[Analysis of the current situation and outlook of thoracic surgery]. / Análisis de la situación actual y previsión de futuro de la especialidad de cirugía torácica.

OBJECTIVE: The objective of this descriptive study was to analyze the current situation and forecast the future requirements for specialists in thoracic surgery, taking into account the number of doctors entering and those possibly leaving this specialty. MATERIAL AND METHODS: The data for this study were taken from the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) (n=304), Thoracic Surgeons' Club (n=122), and the Spanish Council of Medical Associations (n=225). We also took into account the current number of resident surgeons (n=84). Other specialists were included who are not recorded in these databases but who are known to be practicing (n=10). The total number of practicing specialists obtained was 211. RESULTS: There are currently 52 working thoracic surgery departments and the highest number of practicing specialists was recorded in Madrid (n=44), Catalonia (n=33), and Andalusia (n=33). The forecast number of retirements (at age 65 years) and incorporations of new specialists means that there will be a surplus of 57 thoracic surgeons in the next 5 years. CONCLUSIONS: Thoracic surgery needs to limit the intake of new trainee specialists for at least the next 5 years.

Análisis de la situación actual y previsión de futuro de la especialidad de cirugía torácica / Analysis of the Current Situation and Outlook of Thoracic Surgery

Introduccióncon objeto de analizar la situación actual y realizar una previsión de futuro de las necesidades de especialistas de cirugía torácica, se ha llevado a cabo un estudio descriptivo teniendo en cuenta las incorporaciones y posibles salidas del sistema de médicos de esta especialidad.Material y métodoscomo base de datos se han tomado las de la Sociedad Española de Neumología y Cirugía Torácica (n=304), Club de Cirujanos Torácicos (n=122) y Consejo Español de Colegios de Médicos (n=225). También se ha considerado el número actual de médicos residentes (n=84). Se han añadido otros especialistas no censados en esta base de datos de los que se tiene constancia de su ejercicio (n=10). El total de especialistas en ejercicio considerados ha sido de 211.Resultadosactualmente hay 52 unidades de cirugía torácica con actividad y el mayor número de especialistas activos se registra en Madrid (n=44), Cataluña (n=33) y Andalucía (n=33). La previsión de jubilaciones (edad de 65 años) y nuevas incorporaciones de médicos especialistas hace que se prevea un excedente de cirujanos torácicos de 57 en los próximos 5 años.Conclusionesla especialidad de cirugía torácica debería moderar su oferta de formación de nuevos especialistas en los próximos 5 años como mínimo(AU)

ObjectiveThe objective of this descriptive study was to analyze the current situation and forecast the future requirements for specialists in thoracic surgery, taking into account the number of doctors entering and those possibly leaving this specialty.Material and methodsThe data for this study were taken from the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) (n=304), Thoracic Surgeons’ Club (n=122), and the Spanish Council of Medical Associations (n=225). We also took into account the current number of resident surgeons (n=84). Other specialists were included who are not recorded in these databases but who are known to be practicing (n=10). The total number of practicing specialists obtained was 211.ResultsThere are currently 52 working thoracic surgery departments and the highest number of practicing specialists was recorded in Madrid (n=44), Catalonia (n=33), and Andalusia (n=33). The forecast number of retirements (at age 65 years) and incorporations of new specialists means that there will be a surplus of 57 thoracic surgeons in the next 5 years.ConclusionsThoracic surgery needs to limit the intake of new trainee specialists for at least the next 5 years(AU)

Metástasis pulmonar única 23 años después de un carcinoma adenoide quístico de parótida / Single pulmonary metastasis 23 years after an adenoid cystic carcinoma of the parotid

Un nódulo pulmonar solitario no presente en radiografías previas fue descubierto en un paciente varón de forma casual. Veintitrés años antes, el paciente fue operado de carcinoma adenoide quístico de parótida (cirugía radical y radioterapia adyuvante). Los estudios preoperatorios no consiguieron un diagnóstico histológico y se descartó la existencia de enfermedad locorregional. Se le realizó una lobectomía superior derecha y el estudio anatomopatológico indicó una metástasis de parótida. El carcinoma adenoide quístico de parótida puede presentar metástasis a distancia incluso décadas después del tratamiento inicial sin que exista recidiva locorregional. Un seguimiento con radiografías de tórax puede ayudar al diagnóstico de la metástasis pulmonar en estos pacientes (AU)

A solitary pulmonary nodule was discovered on a chest X-ray film in a male patient. The nodule was not present previously. Twenty three years before the patient was operated on of a parotid adenoid cystic carcinoma (radical surgery and adjuvant radiotherapy). Preoperative studies could not get a histological diagnosis. He underwent a right upper lobectomy. Pathological analysis revealed a parotid metastasis. Parotid adenoid cystic carcinoma can give distant metastases even decades after initial treatment and without locoregional recidive. Follow up with chest X-ray films cand help diagnose lung metastasis in such patients (AU)

Quimioterapia neoadyuvante en un timoma invasor. Cirugía curativa con neumonectomía izquierda en bloque / Neoadjuvand chemotherapy of an invasive thymoma. Invasive surgery and left side in bloc pneumonectomy

Presentamos un paciente con un timoma invasor como hallazgo en un estudio radiológico por disneaprogresiva. Tras el diagnóstico histológico fue tratado con quimioterapia (Qt) neoadyuvante consiguiendo unareducción del volumen tumoral del 25%. El tratamiento quirúrgico consistió en una exéresis en bloque deltimoma junto con el pulmón izquierdo por afectación de los vasos pulmonares. La combinación de la Qtneoadyuvante con la cirugía posibilitan un tratamiento con intención curativa

We present a patient suffering from an invasive thymoma discovered in a chest roentgenogram because ofprogressive dyspnea. Neoadjuvant chemotherapy was used after histological diagnosis, observing a tumorvolume decrease of 25 %. The surgical treatment consisted of the thymoma en bloc resection, and a left sidepneumonectomy due to affected pulmonary vessels. The combination of neoadjuvant chemotherapy andsurgery is applied as a curative intention therapy

[Descending necrotizing mediastinitis: treatment by transcervical thoracic drainage]. / Mediastinitis necrosante descendente: tratamiento con drenaje torácico transcervical.

We report the case of a 29-year-old man with descending necrotizing mediastinitis and subcarinal spread secondary to oropharyngeal infection. The thoracic infection was treated by placement of a transcervical thoracic drain, which was removed 15 days after surgery. The outcome was satisfactory and no further invasive treatment was required. We believe that transcervical thoracic drainage is a useful initial treatment for descending necrotizing mediastinitis with subcarinal spread but no pleural cavity involvement.

Mediastinitis necrosante descendente: tratamiento con drenaje torácico transcervical / Descending necrotizing mediastinitis: treatment by transcervical thoracic drainage

Presentamos el caso clínico de un varón de 29 años de edad que presentó una mediastinitis necrosante descendente con extensión infracarinal secundaria a un proceso infeccioso orofaríngeo. La infección torácica fue tratada mediante un drenaje torácico vía transcervical, que se retiró al decimoquinto día del postoperatorio. La evolución fue favorable sin necesidad de una reintervención más radical. Consideramos que en la mediastinitis necrosante descendente con extensión infracarinal sin rotura pleural es útil inicialmente el tratamiento con drenaje torácico transcervical

We report the case of a 29-year-old man with descending necrotizing mediastinitis and subcarinal spread secondary to oropharyngeal infection. The thoracic infection was treated by placement of a transcervical thoracic drain, which was removed 15 days after surgery. The outcome was satisfactory and no further invasive treatment was required. We believe that transcervical thoracic drainage is a useful initial treatment for descending necrotizing mediastinitis with subcarinal spread but no pleural cavity involvement

[Body mass, dyspnea, and quality of life as success predictors in emphysema surgery for reduction of pulmonary volume]. / Masa corporal, disnea y calidad de vida como predictores de éxito en la cirugía de reducción de volumen en el enfisema.

OBJECTIVES: Lung volume reduction surgery has recently been proposed as a palliative treatment for advanced emphysema. Some patients improve and others remains the same, being debated at this time the factors that predict improvement. The purpose of this work is to find predictive factors for positive response in patients operated with this surgery. MATERIAL AND METHODS: Patients with positive response (7 patients) and patients without positive response (5 patients) have been compared in our series of lung volume reduction surgery (12 patients). Positive response to surgery was defined as Delta FEV1 > or = 15%, dyspnea transitional index (Mahler scale) > or = 3, and improvement in the scoring surgery of quality of life for chronic respiratory disease questionnaire (Guyatt and Güell) > or = 1.5 3 months after the surgery. Basal values of FEV1, FEF50/FIF50%, hyperinsufflation degree, heterogeneity, PaO2, PaCO2, type of surgery, body mass index (BMI), dyspnea basal index (DBI) and quality of life questionnaire score (QLQS). RESULTS: Patients without and with positive response were different only because their baseline BMI, DBI and QLQS were lower. Other parameters studied (although the population was rather homogeneous) did not show significant differences between the two groups. CONCLUSIONS: Patients with higher subjective problems (dyspnea and quality of life) and more malnourished are those with less benefit from surgery for pulmonary volume reduction.

[Thoracocentesis for the assessment of lung cancer with pleural effusion]. / La toracocentesis en la evaluación del cáncer de pulmón con derrame pleural

OBJECTIVE: To analyze the pleural and mediastinal effect of thoracentesis tumor-positive cytology in pleural effusions (PE) detected by chest X ray of lung cancer patients. PATIENTS AND METHODS: The study was performed in patients with lung cancer for whom PE was evident in chest X ray films, who then underwent thoracentesis followed by video-assisted thoracoscopy (VAT) to evaluate direct pleural tumor infiltration, mediastinal node involvement and the existence of pleural metastasis. Patients without contraindication underwent the procedure, even if tumor positive cytology was present. When pleural metastasis was found the treatment employed was talc pleurodesis and chemotherapy. Descriptive statistics were compiled and the validity of VAT for pleural metastasis diagnosis, of thoracentesis pleural cytology to detect infiltration of the tumor-adyacent pleura, N2 disease and pleural metastasis were calculated. Survival was also analyzed. RESULTS: PE was present in 188 of 971 consecutive lung cancer patients. Seventy two PEs were visible in the chest X ray films. Volume exceeded 425 mL. Tumor positive pleural cytology was detected in 29 cases (40%). Pleural metastasis were found in 54 patients, 23 of whom had tumor positive pleural cytology. In the other 6 patients with positive cytology the primary neoplasm infiltrated the visceral pleura, completely in 5. In 4 of those 5, the mediastinal pleura was also involved. The primary tumor and diseased lymph nodes were removed from 11 patients, 3 of them with tumoral pleural cytology. Visual pleural inspection by VAT had a sensitivity of 93%, specificity of 82%, positive predicted value (PPV) of 94% and negative predicted value (NPV) of 78% for the diagnosis of pleural metastasis. Thoracentesis cytology showed a sensitivity of 43%, specificity of 67%, PPV of 79% and NPV of 28% for pleural metastasis. For the evaluation of adjacent pleura infiltration, without pleural metastasis, the sensitivity of cytology was 40%, specificity 100%, PPV 100% and NPV 25%. For mediastinal node invasion clinically evaluated, the sensitivity of cytology was 55%, specificity of 62%, PPV 18% and NPV 90%. Survival after thoracotomy was 39% after 2 years, and the median survival time was 14.5 months. In the 11 resected patients, survival was 53% at two years. The difference in survival between patients treated by thoracotomy and those treated by talc pleurodesis after VAT was significant (p < 0.01). The 3 resected patients with pleural tumor-positive cytology survived 84, 39 and 25 months. CONCLUSIONS: Nineteen percent of patients with lung cancer have PE, of which 7% can be seen in chest X ray films. In such patients the likelihood of pleural metastasis is 75%. Pleural metastasis is not necessarily present when PE cytology indicates that tumor is present. VAT can be considered the ideal technique for the assessment of direct pleural invasion by the tumor or of pleural metastasis.

La toracocentesis en la evaluación del cáncer de pulmón con derrame pleural / Thoracentesis for the assessment of lung cancer with pleural effusion

OBJETIVO: Analizar la repercusión pleural y ganglionar mediastínica de la citología tumoral obtenida por toracocentesis del derrame pleural (DP) diagnosticado mediante radiografía de tórax en pacientes con cáncer de pulmón (CP). PACIENTES Y MÉTODOS: Estudio realizado en pacientes con CP primario y DP evidente en la radiografía de tórax a los que se les realizó toracocentesis seguida de videotoracoscopia (VT) para valorar la infiltración pleural directa por el tumor, la afección ganglionar mediastínica y la existencia de diseminación metastásica pleural. Fueron intervenidos quirúrgicamente aquellos sin contraindicación, pese a tener citología tumoral. Al encontrar metástasis pleural se practicó pleurodesis con talco y tratamiento quimioterápico. El estudio estadístico contempló los siguientes aspectos: descripción de las variables epidemiológicas; validez de la VT para el diagnóstico de metástasis pleural y de la citología por toracocentesis para evaluar la infiltración pleural por contigüidad, enfermedad N2 y la existencia de metástasis pleural; supervivencia. RESULTADOS: En 971 pacientes consecutivos con CP hubo 188 con DP, 72 visibles en la radiografía de tórax. El volumen fue superior a 425 ml. La citología fue tumoral en 29 casos (40 per cent). Hubo metástasis pleural en 54 pacientes (75 per cent), 23 con citología tumoral. En los otros 6 pacientes con citología tumoral, la neoplasia primaria infiltraba la pleura visceral, en 5 de forma completa, 4 de los cuales presentaban infiltración de la pleura mediastínica. Se realizó la exéresis del tumor primario y adenopatías en 11 pacientes, 3 con citología tumoral. La evaluación pleural de visu por VT para el diagnóstico de mestástasis pleural dio una sensibilidad (S) del 93 per cent, especificidad (E) del 82 per cent, un valor predictivo positivo (VPP) del 94 per cent y un valor predictivo negativo (VPN) del 78 per cent. La citología por toracocentesis para el diagnóstico de metástasis pleural presentó: S 43 per cent, E 67 per cent, VPP 79 per cent y VPN 28 per cent; para infiltración pleural por contigüidad, sin metástasis pleural: S 40 per cent, E 100 per cent, VPP 100 per cent y VPN 25 per cent; y en la invasión ganglionar mediastínica evaluada clínicamente: S 55 per cent, E 62 per cent, VPP 18 per cent y VPN 90 per cent. La supervivencia tras toracotomía alcanzó el 39 per cent a los 2 años, con una mediana de 14,5 meses y en los 11 pacientes resecados fue del 53 per cent a los 2 años. La comparación de las supervivencias de los pacientes intervenidos por toracotomía y los tratados mediante pleurodesis tras VT fue significativa (p < 0,01). La supervivencia de los 3 pacientes con citología tumoral resecados alcanzó 84, 39 y 25 meses. CONCLUSIONES: El 19 per cent de los pacientes con CP tiene un DP y el 7 per cent puede ser diagnosticado en la radiografía de tórax, en cuyo caso la probabilidad de que coexista con metástasis pleural es del 75 per cent. El hallazgo de citología tumoral en el DP no es equivalente de metástasis pleural. La toracoscopia se puede considerar la técnica idónea en el análisis de la invasión pleural directa por el tumor o la diseminación metastásica. (AU)

[Our experience in the treatment of hyperhidrosis of the upper limbs by video-assisted thoracoscopy: an analysis of our first 100 procedures]. / Nuestra experiencia en el tratamiento de las hiperhidrosis de los miembros superiores mediante videotoracoscopia: análisis tras las primeras 100 intervenciones.

Sympathectomy of the thoracic chain is an effective surgical procedure for treating axillary and palmar hyperhidrosis. The procedure has been performed with minimal invasion and good results in recent years through the use of videothoracoscopic surgery. This paper describes the technique and our experience with a series of 50 patients between 16 and 48 years old. The earliest approach was unilateral in successive operations. The procedure was later performed bilaterally, at first with the patients in sequential lateral decubitus positions and later in semi-seated position. Complications were 1 case of incomplete Claude-Bernard-Horner syndrome that resolved spontaneously two months after surgery; 1 failure when sympathectomy was performed without location of the chain, obliging rapid re-operation; laminar pneumothorax in 12% of the series; compensatory hyperhidrosis in 26%; 10% with chest pain due to intercostal involvement, resolving with time; and slight bleeding in 8%. Outcome was excellent, with complete disappearance of axillary and palmar perspiration. Patient satisfaction was 9.2/10 one year after surgery. Mean hospital stay was less than 36 h.

Nuestra experiencia en el tratamiento de las hiperhidrosis de los miembros superiores mediante videotoracoscopia: análisis tras las primeras 100 intervenciones / Our experience in the treatment of hyperhidrosis of the upper limbs by video-assisted thoracoscopy: an analysis of our first 100 procedures

La simpatectomía de la cadena torácica constituye un procedimiento quirúrgico efectivo en el tratamiento de las hiperhidrosis axilopalmares. La introducción de la cirugía videotoracoscópica ha permitido realizar en los últimos años este procedimiento quirúrgico de manera poco invasiva y con buenos resultados. En este artículo describimos la técnica y nuestra casuística, con una serie de 50 pacientes, con edades comprendidas entre los 16 y los 48 años. El abordaje al principio fue unilateral en tiempos quirúrgicos sucesivos, para pasar después a efectuarlo bilateral, primero en decúbitos laterales secuenciales y luego en posición semisentada. Las complicaciones de la serie consistieron en un síndrome de Claude Bernard Horner incompleto que cedió espontáneamente a los 2 meses de la intervención; un fallo en la consecución de la simpatectomía por no localización de la cadena, lo que obligó a la reintervención temprana. Un 12 per cent de neumotórax laminares; un 26 per cent de hipersudaciones compensadoras, un 10 per cent de dolor torácico por afección de los intercostales que con el tiempo cedieron y un 8 per cent de hemorragias discretas. En todos los casos se obtuvieron excelentes resultados clínicos, con desaparición completa de la sudación tanto axilar como palmar. El grado de satisfacción de los pacientes fue calificado de 9,2/10 (puntuación obtenida en la consulta postoperatoria al año). La estancia hospitalaria media fue inferior a las 36 h (AU)

Thoracic venous aneurysms. Clinical observation.

Venous aneurysms are infrequent vascular alterations. Their origin is not well known, but pathologic study reveals probably a similar natural history than the arterial aneurysms. Their clinical significance arises from the complications they can originate, specially in certain locations, which include pulmonary embolism, and, on the other hand, differential diagnosis with certain malignant pathologies may be necessary, depending upon the clinical context. A patient is presented whose radiographic findings, in association with clinical factors, led to surgical exploration to rule out malignant lung tumor. A left subclavian vein aneurysm was finally diagnosed using magnetic resonance imaging.

Efectos respiratorios y hemodinámicos del alfentanilo epidural torácico o lumbar tras la cirugía torácica / Respiratory and hemodynamic effects of thoracic or lumbar epidural alfentanil after chest surgery

OBJETIVOS: Evaluación de la repercusión sobre la función pulmonar y hemodinámica de tres pautas diferentes de analgesia postoracotomía. MATERIAL Y MÉTODOS: Estudio aleatorio y doble ciego de 45 pacientes, ASA II-IV, distribuidos en 3 grupos, sometidos a toracotomía (lobectomías o neumonectomías). Tras una dosis test epidural torácica en T5-7 (grupos T-A y T-AL) o lumbar en L2-3 (grupos L), se administraron 10 µg/Kg de alfentanilo a todos los grupos. Luego se inició una infusión epidural de alfentanilo más lidocaína (T-AL) o alfentanilo (L-A y T-A) durante la cirugía y primeras 24 horas postoperatorias. Todos los grupos disponían de una PCA intravenosa de morfina postoperatoria para analgesia de rescate. Se analizaron los parámetros hemodinámicos, función pulmonar, calidad analgésica y complicaciones respiratorias. El análisis estadístico consistió en los test de ANOVA, Scheffé y Chi cuadrado. RESULTADOS: Los tres grupos resultaron homogéneos en el tipo de población e intervención quirúrgica practicada. Los requerimientos de analgesia de rescate fueron superiores en el grupo L-A respecto a los otros grupos. Los resultados de la PaO2 (6 y 18 horas) y espirometría (12 y 18 horas) fueron mejores en el grupo T-AL (p 0,05). El resto de variables no mostraron diferencias estadísticamente significativas. CONCLUSIÓN: La analgesia epidural torácica mendiante alfentanilo y lidocaína se asoció con mejores resultados de los parámetros respiratorios que los otros grupos. Los requerimientos de analgesia de rescate fueron mayores en el grupo L-A(AU)

Anestesia general combinada con ropivacaína epidural torácica en una neumorreducción por enfisema pulmonar severo / Combined general and thoracic epidural anesthesia with ropivacaine in lung reduction surgery for severe pulmonary emphysema

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[Respiratory and hemodynamic effects of thoracic or lumbar epidural alfentanyl after thoracic surgery]. / Efectos respiratorios y hemodinámicos del alfentanilo epidural torácico o lumbar tras la cirugía torácica.

OBJECTIVES: The aim of this study was to evaluate the effects on pulmonary function and hemodynamics of three different types of analgesia after thoracotomy. MATERIAL AND METHODS: Forty-five ASA II-IV patients undergoing thoracotomy (for lobectomy or pneumonectomy) were randomized to three groups (n = 15 each) for double-blind study. After a test dose into the epidural space at T5-7 (groups T-A and T-AL) or L2-3 (group L-A) interspace, 10 micrograms/Kg of alfentanil was administered in all groups, followed by epidural infusion of 400 micrograms/h of alfentanil (group T-A and L-A) or 400 micrograms/h of alfentanil with 50 mg/h of lidocaine (group T-AL) during surgery and 24 hours postoperatively. The patients also used a patient-controlled analgesia device to administer intravenous morphine postoperatively. During the study period the following variables were recorded: hemodynamic parameters, lung function, quality of analgesia and respiratory complications. ANOVA was performed and Scheffé and Chi-square tests were applied with 0.05 as the level of statistical significance. RESULTS: No differences were found between groups with respect to patient characteristics or type of surgery. Rescue analgesia requirements were higher in group L-A than in the other groups. PaO2 (6 and 18 hours) and spirometric parameters (12 and 18 hours) were significantly higher in group T-AL than in the other groups (p < or = 0.05). No other statistically significant differences were found. CONCLUSIONS: Respiratory parameters were better after thoracic epidural analgesia with alfentanil and lidocaine than after the other analgesic techniques studied. Group L-A patients had greater need for rescue analgesia than did patients in the other groups.

[Surgery and combined therapy for non-small cell lung cancer with invasion of the mediastinal nodes. A retrospective study]. / Resultados del tratamiento quirúrgico y terapia combinada en el cáncer de pulmón no microcítico con invasión ganglionar mediastínica. Estudio retrospectivo.

OBJECTIVE: To analyze the survival of patients classified N2M0 (N2 cytology/histology)with non-small cell lung cancer treated by surgical resection of the primary tumor, lymphadenectomy and neo-adjuvant therapy. PATIENTS AND METHODS: Among 1,043 consecutive patients with lung cancer treated between 1990 and 2000, 155 were classified N2M0 by histology. Of 130 patients undergoing thoracotomy, excision of the primary pulmonary tumor and lymphadenectomy were performed in 116. Among the 116 N2M0patients undergoing surgical resection, 23 were diagnosed N2c(c3)by mediastinoscopy and/or mediastinotomy and received induction chemotherapy (CT) with mitomycin/ifosfamide/cisplatin (3 cycles)and 93 were diagnosed N2pM0 after examination of samples of mediastinal lymph tissue taken during thoracotomy; for 19 of these patients,earlier surgical exploration of the mediastinum had been negative. The patient diagnosed N2p after thoracotomy also received CT and/or radiotherapy (RT). N2p patients who received induction CT also received RT. Those who were negative after lymphadenectomy and severely ill patients received no adjuvant therapy of any type. RESULTS: Mean survival of resected patients (23/49) diagnosed N2(C3) by mediastinoscopy/mediastinotomy and who received induction CT was 18 months. Survival at 1, 2 and 5 years was 80%, 45% and 30%, respectively. No postoperative deaths occurred in this group. One patient developed a bronchopleural fistula. Nine patients showed no signs of residual mediastinal node disease after lymphadenectomy. The mean survival of resected patients (93/106) diagnosed N2p after thoracotomy was 13 months and survival rates at 1, 2 and 5 years were 56%, 31% and 19%,respectively. Fourteen patients in this group died within 30 days of surgery. Nine patient developed bronchopleural fistulas. The difference in survival between the two groups was not significant. CONCLUSIONS: Histologic or cytologic confirmation of N2 disease can be considered to indicate poor prognosis. Standard, complete surgery with induction CT in selected patients improves survival for those diagnosed N2 upon thoracotomy, with no statistically significant differences.

[Surgical treatment of non-small cell lung cancer with mediastinal node invasion. A retrospective study]. / Resultados del tratamiento quirúrgico y terapia neoadyuvante en el cáncer de pulmón no microcítico con invasión ganglionar mediastínica. Estudio retrospectivo.

OBJECTIVE: To analyze the survival of patients classified as N2M0 (N2 by cytohistology) with non-small cell lung cancer treated by surgical resection of the primary tumor and lymphadenectomy. PATIENTS AND METHODS: Among 1043 consecutive patients with lung cancer who were considered for surgery between 1990 and 2000, 155 were classified N2M0 by histology. Surgical exeresis of the primarily pulmonary tumor and lymphadenectomy were performed in 116 patients of the 130 patients who underwent thoracotomy. Among the 116 N2M0 patients undergoing surgical resection, 23 were diagnosed N2c(C3) by mediastinoscopy and/or mediastinotomy and were given induction chemotherapy (ChT) (mitomycin/ifosfami-de/cisplatin, 3 cycles) and 93 were diagnosed N2pM0 based on samples obtained from mediastinal lymph tissue during thoracotomy. Nineteen of the latter had previously been classified negative during surgical exploration. The patients diagnosed N2p after thoracotomy were given adjuvant ChT, radiotherapy or both. N2p patients who received induction therapy were given radiotherapy. Those found negative after lymphadenectomy and patients with severe disease were given no adjuvant treatment. RESULTS: Mean survival was 18 months for resected patients diagnosed N2 by mediastinoscopy/mediastinotomy and with induction ChT and survival at one, two and five years was 80%, 45% and 30%, respectively. No postoperative mortality was recorded in this group. One patient suffered bronchopleural fistula. Nine patients showed no residual mediastinal node disease after lymphadenectomy. The mean survival of resected patients diagnosed N2p by thoracotomy was 13 months, and one, two and five year survival rates were 56%, 31% and 19%, respectively. Fourteen patients died within 30 days of surgery. Nine patients developed a bronchopleural fistula. The difference in survival of the two groups was not significant. CONCLUSIONS: The prognosis after cytohistologic confirmation of N2 disease can be considered poor. Standard, complete surgery plus induction therapy in screened patients improved survival for those diagnosed N2 by thoracotomy, with no statistically significant differences.

Resultados del tratamiento quirúrgico y terapia combinada en el cáncer de pulmón no microcítico con invasión ganglionar mediastínica. Estudio retrospectivo / Surgery and combined therapy for non-small cell lung cancer with invasion of the mediastinal nodes. A retrospective study

OBJETIVO: Analizar la supervivencia de los pacientes clasificados N2M0 (N2 citohistológicos) con cáncer de pulmón no microcítico tratados mediante resección quirúrgica del tumor primario, linfadenectomía y terapias neo y adyuvantes asociadas. PACIENTES Y MÉTODOS: Entre 1.043 pacientes consecutivos con cáncer de pulmón valorados para cirugía desde 1990 hasta 2000, hallamos 155 clasificados N2M0 por histología y realizamos la exéresis quirúrgica del tumor pulmonar primario y la linfadenectomía en 116 pacientes de los 130 que llevaron toracotomía. En los 116 pacientes N2M0 con resección quirúrgica, 23 fueron diagnosticados N2c(C3) por mediastinoscopia y/o mediastinotomía y siguieron quimioterapia (QT) de inducción (mitomicina/ifosfamida/cisplatino, 3 ciclos), y otros 93 se diagnosticaron N2pM0 con las muestras obtenidas del tejido linfático mediastínico en la toracotomía; de estos últimos, 19 tenían una exploración quirúrgica mediastínica previa negativa. Los pacientes diagnosticados N2p tras la toracotomía siguieron tratamiento adyuvante con QT, radioterapia (RT), o ambas. A los N2p que siguieron terapia de inducción se les administró RT. Los negativizados tras la linfadenectomía y los pacientes graves no recibieron tratamiento adyuvante alguno. RESULTADOS: La mediana de supervivencia de los pacientes resecados (23/49) diagnosticados N2(C3) por mediastinoscopia/mediastinotomía y con QT de inducción fue de 18 meses, y la supervivencia al año, a los 2 y a los 5 años fue del 80, el 45 y el 30 por ciento, respectivamente. No hubo mortalidad postoperatoria en este grupo. Un paciente presentó una fístula boncopleural. En 9 pacientes no se evidenció enfermedad ganglionar mediastínica residual tras la linfadenectomía. La mediana de supervivencia de los pacientes resecados (93/106) diagnosticados N2p en la toracotomía fue de 13 meses, y al año, 2 y 5 años presentaron una supervivencia del 56, el 31 y el 19 por ciento, respectivamente. Fallecieron 14 personas en los 30 primeros días del postoperatorio. Nueve pacientes presentaron una fístula broncopleural. La diferencia de supervivencia entre los pacientes de ambos grupos no fue significativa. CONCLUSIONES: La confirmación citohistológica de enfermedad N2 puede considerarse de mal pronóstico. La cirugía estándar y completa, con terapia de inducción en los pacientes seleccionados, mejoró la supervivencia que presentaron aquellos diagnosticados N2 en la toracotomía, sin diferencias estadísticas significativas (AU)