Tumores malignos de la pared torácica / No disponible

Los tumores de la pared torácica son poco frecuentes. Con la finalidad de revisar los resultados obtenidos en el tratamiento, se presentan los casos tratados quirúrgicamente entre 1992 y 2009. La serie viene constituida por 35 pacientes (23 varones), con una edad media de 55 años (rangos 21-82). La presentación fue con síntomas de duración media de 8,9 meses en 30 casos. El diagnóstico se basó en los medios de imagen (radiografía simple 100%, tomografía computarizada 85,7%, gammagrafía ósea 20,1%, ecografía 17,1%, resonancia magnética 14,3%) y la biopsia de la masa (punción transtorácica 37,1%, biopsia incisional en el 5,7% y en el 62,9% biopsia escisional previa a lacirugía completa). El tratamiento quirúrgico fue la escisión completa con márgenes libres de 3-5 cm, cuando ello fue posible y la ulterior reconstrucción con mallas de pared y mioplastias. Se realizó un análisis de la supervivencia, valorándola en función de parámetros como la edad, sexo, tamaño del tumor y grado de malignidad del tumor. En 2 casos (5,7%) se quedaron márgenes afectos. Recibieron tratamiento adyuvante 11 pacientes (5 quimioterapia y 6 radioterapia). Se produjeron complicaciones postoperatorias en 6 casos (17,3%) y no hubo mortalidad postoperatoria. En cuanto al seguimiento, hubo recidiva locorregional en 6 casos (17,3%) y metástasis en 7 (20%). La supervivencia no se relacionó estadísticamente con el grado de malignidad del tumor. Se concluye que la cirugía de resección de los tumores primarios malignos de la pared torácica no tiene mortalidad en nuestra experiencia. Tiene una escasa morbilidad postoperatoria. Tienen una supervivencia no relacionada con el grado de malignidad de la neoplasia, siempre que se obtengan unos márgenes quirúrgicos correctos (AU)

tumors, we present our cases surgically treated between 1992 and 2009. The series is formed by 35 cases (23 males), with a mean age of 55 (ranges 21-82). The presentation was with symptoms of 8,9 month of average duration in 30 cases. Diagnosis was based in imaging test (chest radiography 100%, computed tomography 85,7%, bone scintigraphy 20,1%, ultrasonography 17,1%, magnetic resonance 14,3%) and tumor biopsy (transthoracic punction 37,1%, incisional biopsy 5,7% and excisional biopsy in 62,9% previous to complete surgical resection). Surgical reatment was complete excision with margin free tumor of 3-5 cm when it was possible and chest wall reconstruction with mesh and myoplastia. Survival analysis was made evaluating age, sex, tumor size and grade. There were affected margins in 2 cases (5,7%). Adjuvant treatment was used in 11 patients (5 chemotherapy, 6 radiotherapy). Postoperative complications were present in 6 cases (17,3%). There was not mortality. Local relapses were present in 6 patients (17,3%) and metastases in 7 (20%). Survival was not related with the tumor grade. We conclude that surgical treatment of malignant chest wall tumors has not mortality in our experience. Postoperative morbidity is low. Survival is not related to tumor grade if enough free tumor margins is obtained (AU)

Composite anatomical-clinical-molecular prognostic model in non-small cell lung cancer.

The objective of the present study was to elaborate a survival model that integrates anatomic factors, according to the 2010 seventh edition of the tumour, node and metastasis (TNM) staging system, with clinical and molecular factors. Pathologic TNM descriptors (group A), clinical variables (group B), laboratory parameters (group C) and molecular markers (tissue microarrays; group D) were collected from 512 early-stage nonsmall cell lung cancer (NSCLC) patients with complete resection. A multivariate analysis stepped supervised learning classification algorithm was used. The prognostic performance by groups was: areas under the receiver operating characteristic curve (C-index): 0.67 (group A), 0.65 (Group B), 0.57 (group C) and 0.65 (group D). Considering all variables together selected for each of the four groups (integrated group) the C-index was 0.74 (95% CI 0.70-0.79), with statistically significant differences compared with each isolated group (from p = 0.006 to p < 0.001). Variables with the greatest prognostic discrimination were the presence of another ipsilobar nodule and tumour size > 3 cm, followed by other anatomical and clinical factors, and molecular expressions of phosphorylated mammalian target of rapamycin (phospho-mTOR), Ki67cell proliferation index and phosphorylated acetyl-coenzyme A carboxylase. This study on early-stage NSCLC shows the benefit from integrating pathological TNM, clinical and molecular factors into a composite prognostic model. The model of the integrated group classified patients with significantly higher accuracy compared to the TNM 2010 staging.

Spontaneous pneumothorax and tuberculosis: long-term follow-up.

Though spontaneous pneumothorax (SP) is a well-known complication of pulmonary tuberculosis (TB), there are very few reports addressing this topic. For this reason, we retrospectively analysed the experience of SP in patients diagnosed with TB in our hospital between 1989 and 2010. Out of 872 patients treated for SP during this period, 47 (5.4%) had TB antecedents, 21 with active TB (0.95% of the 2,089 TB cases diagnosed during this period) and 26 with residual inactive TB. 46 cases were treated with pleural drainage (PD): 40 (85%) with only one PD, two with two, and four with three. The mean ± SD length of PD treatment was 12.9 ± 11.3 days. In 11 (23%) cases, a relapse of SP occurred, with no statistical relationship between the different studied variables. In 13 (28%) cases, it became necessary to carry out a resection (atypical segmentectomy in all cases) for persistent air leaks with PD. Survival statistics were unfavourable only in elderly patients and those infected with HIV. We conclude that the treatment of SP secondary to TB with PD is usually a sound response, with a good general prognosis and a low percentage of cases that require another PD and surgical treatment.

Hemotórax espontáneo por rotura de aneurisma de arteria pulmonar en la enfermedad de Rendu-Osler-Weber / Spontaneous pneumothorax due to a ruptured pulmonary artery aneurysm

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[Giant thymolipoma]. / Timolipoma gigante.

Thymolipoma is an uncommon benign tumor (accounting for 2% to 9% of thymus tumors). We present the case of a 26-year-old man who sought medical attention for left-sided pleural pain of 3 months duration. Computed tomography showed a mass in the left side of the chest occupying both the anterior mediastinum and the left pleural cavity. This mass caused lung collapse and mediastinal shift. Magnetic resonance imaging revealed a large fatty tumor and transthoracic biopsy with radiological guidance confirmed the diagnosis. The tumor was resected through a left thoracotomy. No postsurgical complications occurred and the histopathological diagnosis was thymolipoma.

Timolipoma gigante / Giant thymolipoma

El timolipoma es una neoplasia benigna poco frecuente (constituye del 2 al 9% de los tumores tímicos). Se presenta el caso de un varón de 26 años de edad que consultó por un dolor pleurítico izquierdo de 3 meses de evolución. La tomografía computarizada evidenció una masa torácica izquierda que ocupaba tanto el mediastino anterior como la cavidad pleural izquierda y provocaba un colapso pulmonar y una desviación mediastínica. La resonancia magnética puso de manifiesto una gran tumoración de origen graso y la biopsia transtorácica con control radiológico confirmó su etiología. Se intervino al paciente mediante toracotomía izquierda y se realizó una exéresis en bloque de la tumoración. El curso clínico postoperatorio transcurrió sin complicaciones y el diagnóstico histopatológico fue de timolipoma

Thymolipoma is an uncommon benign tumor (accounting for 2% to 9% of thymus tumors). We present the case of a 26-year-old man who sought medical attention for left-sided pleural pain of 3 months duration. Computed tomography showed a mass in the left side of the chest occupying both the anterior mediastinum and the left pleural cavity. This mass caused lung collapse and mediastinal shift. Magnetic resonance imaging revealed a large fatty tumor and transthoracic biopsy with radiological guidance confirmed the diagnosis. The tumor was resected through a left thoracotomy. No postsurgical complications occurred and the histopathological diagnosis was thymolipoma

¿Se ha modificado el abordaje quirúrgico del cáncer broncogénico? / Changes in the surgical treatment of lung cancer

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[Mediastinoscopy in the diagnosis of mediastinal disease. An analysis of 181 explorations]. / La mediastinoscopia para el diagnóstico de la enfermedad mediastínica: análisis de 181 exploraciones.

To validate our experience with standard cervical mediastinoscopy (SCM) and extended cervical mediastinoscopy (ECM) to diagnose mediastinal nodes and masses, we studied 181 patients between January 1992 and February 2001. SCM and ECM were indicated for diagnostic staging of nodes related to bronchogenic carcinoma (Group I) or of mediastinal masses (Group II). An SCM was performed in all cases to explore the paratracheal region (2R, 2L, 4R, 4L, 7, 10R and 10L); in 21 additional cases, an ECM was performed to explore the aortopulmonary window or the subaortic region (area 5) and the para-aortic region (area 6). In Group I, the sensitivity of SCM was 93.6% and specificity was 100%; the positive predictive value (PPV) was 100%, the negative predictive value (NPV) was 82.8%, and the diagnostic yield was 95.1%. The sensitivity of ECM was 91% and specificity was 100%; PPV was 100%, NPV 93.3% and yield was 96%. In Group II, the sensitivity was 93.3%, specificity 100%, PPV 100%, NPV 81.2% and diagnostic yield 94.8%. The sensitivity of ECM in this group was 80%, specificity was 100%, PPV 100%, NPV 66.7% and yield 85.7%. A 2.7% complication rate was observed, with one case of bleeding after injury to the superior vena cava, one tracheal lesion, one recurring paralysis and two cases of surgical wound infection. The mean postoperative stay was 36 hours and mortality was zero. We conclude that SCM is highly specific for the evaluation of mediastinal node involvement in bronchogenic carcinoma and it is the approach of choice when a diagnosis of lesions located in the mid-mediastinal region has not been reached. ECM is a valid, safe alternative to anterior mediastinotomy for staging nodes and masses occupying para-aortic zones or the aortopulmonary window, with good diagnostic yield, low morbidity and absence of mortality.

La mediastinoscopia para el diagnóstico de la enfermedad mediastínica: análisis de 181 exploraciones / Mediastinoscopy in the diagnosis of mediastinal disease. An analysis of 181 explorations

Para validar nuestra experiencia con la utilización de la mediastinoscopia cervical estándar (MCS) y la mediastinoscopia cervical extendida (MCE) en el diagnóstico de las adenopatías y masas del mediastino, se ha realizado este estudio entre enero de 1992 y febrero de 2001 sobre 181 pacientes. La MCS y MCE se han indicado para la estadificación ganglionar por carcinoma broncogénico (grupo I) y en el diagnóstico de las masas mediastínicas (grupo II). En todos los casos se ha efectuado una MCS para explorar la región paratraqueal (2R, 2L, 4R, 4L, 7, 10R, 10L) y en 32, además, una MCE para la ventana aortopulmonar o región subaórtica (área 5) y región paraaórtica (área 6). En el grupo I, la MCS ha demostrado una sensibilidad (S) del 93,6 per cent, especificidad (E) del 100 per cent, un valor predictivo positivo (VPP) del 100 per cent, un valor predictivo negativo (VPN) del 82,8 per cent y una rentabilidad diagnóstica (RD) del 95,1 per cent. La MCE ha tenido una S del 91 per cent, E del 100 per cent, VPP del 100 per cent, VPN del 93,3 per cent y una RD del 96 per cent. Para el grupo II, la MCS ha presentado una S del 93,3 per cent, E 100 per cent, VPP 100 per cent, VPN 81,2 per cent y una RD del 94,8 per cent mientras que la MCE en este grupo ha tenido una S del 80 per cent, E del 100 per cent, VPP 100 per cent, VPN 66,7 per cent y una RD del 85,7 per cent. El porcentaje de complicaciones ha sido del 2,7 per cent, destacando un sangrado por lesión de la vena cava superior, una laceración traqueal, una parálisis recurrencial y 2 casos de infección de la herida quirúrgica. La estancia media postoperatoria ha sido de 36 h y la mortalidad nula. Concluimos que la MCS es una técnica de gran especificidad en la valoración de la afección ganglionar mediastínica por carcinoma broncogénico y la prueba de elección ante la imposibilidad o ausencia de diagnóstico en las lesiones localizadas en el mediastino medio. La MCE es una alternativa válida y segura a la mediastinotomía anterior en la valoración de las adenopatías y masas que ocupan las regiones paraaórtica y ventana aortopulmonar, presentando una elevada rentabilidad diagnóstica, una baja morbilidad y una nula mortalidad. Para validar nuestra experiencia con la utilización de la mediastinoscopia cervical estándar (MCS) y la mediastinoscopia cervical extendida (MCE) en el diagnóstico de las adenopatías y masas del mediastino, se ha realizado este estudio entre enero de 1992 y febrero de 2001 sobre 181 pacientes. La MCS y MCE se han indicado para la estadificación ganglionar por carcinoma broncogénico (grupo I) y en el diagnóstico de las masas mediastínicas (grupo II). En todos los casos se ha efectuado una MCS para explorar la región paratraqueal (2R, 2L, 4R, 4L, 7, 10R, 10L) y en 32, además, una MCE para la ventana aortopulmonar o región subaórtica (área 5) y región paraaórtica (área 6). En el grupo I, la MCS ha demostrado una sensibilidad (S) del 93,6 per cent, especificidad (E) del 100 per cent, un valor predictivo positivo (VPP) del 100 per cent, un valor predictivo negativo (VPN) del 82,8 per cent y una rentabilidad diagnóstica (RD) del 95,1 per cent. La MCE ha tenido una S del 91 per cent, E del 100 per cent, VPP del 100 per cent, VPN del 93,3 per cent y una RD del 96 per cent. Para el grupo II, la MCS ha presentado una S del 93,3 per cent, E 100 per cent, VPP 100 per cent, VPN 81,2 per cent y una RD del 94,8 per cent mientras que la MCE en este grupo ha tenido una S del 80 per cent, E del 100 per cent, VPP 100 per cent, VPN 66,7 per cent y una RD del 85,7 per cent. El porcentaje de complicaciones ha sido del 2,7 per cent, destacando un sangrado por lesión de la vena cava superior, una laceración traqueal, una parálisis recurrencial y 2 casos de infección de la herida quirúrgica. La estancia media postoperatoria ha sido de 36 h y la mortalidad nula. Concluimos que la MCS es una técnica de gran especificidad en la valoración de la afección ganglionar mediastínica por carcinoma broncogénico y la prueba de elección ante la imposibilidad o ausencia de diagnóstico en las lesiones localizadas en el mediastino medio. La MCE es una alternativa válida y segura a la mediastinotomía anterior en la valoración de las adenopatías y masas que ocupan las regiones paraaórtica y ventana aortopulmonar, presentando una elevada rentabilidad diagnóstica, una baja morbilidad y una nula mortalidad (AU)

Cirugía videotoracoscópica: problemas perioperatorios y complicaciones postoperatorias inmediatas. Análisis de 1.573 casos registrados por el Grupo Cooperativo de Cirugía Videotoracoscópica SEPAR (GCCVTSEPAR) / Video-assisted thoracoscopic surgery: perioperative problems and complications in the immediate postoperative period. Analysis of 1,573 patients registered by the video-thoracoscopic surgery cooperative group separ (gccvt-separ)

Introducción. La cirugía videotoracoscópica ha tenido una gran expansión desde sus primeras descripciones en 1990. Numerosos trabajos han descrito sus ventajas, pero existen escasas referencias en cuanto a complicaciones. Material y método. Con la finalidad de describir las principales complicaciones y problemas perioperatorios se realiza este trabajo multicéntrico en 17 hospitales, analizando de forma prospectiva las complicaciones derivadas de la técnica. Se han recopilado un total de 1.573 procedimientos durante los dos años de recogida de casos (julio de 1996 a julio de 1998).Resultados. La mayoría de las indicaciones han sido para tratamiento de neumotórax espontáneo (45,4 por ciento), realización de biopsias pulmonares (18,4 por ciento), resección de nódulos pulmonares (13,3 por ciento) y simpatectomía torácica (5,3 por ciento). El total de conversiones a toracotomía ha sido de 167 (10,6 por ciento) y el de complicaciones de 171 (10,8 por ciento), destacando las fugas aéreas persistentes (37 por ciento de las complicaciones). Ha habido 10 fallecimientos (0,6 por ciento).Conclusiones. La mayoría de las indicaciones se llevan a cabo en procedimientos quirúrgicos concretos y bien establecidos. La complicación más frecuente ha sido la presencia de fugas aéreas persistentes. La mortalidad se ha limitado a casos de mala situación pulmonar previa (AU)

[Recurring invasive thymoma of the diaphragm]. / Timoma invasor recidivante en el diafragma.

Diaphragmatic recurrence of a thymoma is rare. We report the case of a 70-year-old woman who underwent transternal thymectomy and adjuvant radiation therapy, and who was admitted four years later with recurrence of the thymoma in the left hemidiaphragm with infiltration of the inferior ipsilateral pulmonary lobe. The thymoma was excised along with the left hemidiaphragm, chest wall and three ribs and an atypical segmentectomy of the left lower lobe was performed. The hemidiaphragm was reconstructed and the chest wall was repaired with synthetic mesh. Surgery was complemented with radiotherapy.

[Transthoracic approach to the spinal column]. / Abordaje transtorácico de la columna vertebral.

Thoracotomy is used to approach and treat anterior spinal lesions arising from various causes. Between 1990 and 1997, we treated 56 patients (40 men and 16 women) between 14 and 67 years old (mean 38.4). All had spinal lesions that were impossible or difficult to reach by a posterior approach. Thirty-one (55.3%) had suffered spinal damage, 8 (14.3%) had spinal deformities, 7 (12.5%) had metastatic tumors, 5 (8.9%) had herniated discs, 4 (7.1%) had Pott's disease and 1 (1.8%) had osteolysis at D6. Thoracotomy was left-sided in 35 cases (62.5%) and right-sided in 19 (33.9%). Video-assisted thoracoscopy was used twice (3.6%). The level of incision was based on the site of the lesion, and the pleural cavity was opened in all cases except one. The posterolateral pleuro-diaphragmatic fold was dissected and the diaphragm opened for retroperitoneal access in 37 cases (66.1%) of thoracolumbar disease. Orthopedic treatment consisted of autologous bone grafts in all cases and placement of a Kaneda splint in 32 cases (57.1%). One patient had to undergo surgery a second time due to inappropriate placement of the vertebral splint. Pneumothorax occurred in one patient after removal of pleural drains. The incision became infected in one patient, and one case of ileal paralysis was observed. Overall, morbidity was 7.1%. We conclude that thoracotomy offers a good alternative approach to spinal lesions. Results are good and morbidity low.

Surgical indications for treatment of pulmonary tuberculosis.

Surgery for pulmonary tuberculosis (PTB) has passed through various stages throughout history, having been the treatment of choice in the past. It has now been relegated to second place for treatment of this disease. One of the most strongly debated surgical indications has been clinical picture of multidrug resistance with the focus of pulmonary tuberculous activity located in a segment, lobe, or lung. In these cases some authors have described good results with surgical excision. Another important indication is the complications of PTB, among which bronchiectases (provoking pictures of suppuration, superinfections, or hemoptysis) are found, along with known destructive pulmonary sequelae such as destroyed lung, massive hemoptysis, and the presence of a bronchopleural fistula that cannot be resolved with pleural drainage. The presence of a neoplasm in a patient affected by PTB is a surgical indication if the lesion is resectable. The existence of an unidentifiable pulmonary mass or node is a surgical criterion because it might signal bronchogenic carcinoma. A frequent indication for surgery is pulmonary aspergilloma, which in a large percentage of cases is a destructive PTB sequela and generates serious complications, hemoptysis being the most frequent. Mediastinal tuberculous lymphadenitis that produces compressive symptoms and pulmonary complications, especially in children, is another surgical indication for decompressing the bronchial tree. The surgery in these cases consists in excision and curettage of adenopathies. Surgery therefore now constitutes a valid option for the treatment of certain clinical pictures of PTB that do not respond to medical treatment, are serious, and are potentially fatal.

Surgical treatment of primary spontaneous pneumothorax with video-assisted thoracic surgery.

We report the results of our experience using video-assisted thoracoscopic surgery (VATS) to treat primary spontaneous pneumothorax (PSP) from January 1992 until December 1994 in a multicentered co-operative study. A total of 132 patients (110 males and 22 females, aged 13-38 yrs, mean age 26 yrs) were treated by VATS to deal with the PSP that they presented with. A standard VATS technique was used. Apical bullae were always removed, and mechanical pleural abrasion was performed, leaving a pleural drainage tube. In two cases (1.5%), a switch to thoracotomy was necessary. In eight cases (6%), air leakage persisted for 5 days after surgery, which resolved with pleural drainage. There were eight postoperative relapses (6%), which were treated with pleural drainage (n = 4), VATS (n = 3) or axillar thoracotomy (n = 1). The average postoperative stay was 5.6 days (range 2-15 days). We conclude that video-assisted thoracoscopic surgery is a viable alternative for the treatment of primary spontaneous pneumothorax. There is, however, a high relapse rate, and in a number of cases air leakage persists in the postoperative period.