K-ras: 75%, p=0.001). p53 mutations were more frequent in BAL fluid from squamous cell carcinomas (22%) than from adenocarcinomas (15%). A significant correlation was observed between null GST-Ml genotype and p53 overall mutations (p=0.0003), K-ras mutations (p=0.02), non peripheral tumors (p=0.04) and smoking habits (p=0.002). CONCLUSIONS: We observed that null GSTMl genotype is strongly related to p53 mutations. Individuals at high risk for primary NSCLC, such as heavy smokers or individuals exposed to occupational carcinogens, could be screened by BAL-analysis for cancer biomarkers of susceptibility like GSTM-1 in large scale molecular epidemiology studies.

Double prosthetic replacement of pulmonary artery and superior vena cava and sleeve lobectomy for lung cancer.

We present a case of double prosthetic replacement of the right pulmonary artery and superior vena cava combined with upper sleeve bi-lobectomy for a limited pT4N1 adenocarcinoma occurring in a patient with poor pulmonary reserve, which, to the best of our knowledge, has never been reported before.

Cardiac dislocation after extended pneumonectomy with pericardioplasty.

Two cases of cardiac dislocation occurred after intrapericardial right pneumonectomy with extended pericardiectomy and radical nodal dissection in spite of proper reconstruction with a pericardial fat flap in one case and with a Gore-tex prosthesis in the other. In the case of major pericardial excision resulting in extensive mobilisation of the SVC a complete reconstruction of pericardium and mediastinal pleura is recommended in order to prevent cardiac dislocation.

A standard muscle-sparing utility thoracotomy for VATS procedures.

BACKGROUND: Improvements in surgical equipment have rendered video-assisted thoracic surgery (VATS) an effective device for thoracic surgeons and nowadays several intrathoracic diseases can benefit from this approach. This development has expanded potential use and recently the technical feasibility of major lung resections by VATS has been demonstrated. The authors present their experience with a standard muscle-sparing utility thoracotomy (UT) utilized for all VATS procedures, including major lung resections. METHODS: From November 1996 to October 1997, 30 patients were operated on. There were 22 males and 8 females (medium age 58 years; range 24-78). There were 13 anatomical lung resections (i.e.: 11 lobectomies, 1 left pneumonectomy, 1 segmental resection), 8 wedge resections, 3 lung biopsies, 2 debridements of pleural empyema, 2 mediastinal nodes biopsies, 1 esophageal resection for leiomyoma, 1 excision of benign mediastinal cyst. RESULTS: No mortality or major morbidity were recorded, as well as no rib fractures due to the rib spreader. Two patients suffered from prolonged air-leaks after respectively left upper lobectomy and lung biopsy and required prolonged chest drainage. Concerning anatomic major lung resections the medium hospital stay was 7.9 days and medium chest tube time was 5.6 days. The utility thoracotomy through the auscultatory triangle proved to be a safe approach and confirmed the technical feasibility of various type of surgical procedures with results comparable to standard open thoracotomy. Our data shows that VATS approach did not seriously affect the duration of hospital stay, chest tube time, the overall morbidity or lung function. CONCLUSIONS: As the real benefit of this approach remains controversial, the majority of the studies comparing the VATS approach to conventional muscle-sparing thoracotomy neither nor prospective nor randomized, and several parameters are difficult to evaluate in the literature further study are mandatory.

Unusually located hydatid cysts miming a pulmonary tumor invaliding the spine.

Hydatid disease is a worldwide encountered zoonosis but at present very rare in Europe, liver and lungs being the most frequently involved sites. Bone involvement is very uncommon and the vertebral spine is the most common site of skeletal involvement (less than 1% overall). We report a case of vertebral hydatid disease with secondary pleuro-pulmonary involvement successfully treated by emergency spinal decompression followed by lung resection en bloc with chest wall and partial vertebrectomy.

Postoperative pneumoperitoneum for prolonged air leaks and residual spaces after pulmonary resections.

BACKGROUND: Postoperative air leaks and pleural residual spaces are often encountered during partial lung resections and may adversely affect the immediate outcome prolonging the hospital stay. At present the only treatment consists of maintenance of the chest drainage under suction until resolution of the leaks. METHODS: From January 1995 to December 1997 the authors have operated on and subsequently treated 12 patients presenting prolonged air leaks with residual pleural spaces after lobectomies for lung cancer. The patients underwent respectively: left or right lower lobectomies (n=7), left upper lobectomies (n=3), right upper lobectomies (n=2). In this study the air leak was considered prolonged if it continued and delayed the discharge after surgery beyond the postoperative day 8. The pneumoperitoneum was carried out under local anesthesia. The air was insufflated through a needle inserted just above the umbilical scar as for laparoscopic surgery access up to an amount of about 1200 cc-1300 cc. RESULTS: We have obtained in all cases and without complications an immediate reduction in the air leaks and a complete resolution of the residual pleural spaces. Chest drainages were removed from 3 to 4 days after the procedure. CONCLUSIONS: The good results achieved suggest that this procedure might be considered for selected cases, being a minor procedure, performed under local anesthesia and with minimum discomfort for the patient.

Electromyographic evaluation of the spared serratus anterior after postero-lateral thoracotomy.

Postero-lateral thoracotomy is the standard access in thoracic surgery, and can be carried out dividing or preserving the serratus anterior muscle. This last method, besides its advantages, is still a matter of discussion, in fact traction has been claimed to cause severe muscular damage equal to section. We have studied 20 patients (16 males and 4 females, mean age 63 years), who underwent postero-lateral thoracotomy sparing the serratus anterior, after 6 months from surgery, both clinically and by means of electromyography (EMG), to evaluate the functional status of the spared muscles. In 4 cases (20%) there wasn't any neurogenic damage nor clinical evidence of winging scapula; 3 cases (15%) had medium neurogenic damage. The remaining 13 (65%) cases had a medium neurogenic damage and only one patient showed a winging scapula, neverthless being able to lift the arm to shoulder level. Our data confirmed that retraction during surgery does not damage the serratus anterior, leaving a functionally valid muscle.

Primary pulmonary lymphoma: report of a case diagnosed by transbronchial biopsy.

Primary pulmonary lymphomas are uncommon tumours arising from mucosa associated lymphoid tissue (MALT). The authors report a case diagnosed by transbronchial biopsy and treated by surgery only. They discuss the distinct clinicalpathological features and debate the different ways of treating this condition.