Pleuro-pulmonary disease in central South Africa: A thoracic surgical deficiency.

We wished to estimate the performance gap between thoracic surgical service provision and the burden of thoracic surgical disease in central South Africa (SA). We compared burden of disease data to the number of thoracic operations performed for inflammatory pleuro-pulmonary disease and primary lung cancer. The performance gap was estimated to be a factor of 1:20 for lung cancer and 1:10 for thoracic surgery as a whole. The extent of under-provision of thoracic surgical services in central SA demonstrates that urgent major healthcare system reforms are required at all levels to address the significant performance gap between service provision by thoracic surgery and the burden of disease in central SA.

Fifty years of thoracic surgical research in South Africa.

AIM: To investigate the scope and trends in clinical research in South African thoracic surgery between 1955 and 2006 and to measure its impact on clinical practice. METHOD: A systematic review of all SA thoracic surgical publications was performed. RESULTS: There were 252 general thoracic publications and a marked decrease in publications was noted after the peak period of productivity of the 1980s. There was a shift toward the private sector as an origin of articles and toward a local, non-indexed journal. Inflammatory lung disease was the most frequent topic of publication. Case series and case reports were the most frequent type of article. CONCLUSION: The vulnerability of a small specialty in a developing country is illustrated by the clear trends that emerged. The study provides important indicators for future research, highlights the need for a national database of clinical experience, and emphasises the importance of rekindling interest and a culture of research in thoracic surgery.

CT and histopathological correlation of congenital cystic pulmonary lesions: a common pathogenesis?

AIM: To determine whether similarities exist in both the imaging and histopathological features of congenital cystic lung lesions and whether a more appropriate classification would be to adopt the theory of "malinosculation". MATERIAL AND METHODS: From the histopathology and computed tomography (CT) database, 24 patients (16 male, median age 3 years) with congenital cystic lung lesions were identified. CT studies were reviewed for site and characteristics of the lesions, parenchymal features, bronchial anatomy, and the presence of a feeding systemic vessel. Individual histopathological parameters were also correlated with CT data. RESULTS: There were five type 1 congenital cystic adenomatoid malformations (CCAMs), six type 2 CCAMs, one type 4 CCAM, one bronchial atresia, four pleuropulmonary blastomas (PPBs), and seven sequestrations. CCAMs (types 1, 2 and 4), sequestrations and PPBs appeared as cystic lesions, with cyst size less than 2 cm in type 2 CCAMs. Sequestrations were distinguished radiologically from CCAMs by systemic vessels. Reduced pulmonary attenuation was seen in bronchial atresia, type 2 CCAMs and in sequestrations. Histopathology showed an overlap in entities with sequestrations demonstrating CCAM type 2 histology and segmental atresia noted in both type 2 CCAMs and sequestrations. PPBs showed histological and imaging overlap with type 4 CCAMs and were distinguished on histology by the presence of blastematous proliferation. CONCLUSIONS: This study demonstrates overlap in the CT appearances of congenital cystic lesions. The similarity in CT and histopathology findings across the spectrum of developmental lesions supports the hypothesis of a common aetiology.

Congenital cystic adenomatoid malformation presenting as in-flight systemic air embolisation.

Congenital cystic adenomatoid malformations (CCAMs) are rarely diagnosed in adulthood. The present case study reports a case of a CCAM presenting as a cerebral air embolus during an international flight. In the present case, supportive therapy resulted in a full recovery. The patient later underwent elective excision of the pulmonary malformation. Since the overall mortality of in-flight cerebral air embolisation is high, patients with such asymptomatic cysts should be considered for elective surgery.

Imaging features of isolated unilateral pulmonary artery agenesis presenting in adulthood: a review of four cases.

AIM: To highlight the variation in clinical manifestations, imaging and management of four cases of unilateral pulmonary artery agenesis presenting in adulthood. METHOD: Four patients with unilateral pulmonary artery agenesis were referred to our institution between 1995 and 2005. They underwent a series of investigations, including chest radiography, echocardiography, ventilation perfusion scintigraphy, angiography, computed tomography (CT) and magnetic resonance imaging (MRI). RESULTS: Two of the four patients had absence of the right main pulmonary artery, whilst the remaining two patients had absence of the left main pulmonary artery. One patient showed a restrictive defect on pulmonary function tests. Two patients who had ventilation perfusion scintigraphy showed absent perfusion and reduced ventilation on the affected side. Angiography (where performed), CT and MRI confirmed the anatomy and the presence of multiple collaterals. Bronchiectasis was demonstrated on CT in two patients, with one also demonstrating a mosaic attenuation pattern. One patient had an incidental lung tumour on the side of the agenesis, which was diagnosed as a chondroid hamartoma on histology. Three of the four patients eventually underwent resection of the affected lung. CONCLUSION: Isolated unilateral pulmonary artery agenesis has a non-specific presentation. Awareness of this condition can lead to earlier diagnosis, with cross-sectional imaging making an important contribution.

The future in diagnosis and staging of lung cancer: surgical techniques.

Surgical techniques remain central to the diagnosis and staging of lung cancer. Clinical situations which invoke the role of surgery include the diagnosis of solitary pulmonary masses, staging of the mediastinum, restaging of the mediastinum and the assessment of resectability. The techniques available include cervical mediastinoscopy, anterior mediastinotomy, video-assisted thoracoscopy and different procedures for intra-operative mediastinal lymph node assessment including systematic nodal dissection, lobe-specific nodal dissection and sentinel node mapping. The staging of lung cancer is continuously evolving as technological advances combine with clinical advances to better stratify patients into treatment and prognostic categories and alter pre-operative investigation algorithms. Although most of the surgical techniques have been around for many years, it is their application in future which is likely to change. The increasing use of positron emission tomography/computed tomography fusion imaging is raising the proportion of patients being shown to have additional lesions that could contraindicate surgical treatment but which require tissue confirmation to exclude a false-positive examination. Many such lesions are amenable to the expanding techniques available to the interventional endoscopist. The relationship between the surgeon and the endoscopist must become closer to ensure that the appropriate technique is used at each point in the patient's pathway. The future of surgical techniques will be driven by: (1) developments in screening and imaging, with a likelihood that more early stage cancers will present and may be amenable to minimally invasive surgical approaches with the possibility of a role for robotics and nanotechnology; (2) improvements in neoadjuvant therapies which will demand flawless mediastinal staging and restaging; (3) advances in molecular biology which, whilst currently requiring that surgery provide samples of tumour and lymph node tissue to fully characterize the disease, do hold the promise that ever smaller amounts of tissue will be required and that eventually the genetic fingerprint will provide a biological ultrastaging to perhaps supersede anatomical staging.

Effect and duration of lung volume reduction surgery: mid-term results of the Brompton trial.

UNLABELLED: Although many studies have reported improvement in lung function following LVRS, the magnitude of improvement and subsequent decline has not been evaluated against medical therapy after the second year. METHODS: Existing pulmonary function records were collapsed for ech participant since randomisation from Brompton LVRS trial cohort. Longitudinal data analysis was used to profile th history of medically treated patients and the effect of LVRS. RESULTS: Pulmonary function results were collated from survivors over a median of 25 (17 to 39) months. The estimated immediate increase in mean FEV1, following surgery was +0.2591 (0.179, 0.339), with a rate of change of -0.0051 (-0.009, -0.001) per month compared to medical therapy (p < 0.001). The changes in the secondary outcome measures (LVRS compared to medical therapy) were an increase in FVC (p = 0.004), decrease in RV (p < 0.001) and TLC (p < 0.001), with differences that were maintained over time. The initial reduction in RV/TLC ration was sustained (p < 0.001), but the estimated initial increase in peak flow was accompanied by a gradual decline that was not statistically significant (p = 0.062). KCOc showed no immediate change, but there was a gradual sustained increase with time (p = 0.009). Mean oxygen saturations improved and continued to do so compared to patients on medical therapy (p = 0.001). CONCLUSIONS: The immediate increase in FEV1 is not sustained, although the mechanical improvements of LVRS on increasing FVC, reducing both the RV and RV/TLC ratio, appear to be maintained. The important benefits of LVRS may be the gradual and sustained increase in transfer factor accompanied by improved oxygen saturations.

How we do it: the anterior thoraco-cervical approach to tumours of the thoracic inlet.

KEYPOINTS: Tumours that arise in the thoracic inlet and superior mediastinum may be benign or malignant and present the surgeon with a difficult problem of access. The standard approach to the thoracic inlet from below offers limited exposure to the vascular and neural structures superior to the tumours. The anterior thoraco-cervical approach to the root of the neck and superior mediastinum combines the anterior cervical approach with a limited upper median sternotomy. If further access is required to achieve surgical clearance a full sternotomy split can be performed. The approach offers excellent exposure and helps to facilitate complete resection of benign and malignant tumours, which would otherwise be deemed inoperable or difficult to resect completely through other standard approaches. In contrast to previously described anterior transcervical thoracic approaches which required resection of part of the clavicle or manubrium as well as thoracotomy with increased morbidity, the anterior thoraco-cervical approach is associated with little morbidity and the postoperative stay is short.

TTF-1 expression is specific for lung primary in typical and atypical carcinoids: TTF-1-positive carcinoids are predominantly in peripheral location.

Thyroid transcription factor (TTF)-1 expression in neuroendocrine tumors (NETs) has not been studied as widely as that in non-NETs, with the exception of small cell carcinomas, in which TTF-1 is highly sensitive but not specific for a primary lung tumor. The reported incidence of TTF-1 expression in pulmonary carcinoids has also been highly variable in the literature. To evaluate the expression of TTF-1 in NETs and potential value of TTF-1 in distinguishing pulmonary NETs from those of extrapulmonary origin, we performed an immunohistochemical study by using semiquantitative analysis on formalin-fixed, paraffin-embedded sections from 111 NETs, including 80 pulmonary (11 carcinoid tumorlets [TLs] or foci of neuroendocrine cell hyperplasia [NEH], 36 typical carcinoids [TCs], 17 atypical carcinoids [ACs], 16 large cell neuroendocrine carcinomas [LCNECs]), 13 thymic (3 TCs, 8 ACs, 2 LCNECs), 17 gastrointestinal or pancreatic (13 TCs, 4 ACs), and 1 ovarian (LCNEC). Pulmonary carcinoids were subdivided into those with central and those with peripheral location. TTF-1 positivity was seen exclusively in pulmonary NETs and was significantly higher in NEH or TLs (72.7%) than in TCs (27.8%), ACs (29.4%), and LCNECs (37.5%; P = 0.03). All extrapulmonary NETs were uniformly negative for TTF-1 staining. Interestingly, 12 of 14 TTF-1-positive pulmonary TCs and ACs had a peripheral location with spindle cell morphology, as did all cases of TL, a purported precursor of peripheral carcinoids. In conclusion, TTF-1 expression was 100% specific, though not so sensitive, for the lung primary in TCs and ACs and possibly also in LCNECs. Prevalent TTF-1 positivity in TLs and peripheral carcinoids suggest that they may be histogenetically distinct from the central carcinoids, which are typically composed of TTF-1-negative, more rounded cells.

Effects of airborne World Trade Center dust on cytokine release by primary human lung cells in vitro.

There are continuing concerns regarding the respiratory health effects of airborne particulate matter (PM) after the destruction of the World Trade Centre (WTC). We examined cytokine (interleukin [IL]-8, IL-6, tumor necrosis factor-alpha) release by primary human lung alveolar macrophages (AM) and type II epithelial cells after exposure to WTC PM2.5 (indoor and outdoor), PM10-2.5 (indoor), and PM53-10 (outdoor), fractionated from settled dusts within 2 months of the incident. There was an increase in AM cytokine/chemokine release at 5 and/or 50 microg/well WTC PM, which fell at 500 microg/well. Type II cells did not release tumor necrosis factor-alpha, and the increase in IL-8 and IL-6, although significant, was lower than that of AM. Respirable PM generated by the WTC collapse stimulates inflammatory mediator release by lung cells, which may contribute to the increased incidence of respiratory illness since September 11th 2001.

Infection of patients by bloodborne viruses.

BACKGROUND: Despite taking precautions, healthcare workers performing invasive procedures run a small risk of infection by bloodborne viruses. When injury occurs, the viral status of the patient is often unknown and testing requires informed consent, which may be refused. On the other hand, although the chance of transmission of infection from a healthcare worker to a patient is extremely small, such personnel have an obligation of disclosure and, if seropositive, are barred from performing invasive procedures. METHODS: The medical literature on bloodborne virus transmission between carers and patients was reviewed, and the UK Department of Health, General Medical Council and Royal College of Surgeons of England guidelines on the risk management of these infections were read, along with secondary references from all sources. RESULTS AND CONCLUSION: Patients have complete protection of confidentiality and the right to refuse testing, but these rights do not apply to the healthcare worker. When injured in circumstances in which the patient cannot or will not permit testing, carers can only submit to the risks of prophylactic treatment or go into denial. Infection may have devastating professional, personal and financial implications to carers and their dependants. Ways to re-establish a just balance between the legitimate rights of patients and healthcare workers are discussed.

Oesophagopleural fistula as a novel cause of failed non-invasive ventilation.

Non-invasive ventilatory support is commonly used to palliate symptoms and extend longevity in patients with ventilatory failure due to neuromuscular and restrictive chest wall disease. We describe a patient with ventilatory failure due to a combination of these factors in whom the application of non-invasive ventilation led to intolerable symptoms. An unusual cause for this was found.

Pulmonary fibrosis and lung cancer: risk and benefit analysis of pulmonary resection.

OBJECTIVE: Pulmonary fibrosis is associated with an increased risk of lung cancer and outcome of surgical resection in this setting is unknown. METHODS: We studied 22 patients (24 operations) with pulmonary fibrosis and non-small cell lung cancer treated between 1991 and 2000 (study group) and compared outcome with 951 other patients (964 operations) treated for non-small cell lung cancer over the same period (control patients). RESULTS: The two groups did not differ significantly in age (68 vs 65 years), smoking history (86% vs 95% smokers), forced expiratory volume in 1 second (2.5 L/min vs 2.3 L/min) or forced vital capacity (3.2 L vs 3.7 L), but patients with pulmonary fibrosis were more likely to be male (72% vs 58%, P <.05). The operative mortality was higher in patients with pulmonary fibrosis than in control patients (17% vs 3.1%, P <.01) and there was a higher procedure-specific mortality in pulmonary fibrosis for pneumonectomy (33% vs 5.1%, P <.01) and lobectomy (12% vs 2.6%, P <.01). Patients with pulmonary fibrosis had a higher incidence of postoperative lung injury, (21% vs 3.7%, P <.01) and a longer mean hospital stay (17 vs 9 days, P <.05). In patients with pulmonary fibrosis, the actuarial 3-year survival was 54%. There were 11 deaths in the study group, 4 postoperatively (all acute respiratory distress syndrome) and 7 late deaths (metastatic disease, n = 2; progressive pulmonary fibrosis, n = 5). Median follow-up (to death or last review) was 13 months (range, 0-120 months). Five patients developed postoperative acute respiratory distress syndrome and in 4 of these patients this proved to be fatal. Postoperative acute respiratory distress syndrome was associated with lower preoperative total lung carbon monoxide diffusion capacity (median, 58% vs 70%, P =.03) and lower preoperative carbon monoxide diffusion capacity corrected for alveolar volume (median, 48% vs 58%, P =.05) and a higher preoperative composite physiological index (median, 44 vs 33, P =.008). None of the preoperative lung function parameters or operative finding were predictors of late death. CONCLUSION: Patients with pulmonary fibrosis undergoing pulmonary resection for non-small cell lung cancer have increased postoperative morbidity and mortality, but an important subgroup has a good long-term outcome. Postoperative acute respiratory distress syndrome is associated with low preoperative gas transfer and a high composite physiological index. Resection of non-small cell lung cancer is appropriate in pulmonary fibrosis, provided that the level of functional impairment is carefully factored into patient selection.

Consensus: the follow-up of the treated patient.

This is the first consensus document on the follow-up of the treated patient with non-small cell lung cancer that has been written by this group. The document has been drawn up by doctors coming from many different cultures and philosophical backgrounds. It acknowledges that there are published guidelines on the follow-up particularly those in trials, and does not wish to contradict these. There is lack of evidence-based medicine to recommend a strong general policy in this area. For those patients who were treated with curative intent the initial follow-up will depend upon the toxicity that is evident from the treatment given. Thereafter the interval between follow-up visits should be every 3 months for the first two years, then every 6 months for up to five years. Rapid and easy access to the multidisciplinary team should be available. Full examination and chest X-ray should be carried out on each visit but other investigations should be determined by clinical need. For those patients treated with palliative intent the interval between follow-up visits once the acute reactions have settled will depend upon the adequacy of the control of the symptom and the availability of separate palliative care teams. At all times the patient should have rapid access to the multidisciplinary team and in general frequent follow-up, that is at intervals of one to two months, may be appropriate during the first six months. Follow-up constitutes an important part of lung cancer management. Efforts should be made to gain clinical material to give us evidence-based guidelines.