Cirugía vídeo-toracoscópica en el manejo diagnóstico-terapéutico de los derrames pericárdicos benignos / Video-assisted thoracoscopic surgery in the diagnostic-therapeutic management of benign pericardial effusions

Introducción. El derrame pericárdico es una entidad clínica que requiere un manejo multidisciplinar. Varios procedimientos han sido descritos para practicar una pericardiectomía parcial suficiente para garantizar el drenado óptimo y que, además, permita la toma de muestras biópsicas. El objetivo del presente trabajo es evaluar la rentabilidad de la pericardiectomía parcial mediante cirugía vídeo-toracoscópica (CVT) en los derrames pericárdicos con sospecha clínica de benignidad, valorando las indicaciones y su valor añadido frente a otras técnicas. Material y métodos. Hemos realizado pericardiectomías a 19 pacientes con sospecha clínica de benignidad por CVT. La indicación fue establecida ante la aparición de síntomas atribuibles al derrame o cuando se precisaba la toma de muestras. La presencia de signos radiológicos y/o ecográficos de pericarditis constrictiva o de inestabilidad clínica, fueron contraindicaciones para la técnica. Resultados. El diagnóstico tras estudio patológico fue de inflamación crónica en 6 casos, tuberculosis (TBC) activa en 2 y una pericarditis de origen urémico en otros 4. Etiología neoplásica no diagnosticada previamente fue establecida en 2 pacientes; en 5 casos se drenaron derrames postquirúrgicos de cirugía cardiaca. Conclusiones. La CVT resulta una técnica adecuada para el manejo diagnóstico-terapéutico de aquellos derrames pericárdicos no diagnosticados y en los postquirúrgicos. Su elevado rendimiento diagnóstico, su baja morbilidad y casi nula existencia de recidivas lo hacen especialmente indicado en casos en que se precise la toma de muestras y la supervivencia previsible sea larga (AU)

Introducción. Introduction. Pericardial effusion is a clinical disease that requires multidisciplinary management. Several procedures have been described to perform a sufficient partial pericardiectomy in order to assure optimum drainage and that would also permit biopsy samples to be obtained. The purpose of this work is to evaluate the profitability of the partial pericardiectomy through video-assisted thoracoscopic surgery (VTS) in pericardial effusions with clinical suspicion of benignancy, evaluating its indications and its added value compared to other techniques Material and methods. We have performed pericardiectomies in 19 patients with clinical suspicions of benignancy using VTS. The indication was established due to the appearance of symptoms that could be attributed to effusion or when it was necessary to obtain samples. The presence of radiological and/or ultrasonographic signs of constrictive pericarditis or clinical instability were contraindications for the technique. Results. The diagnosis after the pathology study was chronic inflammation in 6 cases, active tuberculosis (TBC) in 2 cases and uremic pericarditis in 4 more cases. Previously undiagnosed neoplastic etiology was established in 2 patients; in 5 cases, postsurgical effusions of cardiac surgery were drained. Conclusions. VTS is an adequate technique for the diagnostic-therapeutic management of those undiagnosed pericardial effusions and in post-surgical ones. Its high diagnostic performance, low morbidity and almost null existence of relapses has made it especially indicated in cases where it is necessary to obtain samples and the foreseeable survival is long (AU)

Expression of molecular markers in mediastinal nodes from resected stage I non-small-cell lung cancer (NSCLC): prognostic impact and potential role as markers of occult micrometastases.

BACKGROUND: Occult lymph node (LN) metastases are clinically relevant and confer a worse prognosis in non-small-cell lung cancer (NSCLC) patients. Current staging methods are unable to identify patients with poor outcome. Their detection requires both a more sensitive and specific technique. We aimed to assess the role of messenger RNA expression in pathologically negative LNs (pN0) of stage I NSCLC patients as markers of occult micrometastases and to correlate the results with local or distant tumor recurrence and survival. PATIENTS AND METHODS: Potential molecular markers were evaluated in 344 LNs and 38 tumors by quantitative real-time RT-PCR. Only CEACAM5 and PLUNC showed high expression in lung tumor tissue and null expression in RNA from benign LNs. RESULTS: Thirteen per cent of the LNs were positive for CEACAM5 and 16% for PLUNC. Eight of 38 NSCLC patients had positive expression in pN2 nodes by CEACAM5 and/or PLUNC and disease-free survival (P=0.028) and overall survival time was significantly worse in these patients compared with those with negative expression (P=0.0083). CONCLUSIONS: Quantitative real-time RT-PCR of CEACAM5 and PLUNC can estimate the presence of micrometastatic cells in LNs with greater precision than current staging method used for assessing tumor recurrence risk.

[Prognostic value of the carcinoembryonic antigen found in pleural lavage fluid from patients with lung carcinoma]. / Valor pronóstico del antígeno carcinoembrionario hallado en lavados pleurales de pacientes con carcinoma pulmonar.

OBJECTIVE: To detect the tumor marker carcinoembryonic antigen (CEA) in pleural lavage fluid taken during surgery from patients with pulmonary carcinoma without associated pleural effusion and assess its possible prognostic implications. PATIENTS AND METHODS: A prospective, observational study was undertaken to include consecutive patients who underwent surgical treatment for lung carcinoma in which pleural lavage was performed prior to closure of the thoracic cavity (study group). The same techniques and measurements were used in patients undergoing thoracotomy for benign disease (control group). The preoperative blood level of CEA was also quantified. RESULTS: In the study group, the median CEA levels in blood and pleural lavage fluid were 2.90 ng/mL and 0.40 ng/mL respectively; these figures are higher than those corresponding to the control group. A CEA level of 0.30 ng/mL in pleural lavage fluid was established as a cutoff point, based on the corresponding receiver operating characteristic curve, with a sensitivity of 68.4% and a specificity of 35.7%. A graph of survival in relation to this cutoff point revealed a statistically significant effect (P<.05). CONCLUSIONS: It is possible to detect CEA in pleural lavage fluid from the thoracic cavity of patients with lung carcinoma. The values obtained are higher than those found in fluid from patients without neoplastic disease, and this parameter functions as an independent predictor of disease course.

Valor pronóstico del antígeno carcinoembrionario hallado en lavados pleurales de pacientes con carcinoma pulmonar / Prognostic value of the carcinoembryonic antigen found in pleural lavage fluid from patients with lung carcinoma

OBJETIVO: Detectar el marcador tumoral antígeno carcino-embrionario (CEA) en lavados pleurales de pacientes con carcinoma pulmonar sin derrame pleural asociado, en el momento de la cirugía, a fin de estudiar sus posibles implicaciones pronósticas. PACIENTES Y MÉTODOS: Se trata de un estudio observacional prospectivo que recoge de forma consecutiva a los pacientes intervenidos de carcinoma pulmonar a los que se realizó lavado pleural de la cavidad torácica al finalizar su apertura (grupo de estudio). Se practicaron la misma técnica y medición en pacientes toracotomizados por enfermedades benignas (grupo control). También se cuantificó el valor del CEA sanguíneo preoperatorio. RESULTADOS: El CEA (mediana) sanguíneo en el grupo de estudio fue de 2,90 ng/ml y en el lavado pleural de 0,40 ng/ml, cifras superiores a las correspondientes del grupo control. Se estableció como punto de corte del CEA en el lavado pleural el valor de 0,30 ng/ml, establecido según la curva de eficacia diagnóstica correspondiente, con una sensibilidad del 68,4% y una especificidad del 35,7%. La gráfica de supervivencia en función de este punto de corte mostró significación estadística (p < 0,05). CONCLUSIONES: Es posible detectar CEA en lavados pleurales de la cavidad torácica en pacientes con carcinoma pulmonar, con valores superiores a los encontrados en pacientes sin enfermedad neoplásica. La medición de dicho valor es un factor pronóstico independiente en la evolución de la enfermedad

OBJECTIVE: To detect the tumor marker carcinoembryonic antigen (CEA) in pleural lavage fluid taken during surgery from patients with pulmonary carcinoma with out associated pleural effusion and assess its possible prognostic implications. PATIENTS AND METHODS: A prospective, observational study was undertaken to include consecutive patients who underwent surgical treatment for lung carcinoma in which pleural lavage was performed prior to closure of the thoracic cavity (study group). The same techniques and measurements were used in patients undergoing thoracotomy for benign disease (control group). The preoperative blood level of CEA was also quantified. RESULTS: In the study group, the median CEA levels in blood and pleural lavage fluid were 2.90 ng/mL and 0.40 ng/mL respectively; these figures are higher than those corresponding to the control group. A CEA level of 0.30 ng/mL in pleural lavage fluid was established as a cutoff point, based on the corresponding receiver operating characteristic curve, with a sensitivity of 68.4% and a specificity of 35.7%. A graph of survival in relation to this cutoff point revealed a statistically significant effect (P<.05). CONCLUSIONS: It is possible to detect CEA in pleural lavage fluid from the thoracic cavity of patients with lung carcinoma. The values obtained are higher than those found in fluid from patients without neoplastic disease, and this parameter functions as an independent predictor of disease course. A substantial number of patients died of causes unrelated to the NSCLC for which they had been treated

[Localized fibrous tumors of the pleura: clinical and surgical evaluation]. / Tumores fibrosos de localización pleural: valoración clinicoquirúrgica.

Solitary fibrous tumors of the pleura are uncommon and mainly arise in the pleura itself. Such tumors are generally asymptomatic and slow-growing. We report a series of 10 cases (8 men and 2 women with a mean age of 58.6 years) treated over a period of 54 months. The tumors were classified histologically as benign or malignant according to the criteria used by England. The treatment of choice was complete resection of the tumor. Six posterolateral thoracotomies and 4 video-assisted resections were performed. Histology showed a mixture of fibroblast-like cells and collagenous stroma. Sarcomatous degeneration was observed in the excised tumor of 1 patient. The patients were followed for a mean of 23.9 months. We conclude that although fibrous tumors of the pleura are considered benign histologically, complete resection and follow up for all patients are recommended.

Tumores fibrosos de localización pleural: valoración clinicoquirúrgica / Localized fibrous tumors of the pleura: clinical and surgical evaluation

Los tumores fibrosos pleurales solitarios son lesiones infrecuentes que en su mayoría derivan de la pleura. Generalmente asintomáticos, poseen un crecimiento lento. En el presente trabajo se describe una serie de 10 casos (8 varones y 2 mujeres, con una edad media de 58,6 años) tratados en un período de 54 meses. Histológicamente se clasificaron como benignos o malignos basándose en los criterios de England. El tratamiento de elección fue la cirugía con criterios de resección completa. Se realizaron 6 toracotomías posterolaterales y 4 resecciones por videocirugía. Microscópicamente estaban constituidos por células de aspecto fibroblástico, entremezcladas con estroma colagenizada. Uno de los pacientes presentó una degeneración sarcomatosa en la pieza. Se siguió a los pacientes en consultas, con un seguimiento medio de 23,9 meses. En conclusión, los tumores fibrosos pleurales, aunque considerados histológicamente benignos, precisan de la resección completa. Se recomienda el seguimiento evolutivo en todos los pacientes (AU)

[Intraparenchymal pulmonary inflammatory pseudotumors]. / Seudotumor inflamatorio pulmonar de localización intraparenquimatosa.

Inflammatory pseudotumors are rare entities which occasionally affect the pulmonary parenchyma. Their clinical diagnosis arises in a variety of ways and half the time they are detected by chance. Deciding on a therapeutic approach is difficult because a firm diagnosis is established only after studying the excised tissue. We describe our experience with the diagnosis, surgical treatment, and follow up of 4 cases of inflammatory pseudotumor located in the pulmonary parenchyma and treated by surgical resection (by thoracotomy or video assisted thoracoscopic surgery) with good outcomes following complete resection.

Seudotumor inflamatorio pulmonar de localizaciónintraparenquimatosa / Intraparenchymal Pulmonary Inflammatory Pseudotumors

Los tumores seudoinflamatorios son una rara entidad que en ocasiones afecta al parénquima pulmonar. Su diagnóstico clínico es variado, siendo un hallazgo casual en casi la mitad de los casos. Entraña una difícil decisión en cuanto a la mejor opción terapéutica, ya que el diagnóstico de certeza se establece tras el estudio de la pieza quirúrgica. Presentamos nuestra experiencia con el diagnóstico, tratamiento quirúrgico y seguimiento de 4 casos de tumores seudoinflamatorios de localización intraparenquimatosa tratados mediante resección quirúrgica (por toracotomía o cirugía videotoracoscópica) con buenos resultados tras la resección completa (AU)

[Video-assisted thoracoscopic surgery in the treatment of pneumothorax: 107 consecutive procedures]. / Cirugía videotoracoscópica en el tratamiento de los neumotórax: consideraciones sobre 107 procedimientos consecutivos.

The aim of this prospective study was to evaluate video-assisted thoracoscopic surgery (VATS) in primary and secondary spontaneous pneumothoraces. Over a 37-month period, 107 videothoracoscopic interventions were performed to treat spontaneous pneumothorax in 105 patients, 78 men and 27 women, whose average age was 28 years.Indications for surgery included recurrent ipsilateral pneumothorax (47 cases), persistent air leak (23 cases), hypertensive pneumothorax (14 cases), history of contralateral pneumothorax (13 cases), and elective surgery (10 cases). All of these patients were treated by endoscopic resection of the bullae (or apical zone in cases where the suspected abnormalities, or bullae, could not be visualized) plus physical pleurodesis. There were no perioperative deaths. Complications occurred in 6% of the cases of primary spontaneous pneumothorax and in 45% of the cases of secondary spontaneous pneumothorax. The complications among the secondary pneumothorax patients ranged widely from postoperative subcutaneous emphysema (resolved through simple, unassisted observation) to the need for an accessory minithoracotomy. Two patients (1.8%) suffered a recurrence of pneumothorax 4 and 8 months, respectively, after VATS treatment.

Cirugía videotoracoscópica en el tratamientode los neumotórax: consideraciones sobre107 procedimientos consecutivos / Video-assisted thoracoscopic surgery in the treatment of pneumothorax: 107 consecutive procedures

El objetivo del trabajo es valorar la cirugía videotoracoscópica en los neumotórax primarios y secundarios. Para ello se ha realizado un estudio prospectivo a lo largo de 37 meses, durante los cuales se practicaron 107 intervenciones videotoracoscópicas para el tratamiento de los neumotórax espontáneos en un total de 105 pacientes. Se incluyó a 78 varones y 27 mujeres con una edad media de 28 años. Las indicaciones quirúrgicas fueron: neumotórax recurrente ipsolateral en 47 casos; fuga aérea persistente en 23 casos; neumotórax hipertensivo en 14 ocasiones; cuadro de neumotórax contralateral antiguo en 13 casos, y cirugía electiva en 10 casos. Todos los pacientes fueron tratados con resección endoscópica de zona bullosa (o zona apical en caso de no visualizar la zona sospechosa) más pleurodesis física. No hubo mortalidad perioperatoria. Las complicaciones fueron del 6 por ciento en los casos de neumotórax espontáneos primarios y del 45 por ciento en los casos de neumotórax espontáneos secundarios, incluyendo éstas una amplia gama, desde el enfisema subcutáneo posquirúrgico resuelto con simple observación hasta la necesidad de minitoracotomía accesoria. Dos pacientes (1,8 por ciento) sufrieron recidiva del neumotórax a los 4 y 8 meses de la videocirugía, respectivamente (AU)

[Spontaneous pneumothorax as the first sign of pulmonary carcinoma]. / Neumotórax espontáneo como primera manifestación de un carcinoma pulmonar.

We report five cases of spontaneous pneumothorax as the first sign of pulmonary carcinoma. Initial tests did not detect neoplasms. Diagnosis took place during surgery for four patients and the fifth was diagnosed by preoperative computed tomography to assess pulmonary bullous emphysema. All five patients had persistent air leaks in spite of correct placement and functioning of drains, the reason for which surgery was scheduled. Three segmentectomies, one lobectomy and one exploratory thoracotomy for pleural metastasis were performed. Histopathologic diagnoses were 3 giant cell tumors, 1 adenocarcinoma and 1 non-mucinous bronchoalveolar carcinoma. We think that when risk factors are present, the existence of unresolved pneumothorax after correct placement of a drain should lead to a suspicion of associated pulmonary carcinoma.

Neumotórax espontáneo como primera manifestación de un carcinoma pulmonar / Spontaneous pneumothorax as the first sign of pulmonary carcinoma

Presentamos 5 casos de pacientes con un neumotórax espontáneo como primera manifestación de un carcinoma pulmonar. Las exploraciones complementarias iniciales no descubrieron la neoplasia. En 4 casos el diagnóstico fue intraoperatorio y en el quinto al realizar una tomografía computarizada preoperatoria para valorar un enfisema bulloso pulmonar. Todos los pacientes sufrieron fugas aéreas mantenidas pese a la correcta colocación y funcionamiento del drenaje, por lo que se indicó la cirugía. Se llevaron a cabo tres segmentectomías, una lobectomía y una toracotomía exploradora por metástasis pleurales. El examen histopatológico diagnosticó tres tumores de células grandes, un adenocarcinoma y un carcinoma bronquioloalveolar no mucinoso. Creemos que en presencia de factores de riesgo, la existencia de un neumotórax no resuelto tras correcta colocación de drenaje torácico debe poner ante la sospecha clínica de un carcinoma pulmonar asociado. (AU)

[Bronchoplasty in bronchopulmonary tumors. Review of 50 cases]. / Broncoplastias en tumores broncopulmonares. Revisión de cincuenta casos.

Bronchoplasty in oncological surgery is performed to remove a tumor while preserving most of the pulmonary parenchyma. Survival in selected patients is similar to survival after lung removal. We report a series of 50 bronchoplastic procedures performed in 37 patients with bronchopulmonary cancer. Twelve had carcinoid tumors and 1 had single lung metastasis from adenocarcinoma of the colon. Twenty-seven operations were performed on the right side and 23 on the left. The pulmonary parenchyma was not resected in 2 patients. The pulmonary artery was also repaired in 5 patients. Mortality at 30 days was 2% (1 patient) and survival at 5 years was 47% calculated according to the method of Kaplan-Meier. Survival was 37 months in only 1 of the 8 patients with mediastinal adenopathy, for whom complementary radiation therapy was provided. Survival among the patients with carcinoid tumors is 91.6% to date, as all but 1 are alive at present. The single death was due to intestinal diverticulosis. The patient with metastasis is alive 12 years after surgery. Spirometric function tests were performed in 17 patients 1 year after surgery and ventilation perfusion was studied in 13. A slight loss of forced vital capacity and maximum expiratory volume in 1 second, while ventilation perfusion corresponding to the parenchyma preserved was normal. Bronchoplasty is the treatment of choice for endobronchial tumors with low degrees of malignancy. Bronchoplasty is an effective surgical treatment for a select group of carcinomas.