[Results of N1 and N2 surgery in non-small cell lung cancer]. / Ergebnisse der N1- und N2-Chirurgie beim nichtkleinzelligen Lungenkarzinom.

Lymph node involvement in non-small cell lung cancer shows considerable heterogeneity within the N1 and N2 descriptors with respect to localization, the number of lymph nodes affected and the extent of mass and volume. In an attempt to reflect the different prognostic behavior of lymph node metastases, the 8th classification of the TNM has been published with proposals for further subtyping of the N1 and N2 stages into N1a, N1b, as well as N2a1, N2a2, and N2b. The aim of this article is to discuss the value of surgery of non-small cell lung cancer in the N1 and N2 lymph node metastatic stages. While overall survival benefits were seen after concomitant chemotherapy for patients with N1 metastatic disease and surgery, radiotherapy concepts did not provide any survival benefit in this subgroup. For patients with N2 metastasis, surgical resection is part of a multimodal treatment concept with chemotherapy and radiotherapy. Careful restaging after neoadjuvant therapy is recommended in order to provide surgical treatment to patients deemed suitable for curative (R0) resection. In particular, it should be noted that after inductive chemoradiotherapy, patients should only be treated by pneumonectomy in specialized centers, as resection can be associated with a high risk of postoperative complications. With respect to the new subtyping of the N2 involvement situation in N2a1, N2a2, and N2b, further adapted multimodal treatment concepts are expected in the future. Initial results are reported for stage IIIA patients and the use of video-assisted thoracoscopic surgery (VATS), robotic assisted thoracic surgery (RAST) and thoracotomy for local resection. These indicate that the use of minimally invasive techniques can achieve comparable results to open thoracotomy procedures, at least in specialized treatment centers.

Tumour-site-dependent expression profile of angiogenic factors in tumour-associated stroma of primary colorectal cancer and metastases.

BACKGROUND: Tumour-associated stroma has a critical role in tumour proliferation. Our aim was to determine a specific protein expression profile of stromal angiogenic cytokines and matrix metalloproteinases (MMPs) to identify potential biomarkers or new therapy targets. METHODS: Frozen tissue of primary colorectal cancer (n=25), liver (n=25) and lung metastases (n=23) was laser-microdissected to obtain tumour epithelial cells and adjacent tumour-associated stroma. Protein expression of nine angiogenic cytokines and eight MMPs was analysed using a multiplex-based protein assay. RESULTS: We found a differential expression of several MMPs and angiogenic cytokines in tumour cells compared with adjacent tumour stroma. Cluster analysis displayed a tumour-site-dependent stromal expression of MMPs and angiogenic cytokines. Univariate analysis identified stromal MMP-2 and MMP-3 in primary colorectal cancer, stromal MMP-1, -2, -3 and Angiopoietin-2 in lung metastases and stromal MMP-12 and VEGF in liver metastases as prognostic markers (P>0.05, respectively). Furthermore, stroma-derived Angiopoietin-2 proved to be an independent prognostic marker in colorectal lung metastases. CONCLUSION: Expression of MMPs and angiogenic cytokines in tumour cells and adjacent tumour stroma is dependent on the tumour site. Stroma-derived MMPs and angiogenic cytokines may be useful prognostic biomarkers. These data can be helpful to identify new agents for a targeted therapy in patients with colorectal cancer.

[Familial pulmonary cysts and papular skin lesions in a 37-year-old woman]. / Familiäre pulmonale Zysten und papulöse Hauteffloreszenzen bei einer 37-jährigen Patientin.

A 37-year-old female patient presented with sudden dyspnea and chest pain. Spontaneous pneumothoraces had been observed several times before in this patient and two members of the patient´s family in the last years. Moreover, she exhibited papular facial skin lesions. Radiomorphologically a pneumothorax apical on the left side and basal accentuated cystic lung destruction on both sides could be seen. Pleurodesis and several wedge resections with insertion of a drainage on the left side were performed therapeutically. Histology disclosed multiple cysts, whereby typical differential diagnoses could be excluded by immunohistochemistry. A molecular genetic investigation detected a heterozygous mutation in the gene coding for follikulin (FLCN). Thereby, Birt-Hogg-Dubé syndrome (BHDS) was diagnosed. BHDS follows autosomal dominant inheritance and is characterized by cystic lung lesions with recurrent pneumothoraces, cutaneous fibrofolliculomas and an increased risk of renal carcinomas. It is based on mutations in the gene coding for the protein FLCN on chromosome 17.

Synchronous pulmonary metastases from renal cell carcinoma--a whole nation study on prevalence and potential resectability.

BACKGROUND: At the time of diagnosis, almost one third of patients with renal cell carcinoma (RCC) have metastasis. We studied the prevalence, survival, and potential resectability of synchronous pulmonary metastases (SPMs) in a well-defined cohort of RCC patients. MATERIAL AND METHODS: A retrospective whole nation study including RCC patients with SPM diagnosed 1970-2005 in Iceland. Imaging studies and histology were reviewed, the TNM system used for staging the primary tumors, and disease-specific survival estimated. Eligibility for SPM removal was evaluated using different criteria from the literature on surgical management of SPM, including solitary SPM and SPMs confined to one lung. RESULTS: Altogether, 154 patients (16.9%) had SPMs. In 55 of these patients (35.7%) the lungs were the only site, with detailed information available in 46 cases. Of these 46 patients with SPMs, 15 were unilateral, and of those 11 were solitary. All of these 11 patients were in good physical condition and were deemed eligible for surgical resection; however, only one of them was operated with metastasectomy. Disease-specific survival at five years for patients with solitary SPM was 27.2%, as compared to 12.7%, 7.1%, and 12.0% for patients with unilateral SPMs, all patients with SPMs, and patients with extrapulmonal metastases, respectively (p = 0.33). CONCLUSION: At the time of diagnosis, 16.9% of RCC patients had SPM. In one in three of these SPM patients metastases were confined to the lungs, while one in five had solitary pulmonary metastases. Although the benefit of pulmonary metastasectomy in RCC is still debated and criteria for resection are not well defined, it appears that many RCC patients with SPM are potentially eligible for pulmonary metastasectomy.

Survival after pulmonary metastasectomy in patients with malignant melanoma.

BACKGROUND: Surgical resection is an important interdisciplinary treatment for pulmonary metastases of metastatic malignant melanoma. The purpose of this study was to determine the clinical course, outcome and prognostic factors in a subset of patients recently treated by metastasectomy. MATERIAL AND METHODS: Between 1995 and 2007, 30 patients (19 men, 11 women) with pulmonary metastases from malignant melanoma underwent pulmonary resection. Exclusion of primary tumor recurrence and other extrapulmonary metastases was mandatory for inclusion in the study. The median follow-up was 93.7 months. These patients' records were subsequently reviewed. RESULTS: Cumulative 5-year survival rate after pulmonary resection was 35.1% with a median survival of 18.3 months. Complete pulmonary resection was achieved in 27 patients who had a median survival of 20.5 months compared to 13.0 months after incomplete resection; however, completeness of resection was not a statistically prognostic factor for survival. Multivariate analysis identified gender as the only significant prognostic parameter for overall survival in the group of patients after complete resection of pulmonary metastases, with 9.4 months versus 25.0 months for the female and male group, respectively ( P = 0.022). CONCLUSIONS: We conclude that pulmonary metastasectomy for metastases of malignant melanoma is a safe treatment modality which may actually be of benefit in selected patients with stage IV malignant melanoma. When pulmonary metastases of malignant melanoma are present, every attempt should be made to completely resect all clinically detected metastases.

Identification of immunohistochemical prognostic markers for survival after resection of pulmonary metastases from colorectal carcinoma.

BACKGROUND: Although aggressive resection of pulmonary metastases prolongs the survival of patients with metastatic colorectal cancer, there is a need for predictive pathologic parameters to understand the key molecular events of metastatic progression. The aim of this study was to verify immunohistochemical markers in addition to established clinical parameters after surgery. METHODS: From our subset of patients undergoing resection of pulmonary metastases from metastatic colorectal carcinoma, we analyzed 39 patients (23 men and 16 women) between 2003 and 2007. Only patients who met the criteria for a potentially curative operation were included. All patients were analyzed with regard to age and sex, primary tumor location, stage of the primary tumor, history of hepatic metastases, number of pulmonary metastases, pre-thoracotomy carcinoembryonic (CEA) serum antigen level, and the presence of thoracic lymph node metastasis. Furthermore, we immunohistochemically investigated the expression of vascular endothelial growth factor (VEGF)-D, FBJ murine osteosarcoma viral oncogene homolog B (FOS-B), and melanoma antigen (MAGE)-A in the surgical specimens of pulmonary metastatic lesions. RESULTS: The overall 3-year survival was 50.6 %. A significantly longer survival was observed with multivariate analysis in patients with a pre-thoracotomy serum carcinoembryonic antigen level of no more than 4.2 ng/mL ( P = 0.001), and Dukes stage A or B primary tumor ( P = 0.001). A significantly longer recurrence-free survival was observed with multivariate analysis in patients without thoracic lymph node involvement compared to patients with pulmonary and/or mediastinal lymph node metastases ( P = 0.006). The stage of the primary tumor remained significant ( P = 0.029), and FOS-B expression in tumor cells showed a trend towards favorable recurrence-free survival after pulmonary metastasectomy ( P = 0.059). No statistically significant difference was found in the overall survival rate or recurrence-free survival rate of patients with expression of VEGF-D or MAGE-A antigen in pulmonary metastatic tumor cells. CONCLUSIONS: Our results suggest that in addition to clinically prognostic factors, FOS-B expression has a debatable impact on patient survival. We conclude that the evaluation of molecular and clinical prognostic parameters at the time of pulmonary metastasectomy offers a greater understanding of the metastatic process and provides important information for patient selection.

[Current surgical management of pulmonary metastases]. / Aktueller Stand in der chirurgischen Therapie von Lungenmetastasen.

Surgical resection has been the first choice for the treatment of isolated pulmonary metastases secondary to extrapulmonary malignancies. Despite recent advances, systemic chemotherapy for metastatic disease without the use of surgery is considered to be merely palliative, as there are rarely long-term survivors. Criteria for resection and prognostic parameters help facilitate patient selection. In addition to the established parameters the most significant factors in selecting patients for operation include the number of pulmonary metastases, disease-free interval, serum tumour marker level, and the question of mediastinal and hilar lymph node metastases. Complete surgical resection is critical to achieving long-term survival and is best accomplished via open thoracotomy accompanied by a systematic mediastinal and hilar lymph node dissection. The recent development of video-assisted thoracoscopic surgery (VATS) and advances in thoracic imaging technique has made the VATS approach more amenable for resection of small pulmonary nodules. However, the oncological radicality of VATS is questionable for pulmonary metastasectomy, thus the VATS approach is mostly limited to diagnostic purposes and in highly selected groups of patients with limited, peripherally located lesions. These operations should be performed preferably within a prospective study setting. All results together demonstrate that resection and re-resection of pulmonary metastases can be beneficial in patients, carefully selected by a multidisciplinary tumour board of thoracic surgeons and medical oncologists.

Recurrent pleural effusion: who benefits from a tunneled pleural catheter?

Recurrent malignant pleural effusion (MPE) is a common concomitant phenomenon of malignant disease, which can worsen the patient's quality of life and lead to significant morbidity. Tunneled indwelling pleural catheters (TIPC) offer new modalities in patients with recurrent MPE and impaired dilatability of the lung. We report on our experience with 100 consecutive patients suffering from recurrent benign (n = 12) and malignant pleural effusion (n = 88) who were treated with TIPC. The catheter was placed during a VATS procedure or under local anesthesia in an open technique. The median residence time of the TIPC was 70 days; spontaneous pleurodesis was achieved in 29 patients. The rate of complications was low: pleura empyema (n = 4), accidental dislodgement (n = 2), malfunction of the drainage (n = 3). In conclusion, TIPC is a useful method for the palliative treatment of patients with recurrent malignant or nonmalignant pleural effusions and 3 groups of patients seem to benefit most: a) patients with the intraoperative finding of a trapped lung in diagnostic VATS procedure; b) patients after a history of repeated pleuracenteses or previously failed attempts at pleurodesis; c) patients in a reduced condition with a limited lifespan due to underlying disease.

Diagnosis of pulmonary metastases with helical CT: the effect of imaging techniques.

OBJECTIVE: Survival in patients after surgical resection of pulmonary metastases correlates with the complete resection of all metastatic deposits. The purpose of this study was to evaluate the additional value of helical CT to see whether the slice thickness and the reading environment was a factor determining the accuracy of helical scans. METHODS: Between 2004 and 2007, 93 patients (62 men, 31 women) underwent complete resection of pulmonary metastases by open thoracotomy. A total of 125 thoracotomies were performed with manual palpation of the involved lung. We retrospectively examined the helical CT findings obtained using a 5-mm slice thickness in a routine preoperative analysis, and within this study a second reading was performed independently, using 3-mm slice thickness image sets. The CT images were evaluated in a consensus between two radiologists. RESULTS: Computed tomography scanning was performed a median of 12 days before thoracotomy (range 1-121 days). Analysis of helical CT in 5-mm slice thickness detected metastases with a sensitivity of 83.7 % whereas a 3-mm slice thickness had a sensitivity of 88.8 %. There were statistically significantly more lesions using helical CT and a 3-mm slice thickness technique than with the 5-mm slice thickness technique, compared to the surgical results ( P = 0.002). This was also found with regard to nodules which were finally histologically confirmed as lung metastases ( P = 0.014). CONCLUSIONS: We conclude that a reduced slice thickness may have an important positive impact on the treatment and outcome of patients with pulmonary metastases. The use of 3-mm slice thickness helical CT may raise the sensitivity for pulmonary metastases detection compared to 5-mm images, but the rate of false positive results may also increase.

An institutional study on thymomas and thymic carcinomas: experience in 77 patients.

BACKGROUND: Thymomas and thymic carcinomas are rare tumors of the anterior mediastinum. A WHO classification was introduced in 1999, which has been updated in 2004. Meanwhile, several retrospective studies have been carried out which have shown the prognostic significance of this classification together with Masaoka's staging system and the extent of surgery. PATIENTS AND METHODS: Between 1983 and 2000, 77 patients (37 male, 40 female) underwent resection of thymomas and thymic carcinomas in our institution. Complete resection was achieved in 57 patients. The median follow-up was 72.6 months. RESULTS: The overall 5-year survival rate was 71.4 %. The factors "histology" and "extent of resection" had the most important impact on survival. However, even among the patients with complete resection, 12 of them suffered a relapse. Among this patient group, the most important factors for disease-free survival were "tumor stage" and "histology". Patients with an incomplete resection had a 5-year survival rate of only 29 % in spite of adjuvant radiation and/or chemotherapy. Due to the high rate of relapse, the poor survival rate found in incompletely resected patients as well as the failure of classical chemotherapy regimens, especially in type B2 and type B3 thymomas and thymic carcinomas, the search for new chemotherapeutic schemes is mandatory. CONCLUSION: Our study shows that there are still encouraging therapeutic options for thymomas and thymic carinomas. Type B2, type B3 thymomas and thymic carcinomas have worse outcomes in spite of adjuvant chemo- and radiotherapies. Especially in patients with incomplete surgical resection the outcome remains poor.

[Treatment of pleural empyema]. / Behandlung des Pleuraempyems.

Pleural empyema remains a frequently encountered clinical problem and is responsible for significant morbidity and mortality worldwide. Its diagnosis may be difficult; delays in diagnosis and treatment may contribute to morbidity, complications, and mortality. The management of parapneumonic effusion and empyema depends on timely, stage-dependent therapy and the underlying etiology. Thoracentesis and antibiotics remain the cornerstones of treatment in stage I disease. In the early fibrinopurulent phase (stage II) thoracoscopic methods should be considered. As treatment strategy for this stage, fibrinopurulent pleural empyema entails thorough debridement of multiloculated collections from the pleural cavity by video-assisted thoracic surgery. After evacuation of multilocular effusions and the removal of fibrin deposits with drainage by two intercostal chest tubes, irrigation treatment helps to achieve clarity of the pleural discharge. Open thoracotomy and decortication are reserved for organized, multiloculated empyema with lung entrapment (stage III disease). Early drain removal may lead to rapid symptomatic recovery and complete resolution.

[Plastic surgical reconstruction of extensive thoracic wall defects after oncologic resection]. / Plastisch-chirurgische Rekonstruktion von Defekten der Thoraxwand nach onkologischen Resektionen. Interdisziplinäre Strategien.

In defect reconstruction following radical oncologic resection of malignant chest wall tumors, adequate soft-tissue reconstruction must be achieved along with function, stability, integrity, and aesthetics of the chest wall. The purpose of this retrospective analysis was to evaluate the oncoplastic concept following radical resection of malignant chest wall infiltration with an interdisciplinary approach. Between 1999 and 2005, 36 consecutive patients (nine males, 27 females, mean age 55 years, range 20-78) were treated with resection for malignant tumors of the chest wall. Indications were locally recurrent breast carcinoma (patient n=22), thymoma (n=1), and desmoid tumor (n=1). Primary lesions of the chest wall were spinalioma (n=1), sarcoma (n=7), and non-small-cell lung cancer (n=2). There were distant metastases of colon and cervical cancer in one patient each. Soft-tissue reconstruction was carried out using primary closure (n=1), external oblique flap (n=1), pectoralis major myocutaneous flap (n=3), latissimus dorsi myocutaneous flap (n=18), vertical or transversal rectus abdominis myocutaneous flap (n=9), free tensor fascia lata- flap (n=6), trapezius flap (n=1), serratus flap (n=1), and one filet flap. In 15 reconstructive procedures microvascular techniques were used. An average of 3.4 ribs were resected. Stability of the chest wall was obtained with synthetic meshes. The latissimus dorsi flap is considered the flap of choice in chest wall reconstruction. However, alternatives such as pectoralis major flap, VRAM/TRAM flap, free TFL flap, and serratus flap must also be considered. Low mortality and morbidity rates allow tumor resection and chest wall reconstruction even in a palliative setting.

Impact on pulmonary function after lobectomy in patients with chronic obstructive pulmonary disease.

OBJECTIVE: The purpose of this study was to evaluate the operative outcome and pulmonary function after lobectomy; this included systematic mediastinal and hilar lymph node dissection for primary non-small cell lung cancer or pulmonary metastases of extrapulmonary origin in patients with chronic obstructive pulmonary disease (COPD) and a preoperative FEV (1) of less than 1.5 l (< 80 % of predicted value) and FEV (1)/FVC < 70 % (COPD II degrees ). METHODS: A retrospective analysis was undertaken in 79 patients who had consecutively undergone lobectomy with a preoperative FEV (1) < 1.5 l (< 80 %) and FEV (1)/FVC < 70 % (COPD II degrees ). Inclusion criteria were the ability to complete pulmonary function tests and lobectomy for malignancy. Patients with small cell lung cancer and unable to quit smoking less than 6 months prior to surgery were excluded. In 38 cases, pulmonary function tests were performed at 3 months after surgery, and 16 patients had tests at 3 and 6 months. RESULTS: A total of 79 patients were included in this study, with a median age of 70 years (range: 45 - 85 years). The median preoperative FEV (1) was 1.3 l (range: 0.8 - 1.5 l), and patients underwent assisted ventilation for less than 1 hour after surgery (range: 0 - 214 h), and stayed for less than 24 h in the intensive care unit (range: 1 h-56 d). Three patients (3.8 %) died within 30 days after lobectomy. In 14 patients, additional treatment for surgical complications was performed (17.7 %). Follow-up after surgery revealed a significant decrease in FVC and FEV (1) (- 17 % and - 8 %, P < 0.005), but function had improved again (+ 10 % and + 11 %, P < 0.05) at 3 months after surgery and remained stable at 6 months after lobectomy. No statistically significant changes were noticed for paO (2) and paCO (2) values after surgical treatment. CONCLUSIONS: It appears that surgical resection of malignant lung tumours by lobectomy can also be performed successfully in selected patients with low FEV (1) and COPD II degrees without significant loss of pulmonary function.

Bilateral surgical resection in pulmonary epitheloid hemangioendothelioma.

Epitheloid hemangioendothelioma is a vascular tumour with an epitheloid appearance, originating from endothelial cells. Although it is a slow growing tumour, extensive pulmonary involvement, intrathoracic spread, and systemic spread have been documented. We present a case of epitheloid hemangioendothelioma of the lung in a patient with an initial diagnosis made by transthoracic biopsy. The prognosis is unpredictable, with life expectancy ranging from 1 to 20 years. There is no single effective treatment, though spontaneous regression and response to chemotherapy and interferon are reported. Our patient underwent pulmonary lobectomy of the right lower lobe and pulmonary wedge resection of the nodule located in the left lower lobe.

[Prognosis after complete surgical resection for non-small cell lung cancer based on the staging classification]. / Stadienabhängige Prognose nach lokal kompletter Resektion des nicht-kleinzelligen Lungenkarzinoms.

BACKGROUND AND OBJECTIVE: The importance of accurate staging according to the international TNM staging system of non-small cell lung cancer (NSCLC) for patient management and ascertaining individual prognosis cannot be overemphasized. The TNM classification is scheduled to be revised in 2007. In a large single-center collective we investigated the prognosis for patients who had complete resection of a NSCLC. PATIENTS AND METHODS: We retrospectively reviewed hospital records and follow-up data of 2,378 patients operated on between 1996 and 2005 for NSCLC. Complete resection was achieved in 2,083 patients. Systematic hilar and mediastinal lymph node dissection was performed concurrently. Probability of survival was then analysed with the Kaplan-Meier method. The significance of differences between subgroups was calculated using the log-rank test. Odds ratios with 95 % confidence intervals (CI) were calculated for each characteristic. The Cox model was used for multivariate analyses. RESULTS: The 5-year survival for patients after complete resection was 50.7 %. The 5-year survival rates for clinical stages were 72 % for stage IA, 59.8 % for stage IB, not defined for stage IIA, 47,8 % for stage IIB, 45 % for stage IIIA, 38.7 % for stage IIIB, and not defined for stage IV. There were significant differences in survival between stages IIIB and IV (p = 0.013). There was a trend towards significance between patients with IA and IB (p = 0.052). However, there was no significant difference between patients with all the other stages. 5-year survival according to pathological stages was: stage IA 68.5 %; stage IB 66.6 %; stage IIA 55.3 %; stage IIB 49.0 %; stage IIIA 35.8 %; stage IIIB 35.4 %; stage IV not defined. Gender, age and type of histology were found by multivariate analysis to be significant independent prognostic factors for survival. CONCLUSIONS: The TNM and stage grouping classification is valid for defining prognosis and prognosis-related criteria in patients with NSCLC. The difference in prognosis between clinical stages IIIB and IV was significant, but not that between all the other related subgroups. Concordance with histological staging demonstrated the quality of existing clinical staging methods and related strategies. Complete surgical resection, age, gender, histology and stage of the disease significantly influenced long-term survival.

Pulmonary metastasectomy following chemotherapy in patients with testicular tumors: experience in 52 patients.

BACKGROUND: Surgical resection is an important form of treatment for residual post-chemotherapy pulmonary masses in patients with non-seminomatous germ cell tumors. We analyzed the outcome and prognostic factors after surgery. METHODS: Between 1996 and 2001, 52 patients underwent pulmonary resection of thoracic masses following cisplatin-based chemotherapy. These patients' records were subsequently reviewed. RESULTS: The overall 5-year survival rate was 75.8 %. A significantly longer survival was observed using multivariate analysis in patients with normal serum AFP and/or hCG tumor marker levels and after complete surgical resection. In patients with viable malignant tumor cells in the resected specimen and in patients with only necrosis/fibrosis or teratoma, the 5-year survival rates were 49.6 % and 82.8 %, respectively. This difference was only statistically significant in univariate analysis. CONCLUSIONS: We conclude that pulmonary resection in metastatic non-seminomatous germ cell tumors is a safe and effective treatment modality. Incomplete resection and elevated tumor marker levels, AFP and/or hCG, were identified as prognosis-related criteria for a poor outcome in multivariate analysis.

Pulmonary metastasectomy in patients with soft tissue sarcomas: experiences in 50 patients.

BACKGROUND: Pulmonary resection of metastatic soft tissue sarcomas is an accepted method of treatment. The purpose of this study was to determine the clinical course, outcome and prognostic factors after surgery. METHODS: Between 1996 and 2001, 50 patients (27 men, 23 women) with pulmonary metastases from a soft tissue sarcoma underwent surgical resection. Inclusion criteria for the study were the absence of primary tumor recurrence and other extrapulmonary metastases. Complete resection (CR) was achieved in 31 patients. RESULTS: The overall 5-year survival rate was 37.6 %. The 5-year survival rate after complete metastasectomy was 52.7 %, but none of the patients who underwent incomplete resection survived 3 years. Complete resection was found to be a significant prognostic factor for survival following metastasectomy ( P < 0.0001). Of the prognostic factors analyzed, age, sex, repeat thoracotomy, thoracic lymph node involvement, number of metastases, disease-free interval, histology and histological grading did not influence survival. CONCLUSION: We conclude that pulmonary resection of metastatic soft tissue sarcomas is a safe and effective treatment, which offers an improved survival benefit. Prognosis-related criteria are identified which support the necessity of complete surgical resection of all clinically detected metastases.

Surgical treatment of primary soft tissue sarcomas involving the chest: experiences in 25 patients.

BACKGROUND: Primary soft tissue sarcomas of the chest wall are uncommon and data concerning treatment and results are sparse. We reviewed our experience with chest wall resections of these lesions. METHODS: Retrospective review of our database identified 25 patients (12 men, 13 women) who underwent chest wall resection for primary soft tissue sarcoma during the 18-year study period (January 1984 through to January 2002). The mean follow-up period was 46.5 months. RESULTS: The 30-day mortality was zero. The cumulative 5-year survival rate of all 25 patients was 56.9 %, and the median survival 99.5 months. This compared with 42.2 % and a median survival of 36.0 months after chest wall resection for high grade tumor histology. Histological type grading clearly influenced long-term survival ( P = 0.036). Local recurrence occurred in 9 patients, 6 of 8 who were resected with positive margins and 3 of 17 who were resected with negative margins. Chest wall resections extended with lung resections did not significantly impair postoperative pulmonary function compared to patients without concomitant lung resections. CONCLUSIONS: Chest wall resections in primary soft tissue sarcomas can be accomplished safely with a low mortality rate. Long-term survival can be achieved for primary soft tissue sarcomas but histological grading is of prognostic significance.

Pulmonary resection for metastatic osteosarcomas: a retrospective analysis of 21 patients.

BACKGROUND: The use of pulmonary resection for metastatic osteosarcoma as an interdisciplinary treatment concept is being established. The purpose of this study was to determine the clinical course, outcome and prognostic factors in a subset of patients having undergone aggressive polychemotherapy in the most recent period and metastasectomy. METHODS: Between 1997 and 2001, 21 patients (8 men, 13 women) with pulmonary metastases from osteosarcoma of the limb underwent surgical resection. Exclusion of primary tumor recurrence and other extrapulmonary metastases was mandatory for inclusion in the study. Complete resection was achieved in 18 patients. The median follow-up was 60.6 months. RESULTS: Cumulative 5-year survival after complete resection was 34.2%. Of the prognostic factors analyzed, age, sex, repeated thoracotomy, and histologic grading did not influence survival. Complete resection was found to be a significant prognostic factor for survival following metastasectomy (p = 0.04). There was a tendency towards longer survival in patients with less than 7 pulmonary metastases compared to patients with more than 7 metastases, but the difference was not statistically significant (p = 0.07). CONCLUSION: With pulmonary metastases of osteosarcoma, every attempt should be made to completely resect all clinically detected metastases. Repeat thoracotomy in recurrent disease is compatible with long-term survival.

Surgical resection of secondary chest wall tumors.

OBJECTIVE: The objective of this study was to evaluate which factors influence survival following surgical resection of secondary tumors of the chest wall (non-bronchial carcinoma). METHODS: Between 1990 and 2001, 69 patients (23 men, 46 women) underwent chest wall resection with curative intent. All of the patients were retrospectively analyzed for sex and age, presenting symptoms, tumor location, disease-free interval, histology, radiation therapy or chemotherapy, surgical techniques and extent of resection, 30-day mortality and long-term survival. RESULTS: The most common tumors were isolated locally recurrent breast cancer (n = 33) and renal cell carcinoma (n = 17). Resection of chest wall tumors in all of the other patients revealed a kaleidoscope of different pathologies (n = 19). Overall 5-year survival was 38 %. In patients with isolated recurrence of breast cancer and in patients with chest wall metastases of renal cell cancer, the median survival was 40.6 months and 53.7 months, respectively. A disease-free interval of more than 24 months and no systemic chemotherapy after mastectomy were parameters for a favorable prognosis in patients with breast cancer. CONCLUSIONS: We conclude that chest wall resection of secondary chest wall tumors is a safe and effective treatment as part of a multidisciplinary approach. The role of surgery will continue to evolve as improvements in systemic treatment occur.