Solitary metastasectomy in non-small cell lung cancer.

PURPOSE: Stage IV disease at initial presentation ac-counts for approximately 41% of newly diagnosed cases with non-small cell lung cancer (NSCLC). Although the majority of these patients have disseminated metastatic disease at diagnosis, a small percentage of them are found to have a solitary site of extrathoracic metastasis. In addition, patients who have received surgical or multimodality treatment with curative intent may experience metachronous solitary distant recurrences during the natural course of their disease. Our aim was to review the possible role of surgical resection in the management of NSCLC with solitary hematogenous metastasis. METHODS: We performed electronic literature search of PubMed, EMBASE and the Cochrane Library for articles in English using a number of key words. RESULTS: All identified studies reported survival benefit for patients operated for their single metastatic lesion. Patients with metachronous disease had slightly better prognosis than those with synchronous metastatic lesions. We found no prospective randomized trials comparing surgical and non-surgical treatment modalities for NSCLC with solitary hematogenous metastasis. CONCLUSIONS: Available evidence supports the presumption that in highly selected patients with isolated synchronous or metachronous hematogenous metastasis surgical resection as part of an aggressive approach positively affects patients' survival. Factors that are in favor of a satisfactory outcome include control of primary site, confirmed solitary metastatic disease, good performance status (PS), metachronous lesions and longer disease-free interval (DFI). Prospective randomized trials are necessary to provide stronger evidence. Finally, it is worth investigating the biology of these tumors presenting with single-site distant metastasis.

Catamenial pneumothorax.

Catamenial pneumothorax is a rare entity of spontaneous, recurrent pneumothorax occurring in synchrony with the menstrual cycle. The etiology is not completely known, but in most cases it is associated with thoracic endometriosis and/or diaphragmatic fenestrations. We report a case of a 35-year-old woman with three episodes of catamenial pneumothorax. The surgical findings were thoracic endometriosis and diaphragmatic holes. She underwent resection of the affected part of the diaphragm and pleurodesis via a mini-thoracotomy and videothoracoscopy assistance.

Coronary sinus venoarterial CO2 difference in different hemodynamic states.

Myocardial metabolic rate and coronary flow are closely related limiting thus the diagnostic value of coronary sinus saturation monitoring as an indicator of flow. Regional venoarterial CO2 gradient was found elevated during low flow in various clinical and experimental conditions, in animals and humans. This study was undertaken to examine the impact of the variations of cardiac mechanical work on veno-arterial CO2 content and partial pressure difference (deltaPCO2) of the coronary sinus blood. Twenty-seven patients of either sex (m/f = 21/6), undergoing coronary artery bypass grafting under extracorporeal circulation, were studied. Monitoring included a Swan-Ganz catheter and a coronary sinus line. The correct position of the late was verified by the waveform displayed in the monitor. Immediately after cannulae placement, a hemodynamic profile was obtained and simultaneous arterial and coronary sinus sampling for blood gas analysis was done in an ABL 720 (Radiometer Copenhagen) analyzer. A second collection of the same data was obtained five minutes later with the patients in a slight "head-down" position. Conditions for exclusion was intersample variation of hemoglobin's concentration greater than 15% and sodium ion concentration difference greater than 10% of the greater value. Arteriovenous oxygen partial pressure difference (deltaP(a-cs)O2), veno-arterial carbon dioxide partial pressure difference (deltaP(cs-a)CO2), O2 & CO2 content difference and heart's respiratory quotient were calculated and correlated to cardiac output (CO) and the other hemodynamic parameters. Statistical analysis employed t-paired test and linear regression. No ischemia was detected during sampling. "Head-down" position had a significant impact to all hemodynamic parameters except heart rate. In both data rows, although CO ranged widely and altered significantly, coronary sinus oxygen saturation and arteriovenous O2 content difference were stable and showed insignificant correlations to all the hemodynamic parameters that were studied. Carbon dioxide content difference (coronary sinus-arterial) showed a trending of decrease with higher flow. DeltaP(cs-a)CO2 appeared stable and independent of flow. Finally, respiratory quotient decreased significantly from 0.91 +/- 0.4 to 0.86 +/- 0.4 (mean +/- SD; p < 0.05). The heart's high basal oxygen consumption and the almost near hemoglobin's desaturation transcoronary extraction of oxygen limits the value of coronary sinus saturation monitoring as indicator of coronary flow. Heart's little extraction reserve is faced with coronary flow reserve. In the physiologic range and under the conditions of anesthesia, elevated CO2 production is accompanied with increased coronary flow. Under these circumstances, deltaP(cs-a)CO2 appears stable and is not suitable for clinical decisions concerning heart's coronary flow.