Pectus excavatum. Surgical treatment: Structural or aesthetic?

INTRODUCTION: Pectus excavatum is a wall deformity that often warrants medical evaluation. In most cases, it's a purely visual aesthetic alteration, while in others, it comes with symptoms. Several surgical techniques have been described, but their outcomes are difficult to assess due to the heterogeneity of presentations and the lack of long-term follow-up. We present our experience as thoracic surgeons, assessing correction as either structural (remodeling of the thoracic cage through open surgery) or aesthetic (design and implantation of a customized 3D prosthesis). MATERIAL AND METHODS: Retrospective observational study of the indication for surgical treatment of pectus excavatum carried out by a team of thoracic surgeons and the short- to mid-term results. RESULTS: Between 2021 and 2023, we treated 36 cases surgically, either through thoracic cage remodeling techniques or with 3D prostheses. There were few minor complications, and the short- to mid-term results were positive: alleviation of symptoms or compression of structures when present, or aesthetic correction of the defect in other cases. CONCLUSIONS: Surgery for pectus excavatum should be evaluated for structural correction of the wall or aesthetics. In the former, thoracic cage remodeling requiring cartilage excision and possibly osteotomies is necessary. In the latter, the defect is corrected with a customized 3D prosthesis.

CXCR7 Reactivates ERK Signaling to Promote Resistance to EGFR Kinase Inhibitors in NSCLC.

Although EGFR mutant-selective tyrosine kinase inhibitors (TKI) are clinically effective, acquired resistance can occur by reactivating ERK. We show using in vitro models of acquired EGFR TKI resistance with a mesenchymal phenotype that CXCR7, an atypical G protein-coupled receptor, activates the MAPK-ERK pathway via ß-arrestin. Depletion of CXCR7 inhibited the MAPK pathway, significantly attenuated EGFR TKI resistance, and resulted in mesenchymal-to-epithelial transition. CXCR7 overexpression was essential in reactivation of ERK1/2 for the generation of EGFR TKI-resistant persister cells. Many patients with non-small cell lung cancer (NSCLC) harboring an EGFR kinase domain mutation, who progressed on EGFR inhibitors, demonstrated increased CXCR7 expression. These data suggest that CXCR7 inhibition could considerably delay and prevent the emergence of acquired EGFR TKI resistance in EGFR-mutant NSCLC. SIGNIFICANCE: Increased expression of the chemokine receptor CXCR7 constitutes a mechanism of resistance to EGFR TKI in patients with non-small cell lung cancer through reactivation of ERK signaling.

Video-Assisted Thoracic Surgical Repair of the Airway.

We communicate the first reported application of video-assisted thoracic surgery for early repair of a postintubation tracheal laceration. The patient was a 60-year-old man. After an initial unsuccessful approach with conservative measures, surgical repair was indicated. The patient underwent 2-port video-assisted thoracic surgery for direct tracheal repair using a 3-0 resorbable monofilament running suture and two reinforcing X-stitches. Bronchoscopic control after 2 and 4 weeks showed complete restoration of the airway, with no complication.

Clinical Significance of Molecular Micrometastasis in the Sentinel Lymph Node of Early-stage Non-Small Cell Lung Cancer Patients.

OBJECTIVES: Metastatic affectation of lymph node is the main prognostic factor in localized lung cancer. A pathologic study of the obtained samples, even after adequate lymphadenectomy, showed tumor relapses for 20% of stage I patients after oncological curative surgery. We evaluated the prognostic value of molecular micrometastasis in the sentinel lymph node of patients with early-stage lung cancer. PATIENTS AND METHODS: The sentinel node was marked immediately after performing thoracotomy by peritumorally injecting 0.25 mCi of nanocoloid of albumin (Nanocol1) labeled with Tc-99m in 0.3 mL. Guided by a Navigator1 gammagraphic sensor, we proceeded to its resection. The RNA of the tissue was extracted, and the presence of genes CEACAM5, BPIFA1, and CK7 in mRNA was studied. The significant association between the presence of micrometastasis, clinicopathologic characteristics, and patients' outcome was assessed. RESULTS: Eighty-nine stage I-II non-small cell lung cancer patients were included in the study. Of the 89 analyzed sentinel lymph nodes, 44 (49.4%) were positive for CK7, 24 (26.9%) for CEACAM5, and 17 (19.1%) for BPIFA1, whereas 10 (11.2%) were positive for the 3 analyzed genes. A survival analysis showed no significant relation between the presence of molecular micrometastasis in the sentinel node and patients' progression. CONCLUSIONS: The molecular analysis of the sentinel node in patients with early-stage lung cancer shows node affectation in cases staged as stage I/II by hematoxylin-eosin or an immunohistochemical analysis. However, this nodal affectation was not apparently related to patients' outcome.

Características clinicopatológicas de pacientes con cáncer de pulmón no microcítico con mutaciones en el gen del receptor del factor de crecimiento epidérmico en el Área de Salud de La Ribera (Comunidad Valenciana) / Clinicopathological characteristics of non-small cell lung cancer patients with mutations in epidermal growth factor receptor gene in the Health Area of La Ribera (Comunidad Valenciana)

Actualmente los pacientes que presentan cáncer de pulmón no microcítico (CPNM) portadores de mutaciones en el gen receptor del factor de crecimiento epidérmico (EGFR) pueden recibir un tratamiento específico a partir de la detección de dicha mutación en el tejido tumoral, pues estas mutaciones se consideran un factor predictivo de eficacia al tratamiento con inhibidores de la tirosina quinasa (ITK) de EGFR (ITK-EGFR). En el presente trabajo analizamos qué características clinicopatológicas presentan mayoritariamente los pacientes con CPNM EGFR mutado en el Área de Salud de La Ribera (Comunidad Valenciana) entre marzo de 2012 y noviembre de 2014. Nuestros datos muestran una predominancia del género femenino (70%), de pacientes no fumadores (60%), mayores de 65 años (65%) y en estadio avanzado de la enfermedad (75%). Las mutaciones predominantes son la deleción en el exón 19 y la mutación L858R en el exón 21 del gen EGFR (AU)

Currently, patients suffering from non-small cell lung cancer (NSCLC) with mutations in EGFR gene (epidermal growing factor receptor) can benefit from specific treatment based on the detection of these mutations in the tumour tissue. Mutated EGFR is considered as a positive predictor factor of efficacy for EGFR tyrosine kinase inhibitor (ITK) treatment. In the present study we analyzed the predominant clinicopathological characteristics from NSCLC patients with EGFR mutations in the Health Area of La Ribera (Comunidad Valenciana, Spain) between March 2012 and November 2014. Our data show a predominance of females (70%), non-smokers (60%), and patients older than 65 (65%) and in an advanced stage of the disease (75%). Predominant detected mutations are deletion in exon 19 and L858R mutation in exon 21 in EGFR gene (AU)

[Sentinel lymph node in pulmonary carcinoma. Molecular study after radioisotope detection]. / El ganglio centinela en el carcinoma pulmonar. Estudio molecular tras detección con radioisótopo.

INTRODUCTION: Metastatic lymph node affectation is the main prognostic factor in localized lung cancer. Pathological study of the obtained samples even after an adequate lymphadenectomy, present tumoral relapses of 40% of stage I patients after oncological curative surgery. In this paper we have studied micrometastasis in the sentinel lymph node by molecular methods in patients with stage I lung cancer. MATERIAL AND METHODS: The sentinel node was marked by injecting peritumorally performed just after performing the thoracotomy with 2 mCi of nanocoloid of albumin (Nanocol®) marked with 99mTc in 0.3 ml. Guided with a Navigator® gammagraphic sensor, we proceeded to its resection. RNA of the tissue was extracted and the presence of genes CEACAM5, PLUNC and CK7 in mRNA was studied. RESULTS: Twenty nine 29 patients were included. Of the tested genes, CEACAM5 and PLUNC were the ones that showed a high expression in lung tissue. Of the 29 analyzed sentinel lymph nodes, 7 (24%) were positive in the molecular study. A positive sentinel lymph node was found in 4/7 adenocarcinomas and 3/12 squamous-cell tumors. Affected lymph nodes were: station 5 (1/3), station 7 (0/6), station 9 (0/1); station 10 (5/11); station 11 (1/1). CONCLUSIONS: Detection of sentinel node in patients with stage I lung cancer by marking with radioisotope is a feasible technique. The application of molecular techniques shows the tumoral affectation in cases staged as stage I.

El ganglio centinela en el carcinoma pulmonar. Estudio molecular tras detección con radioisótopo / Sentinel lymph node in pulmonary carcinoma. Molecular study after radioisotope detection

INTRODUCCIÓN: La afectación metastásica a nivel ganglionar es el principal factor pronóstico en el carcinoma pulmonar localizado. Pese al estudio anatomopatológico de las piezas obtenidas tras una adecuada linfadenectomía mediastínica, la recidiva tumoral alcanza el 40% en pacientes estadio I tras la cirugía oncológica curativa. En este trabajo hemos realizado el estudio de micrometástasis por métodos moleculares en el ganglio centinela de pacientes con carcinoma pulmonar estadio i. MATERIAL Y MÉTODOS: Marcaje del ganglio centinela mediante la inyección peritumoral de 2 mCi de nanocoloide de albúmina (Nanocol®) marcado con 99mTc en un volumen de 0,3 ml tras la toracotomía. Guiados mediante la sonda gammagráfica Navigator® se procedió a su localización y exéresis. Se extrajo ARN de los tejidos y se analizó la presencia de ARNm de los genes CEACAM5, PLUNC y CK7. RESULTADOS: Se incluyó a 29 pacientes. De los genes testados, el CEACAM5 y el PLUNC fueron los que mostraron una alta expresión en tejido pulmonar. De los 29 ganglios centinela analizados, 7 (24%) fueron positivos para estudio molecular. Se encontró ganglio centinela positivo en: 4/7 adenocarcinomas y 3/12 escamosos. Los ganglios afectos fueron: nivel 5 (1/3), nivel 7 (0/6), nivel 9 (0/1), nivel 10 (5/11), nivel 11 (1/1). CONCLUSIONES: La detección del ganglio centinela en pacientes con carcinoma pulmonar estadio I mediante marcaje con radioisótopo es factible. La aplicación de técnicas moleculares pone de manifiesto la afectación tumoral en casos estadificados como estadio I

INTRODUCTION: Metastatic lymph node affectation is the main prognostic factor in localized lung cancer. Pathological study of the obtained samples even after an adequate lymphadenectomy, present tumoral relapses of 40% of stage I patients after oncological curative surgery. In this paper we have studied micrometastasis in the sentinel lymph node by molecular methods in patients with stage I lung cancer. Material and methods The sentinel node was marked by injecting peritumorally performed just after performing the thoracotomy with 2 mCi of nanocoloid of albumin (Nanocol®) marked with 99 mTc in 0.3 ml. Guided with a Navigator® gammagraphic sensor, we proceeded to its resection. RNA of the tissue was extracted and the presence of genes CEACAM5, PLUNC and CK7 in mRNA was studied. RESULTS: Twenty-nine 29 patients were included. Of the tested genes, CEACAM5 and PLUNC were the ones that showed a high expression in lung tissue. Of the 29 analyzed sentinel lymph nodes, 7 (24%) were positive in the molecular study. A positive sentinel lymph node was found in 4/7 adenocarcinomas and 3/12 squamous-cell tumors. Affected lymph nodes were: station 5 (1/3), station 7 (0/6), station 9 (0/1); station 10 (5/11); station 11 (1/1). CONCLUSIONS: Detection of sentinel node in patients with stage I lung cancer by marking with radioisotope is a feasible technique. The application of molecular techniques shows the tumoral affectation in cases staged as stage I

Endotracheal metastases from colon adenocarcinoma.

Endotracheal metastases (ETM) from non-lung cancer are seldom seen. Their main clinical symptoms are cough, haemoptysis and dyspnoea, although occasionally an incidental finding is made during a bronchoscopy. Breast, colon and kidney adenocarcinoma might be associated with ETM, lung cancer being the most frequent cause. Its finding is associated with advanced disease but survival will depend on the primary origin, patient status and comorbidity. Therefore, treatment should be individual for each patient. In our centre we recommend pre-surgery bronchoscopy to exclude metastatic endotracheal lesions in patients with metastatic colon adenocarcinoma disease, as this might affect the final outcome and therefore management of the disease.

Sarcoma radioinducido de pared torácica / Radio-induced chest wall sarcoma sarcoma

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[Computed tomography-guided radiofrequency ablation of malignant lung lesions: early experience]. / Ablación mediante radiofrecuencia guiada por tomografía computarizada de las lesiones pulmonares malignas: experiencia inicial.

OBJECTIVE: To present our early experience in the treatment of primary malignant and metastatic lung lesions by radiofrequency ablation. PATIENTS AND METHODS: From August 2004 through January 2007 we treated 19 patients (in 26 procedures) with curative or palliative intent. None of the lesions was amenable to surgery and some had been treated previously. The procedure was performed in the radiology room under conscious sedation-analgesia administered by an anesthesiologist. Fourteen patients were treated for pulmonary lesions and 5 for metastatic lung disease in a context of controlled primary disease. Treatment was with curative intent in 15 cases and palliative in 4. RESULTS: The radiofrequency technique was applicable in 26 procedures and the mean follow-up was 8.68 months. The principal complications of radiofrequency treatment were pneumothorax in 4 patients, requiring drainage in only 2 cases; pneumonitis in 4; self-limiting pulmonary hemorrhage in 1; and pleural effusion in 5. There were no procedure-related deaths. Six patients died during the follow-up period. CONCLUSIONS: In our experience, radiofrequency offers a safe and minimally invasive option for the treatment of malignant lung lesions in appropriately selected, nonsurgical patients. Morbidity is low, and in combination with other treatments this technique opens up a wide range of possibilities still to be explored.

Ablación mediante radiofrecuencia guiada por tomografía computarizada de las lesiones pulmonares malignas: experiencia inicial / Computed Tomography-Guided Radiofrequency Ablation of Malignant Lung Lesions: Early Experience

OBJETIVO: Presentar la experiencia inicial en el tratamiento de las lesiones pulmonares malignas (primarias y metastásicas) mediante la ablación por radiofrecuencia (RF). PACIENTES Y MÉTODOS: De agosto de 2004 a enero de 2007 tratamos a 19 pacientes (mediante 26 procedimientos) con intención curativa o paliativa. Todos los casos correspondían a lesiones no quirúrgicas, tratadas o no previamente. La técnica se practicó en la sala de radiología, con sedoanalgesia consciente llevada a cabo por el anestesiólogo. Se trató a 14 pacientes con lesión pulmonar y a 5 con enfermedad metastásica pulmonar, con la enfermedad primaria controlada. En 15 casos el tratamiento se realizó con intención curativa y en 4 era paliativo. RESULTADOS: La técnica de RF pudo realizarse en los 26 procedimientos. La media de seguimiento fue de 8,68 meses. Las principales complicaciones derivadas del tratamiento de RF fueron: neumotórax en 4 pacientes, de los que sólo 2 requirieron drenaje; neumonitis en 4; hemorragia pulmonar autolimitada en 1, y derrame pleural en 5. No hubo mortalidad en relación con el procedimiento. Durante el período de seguimiento fallecieron 6 pacientes. CONCLUSIONES: Según nuestra experiencia, la RF puede ser una opción segura y mínimamente invasiva para el tratamiento de las lesiones pulmonares malignas en pacientes no quirúrgicos adecuadamente seleccionados, con una baja morbilidad. La combinación con otros tratamientos ofrece un amplio abanico de posibilidades pendientes de discernir

OBJECTIVE: To present our early experience in the treatment of primary malignant and metastatic lung lesions by radiofrequency ablation. PATIENTS AND METHODS: From August 2004 through January 2007 we treated 19 patients (in 26 procedures) with curative or palliative intent. None of the lesions was amenable to surgery and some had been treated previously. The procedure was performed in the radiology room under conscious sedation-analgesia administered by an anesthesiologist. Fourteen patients were treated for pulmonary lesions and 5 for metastatic lung disease in a context of controlled primary disease. Treatment was with curative intent in 15 cases and palliative in 4. RESULTS: The radiofrequency technique was applicable in 26 procedures and the mean follow-up was 8.68 months. The principal complications of radiofrequency treatment were pneumothorax in 4 patients, requiring drainage in only 2 cases; pneumonitis in 4; self-limiting pulmonary hemorrhage in 1; and pleural effusion in 5. There were no procedure-related deaths. Six patients died during the follow-up period. CONCLUSIONS: In our experience, radiofrequency offers a safe and minimally invasive option for the treatment of malignant lung lesions in appropriately selected, nonsurgical patients. Morbidity is low, and in combination with other treatments this technique opens up a wide range of possibilities still to be explored

Lesión lítica esternal. Una presentación atípica de la tuberculosis / Sternal lithic lesion. An atypical presentation of tuberculosis

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Protocol for the implantation of a venous access device (Port-A-Cath System). The complications and solutions found in 560 cases.

INTRODUCTION: The cannulation of suitable peripheral veins may be a very painful experience. Implantable venous access systems have to some degree relieved this problem and help to provide an improvement in terms of quality of life. MATERIAL AND METHODS: We have evaluated 560 patients during a follow up period of two years. A low overall complication percentage of 7.32% was seen when using the venous access device. RESULTS: Complications and treatments were: pneumothorax; portal rotation or infection; catheter infection; embolism and migration; extravasation; partial or total obstruction of the device; rupture of the catheter or the membrane. CONCLUSIONS: There is no other system that allows repeated venous access on such a long term basis. Placing the devices completely under the skin allows the patient to conduct a normal life style, and its maintenance does not need any special care, with the exception of the monthly heparinised serum infusion. The preferred option is to insert the catheter through the cephalic vein in the delto pectoral groove.

Actualización sobre tumores fibrosos solitarios de pleura / Solitary fibrous tumor of the pleura: an update

Los tumores fibrosos solitarios de pleura son tumores de origen conectivo derivados del tejido submesotelial pleural. Aunque la mayoría son benignos, las formas malignas también han sido descritas. Estos tumores no parecen asociarse con la exposición al asbesto. Su frecuencia de presentación es semejante para hombres y mujeres, con un pico de incidencia sobre la quinta y octava décadas. Casi todos son asintomáticos y se descubren al realizar una radiografía de tórax rutinaria. Los tumores de mayor tamaño son los que presentan síntomas de disnea, tos y dolor torácico. Un pequeño porcentaje de casos se asocia con diversos síndromes sistémicos. Suelen presentar crecimiento intratorácico, son pediculados y derivan de la pleura visceral. Microscópicamente aparecen como lobulados y bien circunscritos. Muestran un bajo índice mitótico, no invaden estructuras vecinas y rara vez muestran atipias, en contraposición a los mesoteliomas malignos. Histológicamente se caracterizan por haces de fibroblastos y tejido conectivo en diferentes proporciones. Las formas benignas muestran positividad para el CD34 y la vimentina y son negativos para las citoqueratinas. El tratamiento es la resección quirúrgica completa (toracotomía versus toracoscopia). Algunas lesiones precisan resecciones anatómicas al ser de localización parenquimatosa. Las recurrencias son raras pero debe realizarse un seguimiento adecuado en estos pacientes. El papel de la terapia adyuvante no ha sido definido

[Oncoplastic surgery for thoracic wall tumours]. / Cirugía oncoplástica en tumores de pared torácica.

INTRODUCTION: Surgical treatment of tumours of the chest wall (primary or metastatic) requires special skills by the thoracic and the plastic surgeons, from the functional as well as the aesthetic perspective (oncoplastic surgery), when the treatment requires surgical reconstruction. MATERIAL AND METHODS: We present a series of 14 patients who needed extensive resection of the thoracic wall (external and/or 3 or more ribs) with disease-free margins and reconstruction with prostheses (7 with polytetrafluoroethylene [PTFE(R)] and 7 with the Sandwich Marlex-Methyl Metacrylate) technique with additional covering with muscle-skin flaps (6 pectoral, 5 recto-anterior, 3 dorsal) pedicled during the same surgical intervention. RESULTS: The aetiology of the extirpated tumours, following pathology assessment, were: 4 chondrosarcoma, 3 metastatic sternum, 2 breast cancer relapse, 1 desmoid tumour, 1 neurofibrosarcoma, 1 rhabdomiosarcoma, 1 malignant schwannoma and 1 radiation induced sarcoma. One patient died from complications and another 4 from disease progression before the conclusion of the study follow-up (3-22 months). CONCLUSIONS: Extensive resection of tumours of the chest wall with reconstruction using prostheses and muscle-skin flaps is a safe method that can be performed in the same surgical intervention period when combining the skills of the thoracic surgeon with that of the plastic surgeon.

Cirugía oncoplástica en tumores de pared torácica / Oncoplastic surgery for thoracic wall tumours

Introducción. El tratamiento quirúrgico de los tumores de pared torácica (primarios o metastásicos) requieren un manejo especial por parte de cirujanos torácicos y plásticos en donde la cirugía oncológica precisa de una reconstrucción adecuada desde un punto de vista funcional y estético (cirugía oncoplástica). Material y métodos. Presentamos una serie de 14 pacientes que precisaron resección amplia de pared torácica (esternal y/o con 3 o más costillas) con márgenes libres de enfermedad y reconstrucción mediante prótesis (7 de politetrafluoroetileno [PTFE®] y 7 con técnica Sandwich Marlex-Metil Metacrilato®) más recubrimiento con colgajos musculocutáneos (6 pectorales, 5 de recto anterior, 3 dorsales) pediculados en el mismo acto quirúrgico. Resultados. La etiología de los tumores extirpados tras el análisis patológico fue: 4 condrosarcomas, 3 metástasis esternales, 2 recidivas de carcinoma mamario, 1 tumor desmoide, 1 neurofibrosarcoma, 1 rabdomisarcoma, 1 schwanoma maligno y 1 sarcoma radio inducido. Una paciente falleció por complicaciones y otros 4 por progresión de la enfermedad antes del cierre del estudio (3-22 meses). Conclusiones. La resección amplia de tumores de pared torácica con reconstrucción mediante prótesis y colgajos músculo cutáneos es un método seguro que puede practicarse en un solo tiempo mediante la colaboración de cirujanos torácicos y plásticos

Introduction. Surgical treatment of tumours of the chest wall (primary or metastatic) requires special skills by the thoracic and the plastic surgeons, from the functional as well as the aesthetic perspective (oncoplastic surgery), when the treatment requires surgical reconstruction. Material and methods. We present a series of 14 patients who needed extensive resection of the thoracic wall (external and/or 3 or more ribs) with disease-free margins and reconstruction with prostheses (7 with polytetrafluoroethylene [PTFE®] and 7 with the Sandwich Marlex ­ Methyl Metacrylate®) technique with additional covering with muscle-skin flaps (6 pectoral, 5 recto-anterior, 3 dorsal) pedicled during the same surgical intervention. Results. The aetiology of the extirpated tumours, following pathology assessment, were: 4 chondrosarcoma, 3 metastatic sternum, 2 breast cancer relapse, 1 desmoid tumour, 1 neurofibrosarcoma, 1 rhabdomiosarcoma, 1 malignant schwannoma and 1 radiation induced sarcoma. One patient died from complications and another 4 from disease progression before the conclusion of the study follow-up (3 ­ 22 months).Conclusions. Extensive resection of tumours of the chest wall with reconstruction using prostheses and muscle-skin flaps is a safe method that can be performed in the same surgical intervention period when combining the skills of the thoracic surgeon with that of the plastic surgeon

La videocirugía en el tratamiento del neumotórax / Video-assisted surgery in the treatment of pneumothorax

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