Surgical Strategy and Clinical Outcome in Patients with Bronchial Carcinoids.

Carcinoids are malignant neuroendocrine neoplasms showing good long-term survival after oncologic therapy. The study evaluated the influence of operative strategies and individual decision-making on the outcome and long-term survival in 222 patients with bronchial carcinoids. The patients underwent preoperative pulmonary function tests and bronchoscopy to facilitate surgical decision-making. A hundred and twelve tumors were detected endoscopically, including 32 in the main and lobar bronchi. We performed 5 isolated bronchus resections, 4 segmentectomies, 15 wedge resections, 10 pneumonectomies, 19 sleeve resections, 26 bilobectomies, 138 lobectomies, and 2 chest wall resections. Three patients were technically inoperable. Systematic mediastinal lymphadenectomy was routinely performed although most patients' computer tomography scans showed N0. A hundred and sixty-two patients had typical (155 N0, 7 N+) and 60 patients had atypical carcinoids (39 N0, 21 N+). There was no intraoperative mortality. The hospital mortality was below 2%. Overall, 1-, 5-, and 10-year survival rates were 99%, 94%, and 89%, respectively, in typical carcinoids. Atypical carcinoids show similar 1- and 5-year survival rates, but the 10-year survival rate was below 70%, decreasing in higher N-stages. The N-stage was the most important survival factor. In conclusion, bronchial carcinoids should be surgically treated the way lung cancer is. Anatomic resection and systematic lymphadenectomy are the treatments of choice. The availability of bronchoplastic techniques and preoperative assessment is essential for individual decision-making, focusing predominantly on postoperative quality of life.

Pulmonary metastasetomy for osteosarcoma: is it justified?

UNLABELLED: Lung metastases are found in up to 30% of patients with osteosarcoma. Survival rates up to 45% are possible in interdisciplinary concepts, i.e. studies with aggressive surgical approach and (neo-) adjuvant chemotherapy. To elucidate these concepts concerning pulmonary metastasectomy, existing studies are reviewed and our own results are presented. METHODS: Studies with the main topic in pulmonary metastases in osteosarcoma were reviewed. They overlook a period of 70 years and a total of more than 10,000 osteosarcoma patients and about 1,800 patients with pulmonary metastases. Studies have been reviewed concerning surgical concepts, prognostic factors and survival outcome. Our own results in 85 patients operated on for pulmonary metastases in 164 operations are presented and surgical procedures, prognostic factors and outcome are discussed. RESULTS: About 1,800 patients with pulmonary metastases are presented in the reviewed studies from 1939 to 2007. There is a surprising consistency concerning surgical techniques, historically changing with the introduction of stapling machines and laser surgery. Survival rates between 30% and 40% also show a certain consistency in interdisciplinary studies, with a range from 11% to 63% in all studies. The main prognostic factor affecting survival is complete surgical remission (CSR). It shows high significance particularly in studies with large numbers of patients. Time of metastatic presentation, and number and localization of metastases show significance more infrequently. Our own series focusses on overall survival rate (48%) and the importance of CSR as a prognostic factor (p < .001). CONCLUSION: Pulmonary metastasectomy is mandatory for long-term survival in patients with pulmonary metastases in osteosarcoma. This does not depend on the metastatic stage or the number of operations needed to achieve CSR, which is the main prognostic factor for survival. Bilateral surgery is necessary in most patients; minimally invasive techniques should not be used routinely.

Diagnostics and staging procedures in non-small cell lung cancer - is less more?

INTRODUCTION: Non-small cell lung cancer (NSCLC) is a common cancer with approximately 85% of patients dying of the disease. The only chance for cure is in the early stages, when surgery or definite chemoradiotherapy can be performed. Diagnosis and staging of lung cancer can sometimes be difficult, particularly because the intrathoracic structures are not easy to reach. OBJECTIVE: This review discusses the diagnosis and staging of lung cancer. RESULTS: When performing lung cancer diagnostics, both invasive and noninvasive procedures, such as computed tomogram of the chest, bronchoscopy and abdominal ultrasound, are mandatory. Suspected mediastinal involvement should be differentiated: bulky disease, contralateral or high mediastinal nodes need further clarification by endoscopic ultrasound, endobronchial ultrasound or mediastinoscopy. In opposition to current guidelines, in all other cases, surgery should be performed. Positron emission tomography will gain even more importance when becoming widely accessible and might replace other imaging techniques in the future. In case of advanced disease, staging should be limited to those examinations with impact on symptom control. CONCLUSION: The diagnosis and staging of lung cancer should involve both invasive and noninvasive diagnostic procedures. In the case of advanced disease, staging should be limited to those examinations with impact on symptom control, whereas early stages call for rapid and thorough diagnosis.

Pyothorax-associated lymphoma (PAL): report and review of a rare entity.

Pyothorax-associated lymphoma (PAL) is a rare haematological malignancy often associated with artificial pneumothorax due to the treatment of pulmonary tuberculosis. A 76 year old man with chronic tube-drained pyothorax and a history of artificial pneumothorax for pulmonary tuberculosis was admitted to our hospital because of progressive right thoracic pain, weight loss, and pyrexia. After clinical examination and imaging processes a chest wall tumour anterior on the right side was diagnosed as well as a persisting pyothorax. Surgery was performed to resect the tumour and drain the pleural cavity. A diagnosis of a high grade B-cell lymphoma was established after histological examination of the surgical biopsy. Epstein-Barr virus (EBV) was identified in the tumour by immunocytochemical and molecular methods. Additional gastric involvement of B-cell lymphoma could be diagnosed by gastroscopy because of postoperative gastrointestinal bleeding. The patient received chemotherapy with 2 courses of cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP). The response was favourable initially, but 2 months later the patient died because of lymphoma progression.Most cases of PAL have been described by Japanese investigators and only a few cases are reported in Western countries. To the best of our knowledge this case of PAL is the first to be documented in Germany.Awareness of this rare entity, together with diligent histological examination, in patients with chronic pyothorax are essential for a correct diagnosis and correct early treatment.