[Lung transplantation: bronchogenic carcinoma in the native lung]. / Trasplante pulmonar. Carcinoma broncogénico en pulmón nativo.

In lung transplantation, the presence of bronchogenic carcinoma in the native organ is uncommon, but doubtless affects patient survival, independently of the transplantation process itself. We describe 2 cases in which a primary tumor was found in the explanted lung--1 case of adenocarcinoma in a patient with pulmonary emphysema and 1 case of bronchioloalveolar carcinoma in a patient with idiopathic pulmonary fibrosis. Both patients died due to the recurrence of the neoplastic disease. Distant metastasis was the initial manifestation of the recurrence.

[Perioperative mortality of lung transplantation in chronic obstructive pulmonary disease]. / Mortalidad perioperatoria del trasplante pulmonar en la enfermedad pulmonar obstructiva crónica.

INTRODUCTION: Lung transplantation (LT) has been considered an alternative therapeutic approach in terminal patients. However, this process in COPD is not controversy-free. This paper aimed to analyze 30-day mortality (PM) patterns and their risk factors in COPD patients undergoing LT. PATIENTS AND METHOD: A retrospective cohort with 107 COPD patients, transplanted at the University La Fe Valencia, Spain, treated from January 1991 to December 2008. Demographics values, degree of dyspnoea, diagnosis, BODE index, single versus bilateral LT, cardio-pulmonary bypass, donor age, steroid dependence, presence of bronchiectasis, retrograde perfusion, transfusion of blood products, and PaO2/FiO2 were analyzed. Continuous variables were expressed as mean±SD and categorical variables as absolute frequency and percentage. A Cox regression model was used for multivariate analysis. RESULTS: Ninety-four men and 13 women of a mean age of 52.58±8.05 years were transplanted. Of all patients, 75% obtained a BODE score above 7. There were 76 bilateral LT. PM was established at 14%. Main causes of death were infection (53.3%) and surgical complications (33.3%). Presence of bronchiectasis and chronic use of corticosteroids, donor/recipient difference in size and presence of fat in retrograde perfusion fluid were important risk factors for PM. Moreover, PaO2/FiO2 ratio at 6h was a protective factor for the event, thus a higher ratio value, lowered the risk of PM. CONCLUSIONS: LT is a procedure with a high PM rate. Use of corticosteroids, the presence of bronchiectasis and fat emboli in the retrograde reperfusion, and PaO2/FiO2 significantly determine PM.

[Mortality in early-stage, surgically resected non-small cell lung cancer less than 3 cm of size: Competing risk analysis]. / Mortalidad en carcinoma pulmonar no microcítico resecado, con tamaño máximo de 3 cm y sin afectación ganglionar: análisis de riesgos competitivos.

BACKGROUND AND OBJECTIVE: Survival studies of non-small cell lung cancer (NSCLC) are usually based on the Kaplan-Meier method. However, other factors not covered by this method may modify the observation of the event of interest. There are models of cumulative incidence (CI), that take into account these competing risks, enabling more accurate survival estimates and evaluation of the risk of death from other causes. We aimed to evaluate these models in resected early-stage NSCLC patients. PATIENTS AND METHOD: This study included 263 patients with resected NSCLC whose diameter was ≤ 3 cm without node involvement (N0). Demographic, clinical, morphopathological and surgical variables, TNM classification and long-term evolution were analysed. To analyse CI, death by another cause was considered to be competitive event. For the univariate analysis, Gray's method was used, while Fine and Gray's method was employed for the multivariate analysis. RESULTS: Mortality by NSCLC was 19.4% at 5 years and 14.3% by another cause. Both curves crossed at 6.3 years, and probability of death by another cause became greater from this point. In multivariate analysis, cancer mortality was conditioned by visceral pleural invasion (VPI) (P=.001) and vascular invasion (P=.020), with age>50 years (P=.034), smoking (P=.009) and the Charlson index ≥ 2 (P=.000) being by no cancer. CONCLUSIONS: By the method of CI, VPI and vascular invasion conditioned cancer death in NSCLC >3 cm, while non-tumor causes of long-term death were determined.

Functional outcomes after lung transplant in chronic obstructive pulmonary disease.

INTRODUCTION: Lung transplantation (LT) is a therapeutic option with controversial results in chronic obstructive pulmonary disease (COPD). We aimed to analyze the outcomes of transplantation in terms of lung function and to identify prognostic factors. METHOD: A retrospective analysis of 107 patients with COPD receiving lung transplants in the La Fe Hospital between 1991 and 2008 was performed. Preoperative variables, pulmonary function tests before and after LT, surgical procedure variables and long-term monitoring, expressed as mean or percentage, as applicable, were analyzed. Spirometric results before and after LT were analyzed. Linear or logistic regression were used for multivariate analysis depending on the variable. RESULTS: Ninety-four men (87.9%) and 13 women (12.1%) were transplanted, with a mean age±standard deviation of 52.58±8.05 years; 71% of LTs were double-lung transplantations. Spirometric values improved after LT: FVC: +1.22L (+34.9%), FEV1: +1.66L (+56.7%) and FEF25-75: +1.85L (+50.8%); P=.001. This functional improvement was maintained after 5 years only in the group with BODE score >7 (P=.001). Recipient height, type of LT, use of extracorporeal circulation during the surgical procedure, presence of bronchiolitis obliterans syndrome and the age and cause of death of the donor significantly influenced lung function over time. CONCLUSIONS: LT improves lung function in COPD patients. This improvement was maintained at 5years only in patients with BODE>7. Double lung transplantation provides better functional results than single-lung transplantation.

Prognostic Factors in Non-Small Cell Lung Cancer Less Than 3 Centimeters: Actuarial Analysis, Accumulative Incidence and Risk Groups.

INTRODUCTION: In TNM classification, factors determining the tumor (T) component in non-small cell lung cancer have scarcely changed over time and are still based solely on anatomical features. Our objective was to study the influence of these and other morphopathological factors on survival. METHODS: A total of 263 patients undergoing lung resection due to stage I non-small cell lung cancer ≤3cm in diameter were studied. A survival analysis and competing-risk estimate study was made on the basis of clinical, surgical and pathological variables using actuarial analysis and accumulative incidence methods, respectively. A risk model was then generated from the results. RESULTS: Survival at 5 and 10 years was 79.8 and 74.3%, respectively. The best prognostic factors were presence of symptoms, smoking habit and FEV1>60%, number of resected nodes>7, squamous histology, absence of vascular invasion, absence of visceral pleural invasion and presence of invasion more proximal than the lobar bronchus. All these were statistically significant according to the actuarial method. The factor "age<50 years" was close to the margin of statistical significance. Pleural invasion and vascular invasion were entered in the multivariate analysis. The competing-risk analysis showed a probability of death due to cancer of 14.3 and 35.1% at 5 and 10 years, respectively. Significant variables in the univariate and multivariate analyses were similar, with the exception of FEV1>60%. CONCLUSIONS: Pleural invasion and vascular invasion determine survival or risk of death due to non-small cell lung cancer ≤3cm and can be used for generating a predictive risk model.

Surgical results of stage I non-small cell lung cancer: comparison between elderly and younger patients.

OBJECTIVE: The aim of this study was to evaluate the overall cancer-related survival in younger and elderly (over 70 years old) patients with stage I non-small cell lung cancer (NSCLC) together with prognostic factors in the elderly. METHODS: The patient records of 797 patients who underwent surgery for stage I NSCLC were analyzed retrospectively. A total of 132 patients were over 70 years old. The clinical variables and overall cancer-related survival were compared between two groups. An analysis was performed to determine the risk factors that influenced the survival of elderly patients. Variables analyzed included sex, presence of symptoms, operative procedure, histopathology, size of tumor and tumor classification. RESULTS: Between the two groups, the nature of the operation performed (pneumonectomy or not) and the presence of symptoms reached statistical significance (P<0.001). Overall 5- and 10-year survival rates were 64.5% and 53.68% in younger patients and 58.23% and 52.24% in the elderly. There was no significant difference in survival between the groups (P=0.35). The only significant prognostic factor in the elderly patients was the size of the tumor in the multivariate analysis (P=0.0442, relative risk 2.28 (1.02-5.10 95% CI)). CONCLUSIONS: Surgical resection for stage I NSCLC in elderly patients over the age of 70 years results in a comparable overall cancer-related survival to that evident in younger patients. The size of the tumor is the only significant factor to influence the survival of elderly patients. Continued careful selection of elderly patients for surgical resection is important for acceptable operative results.

Experience with lung resection in a fast-track surgery program.

INTRODUCTION: This paper intends to assess the influence of a fast-track surgery program on hospital stay and morbidity/mortality in lung resection surgery. PATIENTS AND METHODS: A prospective study including 100 patients who underwent open lung resection due to neoplastic pathologies. The variables analyzed were demographic, clinical, resection type, length of hospital stay and postoperative complications, adjusting these to the classification established according to the treatment required. RESULTS: Seventy-three patients were men, and mean age was 60.8. 82% of the subjects were asymptomatic, 97% had a history of smoking and the majority presented associated comorbidities. The resection types included 7 pneumonectomies, 79 lobectomies, 6 bilobectomies and 8 segmentectomies. Mean hospital stay was 5.4±4.2 days (range: 3-23), varying between 3.4±0.8 days (range: 3-6) and 9.8±5.3 days (range: 4-23) according to the absence or presence of complications. Associated mortality was 2% and morbidity 31%; the most frequent complications were persistent air leak (10%) and atrial fibrillation (6%). 51.5% of the complications were classified within the lower grade complication group, depending on treatment required. Four patients required readmittance after hospital discharge. CONCLUSIONS: Fast-track surgery programs are able to reduce hospitalization times by planning a multidisciplinary strategy of the surgical procedure, in which the patient him/herself participates. It is equally necessary to establish systems to classify postoperative complications that can evaluate the quality of the surgery.

[Lung transplantation in sporadic lymphangioleiomyomatosis: study of 7 cases]. / Trasplante pulmonar en la linfangioleiomiomatosis esporádica. Estudio de 7 casos.

BACKGROUND AND OBJECTIVE: Sporadic lymphangioleiomyomatosis (S-LAM) is a rare disease that affects only women. It is characterized by an abnormal proliferation of immature smooth muscle cells (LAM cells) that grow in an aberrant manner in the airway, parenchymal lung lymph and blood vessels, determining the onset of pulmonary cystic lesions. The disease has no treatment, progressing to respiratory failure, and lung transplantation (LT) may be a treatment option at this stage. Our goal was to study 7 patients undergoing LT for S-LAM. MATERIAL AND METHOD: We studied a series of clinical and demographic characteristics, diagnostic modality and post-transplant outcomes. We performed a descriptive analysis of the series. The Kaplan-Meier method was used to estimate survival. RESULTS: The mean age of onset of symptoms was 35 years, the diagnosis of 37 years and that of LT 38 years. The most common symptom was dyspnea. Four patients had a history of pneumothorax and pleural effusion. The mean forced expiratory volume in one second was 32.7% and the diffusing capacity for carbon monoxide was 29%. All patients were subjected to LT and survival was 100, 85.7 and 57.1% at one, 3 and 5 years, respectively. Three died of bronchiolitis obliterans and 2 necropsies did not show evidence of disease recurrence. CONCLUSIONS: LT is a therapeutic option in patients with S-LAM with an advanced respiratory functional impairment.

[Complications after lung transplantation in chronic obstructive pulmonary disease]. / Complicaciones del trasplante de pulmón en la enfermedad pulmonar obstructiva crónica.

BACKGROUND AND OBJECTIVE: Lung transplantation (LT) in chronic obstructive pulmonary disease (COPD) is a procedure with a high rate of morbimortality. The aim of this paper is to analyze the early and late rates of complications and mortality in COPD patients undergoing LT. PATIENTS AND METHOD: Retrospective study of 107 COPD patients transplanted in the Hospital Universitario La Fe, between 1991 and 2008. Preoperative variables were collected as well as all the complications, medical and surgical, occurred in the follow-up, which are expressed as mean or percentage as appropriate. The 30-day mortality and long term survival were established. RESULTS: A total of 94 men (87.9%) and 13 women (12.1%) were transplanted with a mean age (SD) of 52.58 (8.05) years with 71% of double-lung LT. BODE score was 7.24 (1.28). The rate of primary graft dysfunction was 39.3%. The most common surgical complications were phrenic paralysis (16.8%), hemothorax (17.8%) and pleural effusion (30.8%). There was a high number of postoperative hospitalization (30%) and medical complications such as hypertension (36%), diabetes mellitus (16.7%) and renal failure (40%), secondary to treatment. Perioperative mortality was 14% and 34.5% after a year, being the most frequent causes infections (34.6%) and chronic rejection (BOS) (17.8%). Five-year survival was 40.9% with bronchiectasis and smoking history being the risk factors. CONCLUSIONS: LT is a procedure with a high early mortality rate associated with high medical and surgical complications that affect the outcome.

The Spanish Society of Pulmonology and Thoracic Surgery Lung Cancer Cooperative Group-II registry. A descriptive study.

INTRODUCTION AND OBJECTIVES: The seventh edition of the TNM classification, together with undeniable advantages, has limitations. The International Association for the Study of Lung Cancer (IASLC) Staging Committee has designed an international prospective study to improve this classification. A group of thoracic surgeons and pulmonologists was established in the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) Oncology area, and created a registry of new lung cancer (LC) cases to participate in this project. The aim of this paper is to describe the main characteristics of the patients included. MATERIALS AND METHODS: Prospective, observational, multicentre, multiregional data collection (epidemiological, clinical, therapeutic and, especially, anatomical extension) study, according to the IASLC protocol, to analyse its prognostic value. RESULTS: Two thousand, four hundred and nineteen patients (83.6% men) from 28 hospitals were included. Ninety-six percent of the men and 54% of the women were smokers or ex-smokers. Chest/abdominal computed tomography (CT) scanning was performed in over 90% and positron emission tomography (PET)/CT scanning in 51.5% of cases. Among the 1035 patients who underwent surgery, 77% had early stages (ia to iib), and 61.6% of those treated using other methods had stage iv. Respiratory comorbidity was higher in men (47.9% versus 21.4%). The most common histological subtype was adenocarcinoma (34%), especially in non-smoking women (69.5%). CONCLUSIONS: The proportion of women and adenocarcinomas, as well as those resected at an early stage, increased among LC cases in Spain.

[Sporadic lymphangioleiomyomatosis and pulmonary hypertension. Clinical and pathologic study in patients undergoing lung transplantation]. / Linfangioleiomiomatosis esporádica e hipertensión pulmonar. Estudio clínico-patológico en pacientes receptoras de un trasplante pulmonar.

BACKGROUND AND OBJECTIVE: Lymphangioleiomyomatosis (LAM) is a rare disease characterized by an aberrant immature smooth muscle cells proliferation. This excessive growth of LAM cells around airways, parenchyma, lymphatic ganglia and lung vessels, produces cystic damages. LAM affects mainly women and can lead to pulmonary hypertension (PH). The aim of this research is the clinical study, as well as the analysis of the morphological features, expressing PH, of the native lungs from lung transplant (LT) patients. PATIENTS AND METHODS: Several clinical variables were studied in 7 patients who had a LAM and who were subjected to LT. The variables analyzed using morphologic and immunohistochemistry techniques were: histological alterations in native lungs, their severity rate, the presence of haemosiderosis in the air spaces and correlation index between thickness of the middle layer and the pulmonary arterial vascular diameter, morphological expression of HP. RESULTS: The average age was 34 years old and the predominant symptom was dyspnea. The respiratory functional pattern was mixt, with decrease of DLCO% and KCO%, serious hypoxemia and normocapnia. In the cardiological study, subclinical signs of HP were found. The immunohistochemistry was positive for smooth muscle and melanic expression markers, estrogen receptor in 6 cases and progesterone receptor in 4. Vascular correlation index showed HP criteria at all. CONCLUSIONS: This research shows the presence of clinical and morphological HP criteria in advanced LAM patients. Therefore, cardiological assessment before LT with right catheterization will be justified. Future research should be addressed to clarify whether the HP should be criteria for LT in LAM patients.

Lymphangioleiomyomatosis.

Lymphangioleiomyomatosis (LAM) is a rare disease that mainly affects women, particularly at fertile age. It is sporadic or associated with tuberous sclerosis complex. It is characterised by an abnormal proliferation of immature smooth muscle cells (SMC), which grow aberrantly in the airway, parenchyma, lymphatics and pulmonary blood vessels and which can gradually lead to respiratory failure. It affects several systems, affecting the lymphatic ganglia and causing abdominal tumours. Given its very low prevalence, a difficult to establish early diagnosis, absence of curative treatment and the difficulty in obtaining information, places LAM under the heading of the so-called Rare Diseases. There is a growing interest in the study of this disease which has led to the setting up of patient registers and an exponential growth in LAM research, both at a clinical level and cellular level.

Factores pronóstico en el carcinoma bronquial no microcítico menor de 3 centímetros (análisis actuarial, incidencia acumulativa y grupos de riesgo) / Prognostic factors in non-small cell lung cancer less than 3 centimeters: actuarial analysis, accumulative incidence and risk groups

Introducción: En la clasificación TNM, los factores determinantes del factor T en el carcinoma pulmonar no microcítico apenas han variado con el tiempo y todavía se basan únicamente en características anatómicas. Nuestro objetivo fue estudiar la influencia en la supervivencia de estos y otros factores de tipo morfopatológico. Métodos: Se incluyeron 263 pacientes sometidos a resección pulmonar por carcinoma pulmonar no microcítico en estadio I patológico y diámetro ≤ 3 cm. Se realizó un estudio de supervivencia y de estimación del riesgo competitivo observando variables clínicas, quirúrgicas y patológicas, siguiendo los métodos de análisis actuarial y de incidencia acumulativa, respectivamente. Posteriormente, se creó un modelo de riesgo de acuerdo con los resultados. Resultados: La supervivencia fue de 79,8 y 74,3% a los 5 y 10 años, respectivamente. Los factores con mejor pronóstico, estadísticamente significativo según el método actuarial fueron: presencia de síntomas, hábito tabáquico, FEV1 > 60%, número de ganglios resecados > 7, tipo histológico escamoso, ausencia de invasión vascular, ausencia de invasión pleural visceral y presencia de invasión bronquial lobar proximal. La edad < 50 años rozó la significación estadística. En el análisis multivariante entraron en regresión la invasión pleural visceral y la invasión vascular. El estudio de riesgo competitivo mostró una probabilidad de muerte por cáncer de 14,3 y 35,1% en 5 y 10 años, respectivamente. Las variables significativas en los análisis univariante y multivariante fueron similares excepto el FEV1 > 60%. Conclusiones: La presencia de invasión pleural visceral y la invasión vascular determina la supervivencia o el riesgo de muerte por carcinoma pulmonar no microcítico ≤ 3 cm y permiten elaborar un modelo predictivo de riesgo

Introduction: In TNM classification, factors determining the tumor (T) component in non-small cell lung cancer have scarcely changed over time and are still based solely on anatomical features. Our objective was to study the influence of these and other morphopathological factors on survival. Methods: A total of 263 patients undergoing lung resection due to stage I non-small cell lung cancer ≤ 3 cm in diameter were studied. A survival analysis and competing-risk estimate study was made on the basis of clinical, surgical and pathological variables using actuarial analysis and accumulative incidence methods, respectively. A risk model was then generated from the results Results: Survival at 5 and 10 years was 79.8 and 74.3%, respectively. The best prognostic factors were presence of symptoms, smoking habit and FEV1 > 60%, number of resected nodes > 7, squamous histology, absence of vascular invasion, absence of visceral pleural invasion and presence of invasion more proximal than the lobar bronchus. All these were statistically significant according to the actuarial method. The factor 'age < 50 years' was close to the margin of statistical significance. Pleural invasion and vascular invasion were entered in the multivariate analysis. The competing-risk analysis showed a probability of death due to cancer of 14.3 and 35.1% at 5 and 10 years, respectively. Significant variables in the univariate and multivariate analyses were similar, with the exception of FEV1 > 60%. Conclusions: Pleural invasion and vascular invasion determine survival or risk of death due to non-small cell lung cancer ≤ 3 cm and can be used for generating a predictive risk model

Resultados funcionales del trasplante pulmonar en la enfermedad pulmonar obstructiva crónica / Functional Outcomes After Lung Transplant in Chronic Obstructive Pulmonary Disease

Introducción: El trasplante pulmonar (TP) es una opción terapéutica con resultados controvertidos en la enfermedad pulmonar obstructiva crónica (EPOC). Nuestro objetivo es analizar los resultados del trasplante en términos de función pulmonar, así como identificar los factores pronósticos. Método: Se realizó un análisis retrospectivo de 107 pacientes con EPOC trasplantados en el Hospital Universitario La Fe entre 1991 y 2008. Se analizaron variables preoperatorias, estudio funcional pre y post-TP, variables del procedimiento quirúrgico y del seguimiento a largo plazo, expresadas en media o porcentaje según el caso, comparándose los resultados espirométricos antes y después del TP. Para el análisis multivariante se utilizó regresión lineal o logística según la variable. Resultados: Fueron trasplantados 94 hombres (87,9%) y 13 mujeres (12,1%), con una edad media ± desviación estándar de 52,58 ± 8,05 años; el 71% de TP fueron bipulmonares. Los valores espirométricos mejoraron tras el TP: FVC: +1,22 l (+34,9%), FEV1: +1,66 l (+56,7%) y FEF25-75: +1,85 l (+50,8%); p = 0,001, manteniéndose esta mejoría funcional tras 5 años solo en el grupo con puntuación BODE > 7 (p = 0,001). La talla del receptor, el tipo de TP, la utilización de circulación extracorpórea durante el procedimiento quirúrgico, la presencia de síndrome de bronquiolitis obliterante junto con la edad y la causa de muerte del donante influyeron significativamente en la función pulmonar a largo plazo. Conclusiones: El TP mejora la función pulmonar de los pacientes con EPOC. Esta mejoría se mantiene a los 5 años solo en los pacientes con BODE mayor de 7. El trasplante bipulmonar proporciona mejores resultados funcionales que el unipulmonar

Introduction: Lung transplantation (LT) is a therapeutic option with controversial results in chronic obstructive pulmonary disease (COPD). We aimed to analyze the outcomes of transplantation in terms of lung function and to identify prognostic factors. Method: A retrospective analysis of 107 patients with COPD receiving lung transplants in the La Fe Hospital between 1991 and 2008 was performed. Preoperative variables, pulmonary function tests before and after LT, surgical procedure variables and long-term monitoring, expressed as mean or percentage, as applicable, were analyzed. Spirometric results before and after LT were analyzed. Linear or logistic regression were used for multivariate analysis depending on the variable. Results: Ninety-four men (87.9%) and 13 women (12.1%) were transplanted, with a mean age ± standard deviation of 52.58 ± 8.05 years; 71% of LTs were double-lung transplantations. Spirometric values improved after LT: FVC: +1.22 L (+34.9%), FEV1: +1.66 L (+56.7%) and FEF25-75: +1.85 L (+50.8%); P = .001. This functional improvement was maintained after 5 years only in the group with BODE score > 7 (P = .001). Recipient height, type of LT, use of extracorporeal circulation during the surgical procedure, presence of bronchiolitis obliterans syndrome and the age and cause of death of the donor significantly influenced lung function over time. Conclusions: LT improves lung function in COPD patients. This improvement was maintained at 5 years only in patients with BODE > 7. Double lung transplantation provides better functional results than single-lung transplantation

Mortalidad perioperatoria del trasplante pulmonar en la enfermedad pulmonar obstructiva crónica / Perioperative mortality of lung transplantation in chronic obstructive pulmonary disease

Introducción: El trasplante pulmonar (TP) es una alternativa terapéutica en pacientes con EPOC en fase terminal. Nuestro objetivo es analizar la mortalidad perioperatoria (30 días) (MP) y los factores de riesgo que la condicionan en pacientes con EPOC sometidos a TP. Pacientes y método: Cohorte retrospectiva de 107 pacientes con EPOC trasplantados en el Hospital Universitario La Fe (1991-2008). Los datos demográficos, el grado de disnea, el diagnóstico, el índice BODE, el tipo de trasplante, la circulación extracorpórea, la edad del donante, la dependencia de glucocorticoides, la presencia de bronquiectasias, la reperfusión retrógrada, la transfusión de hemoderivados y la relación PaO2/FiO2 fueron analizadas. Las variables continuas se expresaron como media ± DE y las categóricas, con frecuencias absolutas y porcentajes. El análisis multivariante se realizó mediante el modelo de regresión de Cox. Resultados: Se trasplantaron 94 hombres y 13 mujeres con una edad media de 52,58 ± 8,05 años. El 75% de los pacientes tuvieron un BODE ≥ 7. Se realizaron 76 procedimientos bipulmonares. La MP fue del 14%. Las causas de muerte fueron las infecciones (53,3%) y las complicaciones quirúrgicas (33,3%). La presencia de bronquiectasias, el uso de glucocorticoides, la diferencia de talla entre receptor/donante y la presencia de émbolos grasos en la reperfusión retrógrada fueron factores de riesgo para la MP. La relación de PaO2/FiO2 a las 6 h fue un factor protector para la MP. Conclusiones: El TP es un procedimiento con una elevada tasa de MP. El uso previo de glucocorticoides, la presencia de bronquiectasias y de émbolos grasos en la reperfusión retrógrada, así como la PaO2/FiO2condicionaron la MP (AU)

Introduction: Lung transplantation (LT) has been considered an alternative therapeutic approach in terminal patients. However, this process in COPD is not controversy-free. This paper aimed to analyze 30-day mortality (PM) patterns and their risk factors in COPD patients undergoing LT. Patients and method: A retrospective cohort with 107 COPD patients, transplanted at the University La Fe Valencia, Spain, treated from January 1991 to December 2008. Demographics values, degree of dyspnoea, diagnosis, BODE index, single versus bilateral LT, cardio-pulmonary bypass, donor age, steroid dependence, presence of bronchiectasis, retrograde perfusion, transfusion of blood products, and PaO2/FiO2 were analyzed. Continuous variables were expressed as mean ± SD and categorical variables as absolute frequency and percentage. A Cox regression model was used for multivariate analysis. Results: Ninety-four men and 13 women of a mean age of 52.58 ± 8.05 years were transplanted. Of all patients, 75% obtained a BODE score above 7. There were 76 bilateral LT. PM was established at 14%. Main causes of death were infection (53.3%) and surgical complications (33.3%). Presence of bronchiectasis and chronic use of corticosteroids, donor/recipient difference in size and presence of fat in retrograde perfusion fluid were important risk factors for PM. Moreover, PaO2/FiO2 ratio at 6 h was a protective factor for the event, thus a higher ratio value, lowered the risk of PM. Conclusions: LT is a procedure with a high PM rate. Use of corticosteroids, the presence of bronchiectasis and fat emboli in the retrograde reperfusion, and PaO2/FiO2 significantly determine PM (AU)

Mortalidad en carcinoma pulmonar no microcítico resecado, con tamaño máximo de 3 cm y sin afectación ganglionar: análisis de riesgos competitivos / Mortality in early-stage, surgically resected non-small cell lung cancer less than 3 cm of size: Competing risk analysis

Fundamentos y objetivo: Los estudios de supervivencia en el carcinoma pulmonar no microcítico (CPNM) se basan, habitualmente, en el método de Kaplan-Meier. Sin embargo, otros factores, no contemplados por este método, pueden modificar la observación del suceso de interés. Existen modelos de incidencia acumulativa (IA) que, teniendo en cuenta estos riesgos competitivos, permiten estimaciones más precisas de la supervivencia y valorar el riesgo de muerte por otras causas. Nuestro objetivo es evaluar dichos modelos en pacientes operados de CPNM en estadio precoz. Pacientes y método: Estudio de 263 pacientes resecados de un CPNM con un diámetro ≤ 3 cm y sin afectación ganglionar (N0). Se analizaron variables demográfico-clínicas, morfopatológicas, quirúrgicas, clasificación TNM y evolución a largo plazo. Para el análisis de la IA se consideró suceso competitivo la mortalidad por otra causa. Para el análisis univariante se utilizó el método de Gray, y para el multivariante, el de Fine y Gray. Resultados: La mortalidad por CPNM fue del 19,4% a los 5 años y del 14,3% por otra causa. Ambas curvas se cruzaron a los 6,3 años, siendo la probabilidad de muerte por otra causa mayor a partir de este punto. En el análisis multivariante, condicionaron la mortalidad por cáncer la invasión pleural visceral (IPV) (p = 0,001) y la vascular (p = 0,020), mientras que para la mortalidad por otra causa diferente del cáncer lo fueron la edad > 50 años (p = 0,034), el tabaquismo (p = 0,009) y el índice de Charlson ≥ 2 (p = 0,000). Conclusiones: Mediante el método de IA, la IPV y la invasión vascular condicionaron la muerte por cáncer en CPNM > 3 cm y se determinaron cuáles fueron las causas no tumorales de muerte a largo plazo (AU)

Background and objective: Survival studies of non-small cell lung cancer (NSCLC) are usually based on the Kaplan-Meier method. However, other factors not covered by this method may modify the observation of the event of interest. There are models of cumulative incidence (CI), that take into account these competing risks, enabling more accurate survival estimates and evaluation of the risk of death from other causes. We aimed to evaluate these models in resected early-stage NSCLC patients. Patients and method: This study included 263 patients with resected NSCLC whose diameter was ≤ 3 cm without node involvement (N0). Demographic, clinical, morphopathological and surgical variables, TNM classification and long-term evolution were analysed. To analyse CI, death by another cause was considered to be competitive event. For the univariate analysis, Gray's method was used, while Fine and Gray's method was employed for the multivariate analysis. Results: Mortality by NSCLC was 19.4% at 5 years and 14.3% by another cause. Both curves crossed at 6.3 years, and probability of death by another cause became greater from this point. In multivariate analysis, cancer mortality was conditioned by visceral pleural invasion (VPI) (P = .001) and vascular invasion (P = .020), with age > 50 years (P = .034), smoking (P = .009) and the Charlson index ≥ 2 (P = .000) being by no cancer. Conclusions: By the method of CI, VPI and vascular invasion conditioned cancer death in NSCLC > 3 cm, while non-tumor causes of long-term death were determined (AU)

Experiencia de un programa de fast-track surgery en resección pulmonar / Experience With Lung Resection in a Fast-Track Surgery Program

Introducción: Este trabajo pretende evaluar la influencia de un programa de fast-track surgery en la estancia hospitalaria y en la morbimortalidad en cirugía de resección pulmonar. Pacientes y métodos Estudio prospectivo de 100 pacientes sometidos a resección pulmonar abierta por afección neoplásica. Se analizaron las variables demográficas y las clínicas, el tipo de resección, la estancia hospitalaria y las complicaciones postoperatorias, ajustándolas a la clasificación establecida en función del tratamiento requerido. Resultados: Setenta y tres pacientes fueron hombres y la media de edad de 60,8 años. El 82% fueron asintomáticos y el 97% tenía historia de tabaquismo. La mayoría presentó comorbilidad asociada y se realizaron 7 neumonectomías, 79 lobectomías, 6 bilobectomías y 8 segmentectomías. La estancia media fue de 5,4±4,2 días (rango, 3-23), variando entre 3,4±0,8 días (rango, 3-6) y de 9,8±5,3 días (rango, 4-23) en función de la ausencia o presencia de complicaciones. La mortalidad asociada fue del 2% y la morbilidad del 31%, siendo las complicaciones más frecuentes la fuga aérea persistente (10%) y la fibrilación auricular (6%). El 51,5% de las complicaciones se clasificaron dentro del grupo de complicaciones de menor grado en función del tratamiento requerido. Cuatro pacientes requirieron reingreso tras el alta hospitalaria. Conclusiones: Los programas de fast-track surgery permiten conseguir una reducción de los tiempos de estancia hospitalaria al planificar una estrategia multidisciplinar del procedimiento quirúrgico, en el que toma parte activa el propio paciente. Igualmente, se hace necesario establecer sistemas de clasificación de las complicaciones postoperatorias que puedan evaluar la calidad de la cirugía(AU)

Introduction: This paper intends to assess the influence of a fast-track surgery program on hospital stay and morbidity/mortality in lung resection surgery. Patients and methods A prospective study was conducted including 100 patients who underwent open lung resection due to neoplastic pathologies. The variables analyzed were demographic, clinical, resection type, length of hospital stay, and postoperative complications, adjusting these to the classification established according to the treatment required. Results: Seventy-three patients were men, and mean age was 60.8. 82% of the subjects were asymptomatic, 97% had a history of smoking and the majority presented associated comorbidities. The resection types included 7 pneumonectomies, 79 lobectomies, 6 bilobectomies, and 8 segmentectomies. Mean hospital stay was 5.4±4.2 days (range, 3–23), varying between 3.4±0.8 days (range, 3–6) and 9.8±5.3 days (range, 4–23) according to the absence or presence of complications. Associated mortality was 2% and morbidity 31%; the most frequent complications were persistent air leak (10%) and atrial fibrillation (6%). 51.5% of the complications were classified within the lower grade complication group, depending on treatment required. Four patients required readmittance after hospital discharge. Conclusions: Fast-track surgery programs are able to reduce hospitalization times by planning a multidisciplinary strategy of the surgical procedure, in which the patient him/herself participates. It is equally necessary to establish systems to classify postoperative complications that can evaluate the quality of the surgery(AU)

Necrosis grasa pericárdica asintomática / Asymptomatic pericardial fat necrosis

La necrosis grasa pericárdica es una entidad poco frecuente, benigna y de causa desconocida. Se suele presentar como un dolor torácico agudo, de características pleuríticas, en personas previamente sanas. Radiológicamente se asocia con un aumento de densidad de localización anterior, a nivel paracardíaco, de contornos bien definidos, en la radiografía de tórax posteroanterior. Con carácter excepcional, constituye un hallazgo incidental. El objetivo de esta nota clínica es presentar un caso de necrosis grasa pericárdica en un varón de 38 años asintomático, hallado intraoperatoriamente durante la resección de un carcinoma pulmonar(AU)

Pericardial fat necrosis is an uncommon benign condition of unknown cause. It presents as acute pleuritic chest pain in previously healthy persons associated with a well-defined anterior paracardiac density on posteroanterior chest radiography. Exceptionally, it constitutes an incidental finding. The objective of this study is to report a clinical case of pericardial fat necrosis in an asymptomatic 38-year-old man, found intraoperatively during a lung carcinoma resection(AU)

Trasplante pulmonar en la linfangioleiomiomatosis esporádica. Estudio de 7 casos / Lung transplantation in sporadic lymphangioleiomyomatosis: Study of 7 cases

Fundamentos y objetivo: La sporadic lymphangioleiomyomatosis (S-LAM, «linfangioleiomiomatosis esporádica») es una enfermedad rara que afecta a la mujer. Se caracteriza por una proliferación anormal de células musculares lisas inmaduras, células LAM, que crecen de una manera aberrante en el pulmón. La enfermedad no tiene tratamiento, evolucionando hacia la insuficiencia respiratoria. El trasplante pulmonar (TP) puede ser una opción terapéutica en este estadio. Nuestro objetivo es el estudio de 7 pacientes sometidas a TP por S-LAM. Material y método: Se estudiaron las características clinicodemográficas, de diagnóstico, y los resultados. Se realizó un análisis descriptivo y se estimó la supervivencia mediante el método de Kaplan-Meier. Resultados: La edad media de aparición de los síntomas, diagnóstico y TP fue de 35, 37 y 38 años, respectivamente. El síntoma más frecuente fue la disnea. La media del volumen espiratorio forzado en el primer segundo fue del 32,7%, y la de difusión del monóxido de carbono, del 29%. La supervivencia fue del 100, 85,7 y 57,1% a uno, 3 y 5 años, respectivamente. Tres pacientes fallecieron por bronquiolitis obliterante y en 2 necropsias realizadas no se observó recidiva de la enfermedad. Conclusiones: El TP es una opción terapéutica en pacientes con S-LAM en insuficiencia respiratoria avanzada (AU)

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