Risk of mortality from cardiovascular and respiratory causes in patients with chronic obstructive pulmonary disease submitted to follow-up after lung resection for non-small cell lung cancer.

AIM: Considerable controversy surrounds mortality from non-neoplastic diseases during the postoperative follow-up of patients with non-small cell lung cancer (NSCLC) and chronic obstructive pulmonary disease (COPD). This study investigated the incidence of mortality from cardiovascular and respiratory (CVR) causes in patients with COPD submitted to follow-up after lung resection for NSCLC, and identified preoperative and postoperative risk factors. METHODS: A total of 398 patients with mild or moderate COPD were followed up in our department after lung resection for NSCLC (median follow-up 61 months). Statistical analysis of the data was carried out to determine the incidence and the prognostic factors of postoperative death from CVR causes. RESULTS: Of the 398 resected patients, 186 survived without tumor recurrence; 24/186 (12.9%) died of CVR causes (acute respiratory failure, pneumonia, pulmonary embolism, acute pulmonary edema, acute myocardial ischemia or stroke). These 24 patients had a higher frequency of pre-existing coronary artery disease or heart failure (P=0.0003), predicted postoperative FEV1 <1000 mL (P=0.0008), exertional dyspnea (P=0.0000), and 30-day operative cardiopulmonary complications (P=0.001). Protective features were young age (<40 years), early stage disease, and minor resection (lobectomy). Independently significant adverse prognostic factors were stage III-IV disease (cumulative CVR death rate 47% at 5-10 years; P=0.028 vs. stage I-II) and completion pneumonectomy or partial resection of the other lung for a second primary tumor (cumulative CVR death rate 50% and 57%, respectively, at 5-10 years; P=0.0016 vs. all other resections). Older age and tumor histology were significant risk factors only in patients with advanced stage disease. CONCLUSION: The findings suggest that postoperative CVR death may be expected in patients with COPD and advanced stage NSCLC or in those undergoing completion pneumonectomy or partial resection of the other lung for a second primary tumor. Other risk factors are previous coronary artery disease and/or heart failure, exertional dyspnea and predicted postoperative FEV1 <1000 mL.

Isolated intestinal neurofibromatosis of colon. Single case report and review of the literature.

Isolated intestinal neurofibromatosis of the colon is a most unusual disease: from 1937 to 1999 only 12 cases have been reported. The differential diagnosis and treatment of this lesion are very difficult. A review of the literature is made and personal experience in the diagnosis and treatment of a case in a 68-year-old female is described.

Esophagocardiomyotomy with Dor gastroplasty in the treatment of esophageal achalasia.

Thirteen patients affected by achalasia of the esophagus, undergoing esophagocardiomyotomy with Dor gastroplasty, are reported. No postoperative deaths or complications occurred. Overall long-term results were satisfactory: excellent or good in 92.3% of cases, fair in 7.7%. Manometry after esophagocardiomyotomy as compared to preoperative assessment showed a decreased resting pressure in the esophageal body, in all patients in whom it was elevated, and the appearance of some peristaltic waves in 23.1% of them (3 patients). As for lower esophageal sphincter, some relaxation after deglutition was observed in one patient. The 24h pH monitoring showed signs of gastroesophageal reflux only in one patient. Based on the obtained results which compare well with those of the literature, the authors be believe that the procedure represents an effective treatment of esophageal achalasia.

Thymostimulin effect on the immune response in neoplastic patients submitted to surgical treatment.

We selected the data from performance status, disease state, skin tests, circulating lymphocytes and relative subsets, serum immunoglobulin classes to evaluate the immune response in 29 neoplastic patients treated with surgery and undergoing Thymostimulin administration during long term follow-up. Moderate drug intolerance was observed in 3 patients. After treatment lymphocyte count increase (41% mean increase) in 61.5% of cases; CD3, CD4, CD8, CD16 respectively 95-74-87-82% of cases; immunoglobulin classes in about 90% of cases. A clear-cut improvement of Karnofsky's index was observed in 34.6% of cases, worsening in 11.5%. A manifest improvement in the delayed hypersensitivity skin test resulted in 36% of cases. Most patients (85%) have shown signs of complete disease remission. Disease progression was observed only in 3 patients. There were no infections during this study.

The usefulness of biliary drainage for restoring liver function in obstructive jaundice.

In eighty patients with obstructive jaundice treated with percutaneous or endoscopic drainage, the results of biochemical liver-function tests (serum bilirubin, transaminase, gamma-glutamyl transferase, alkaline phosphatase, and albumin) were analyzed to evaluate the return of liver function after biliary decompression. Before decompression all the patients had increased serum concentrations of all the liver-function indicators measured. Conjugated bilirubin normalized within 7 days in 67.5% of the patients and within 14 days in 94.5%. The other serum responses normalized as follows: glutamic oxaloacetic transaminase (7 days in 45%, 14 days in 100%); glutamic pyruvic transaminase (7 days in 46.2%, 14 days in 100%); gamma-glutamyl transferase (7 days in 56.2%, 14 days in 89.1%); alkaline phosphatase (7 days in 52.5%, 14 days in 90.4%); and albumin (7 days in 100%, 14 days in 90.4%). The low mortality and morbidity rates in this series of patients with obstructive jaundice: 0% and 7% after endoscopic and 2.1% and 10.4% after percutaneous drainage suggest that biliary drainage has a valuable place in the preparation of jaundiced patients for surgery and in some cases provides a definitive intervention.

The role of surgery in stage IIIa non-small cell lung cancer. Surgery in IIIa NSCLC.

The authors have reviewed the records of 50 consecutive patients resected for stage IIIa non-small cell lung cancer and included in a long-term follow-up study at the 1st Department of Surgery, University of Rome "La Sapienza". Overall survival was 60-20-16.6-16.6% at 1-5-7-10 years with an incidence of recurrence and/or metastasis respectively of 56-80-85.6-85.6%. These percentages were not influenced by the histological type. Tumours with the best prognosis were those classified as T1N2 and T3N0 (7-year survival rate: 33.3 and 29.4% respectively). Tumours with the worst prognosis were those classified as T3N2 with the highest incidence of relapse after 6 months (T3N0 vs T3N2 0.01 < p < 0.025) and no survival after 3 years (T3N0 vs T3N2 0.005 < p < 0.01). Regarding T3 tumours, infiltration of mediastinal pleura or pericardium was a negative prognostic factor implying no survival at 30 months. Involvement of chest wall or parietal pleura showed better survival overall although not statistically significant (10-year survival rate: 37.4 vs 24% respectively).

Rhodococcus equi pneumonia in a patient with occult HIV infection: successful therapy.

We report a case of Rhodococcus equi cavitary pneumonia in a 37-year-old patient with occult HIV infection. Because of his good immune status, the patient was given oral erythromycin and rifampin which rapidly resolved the infection. This modality of treatment may be sufficient in HIV-positive selected patients fur the resolution of Rhodococcus equi pneumonia.

Thymostimulin effect on the immune response in pulmonary carcinoma with or without surgical treatment.

Experience with 54 patients affected by pulmonary carcinoma treated or not with surgery and undergoing thymostimulin administration during long-term follow-up (70 mg i.m. every other day for 3 months), is reported. Drug intolerance was observed in 5.5% of cases. In patients who were able to complete the therapeutic cycle (50 cases) objective improvement of Performance Status was obtained in 46% of cases and subjective improvement in nearly 90%. The course of neoplastic disease showed definite progression (presence of local recurrence or distant metastasis) in 20% of cases, remission in 6%. No case of onset of pulmonary or extrapulmonary infections was observed. After treatment, a significant increase (between 24% and 108%) in blood parameters (circulation lymphocytes, CD3, CD4, CD8, CD16, IgG, IgA, IgM) was observed in 28-56% of cases. As for CD4 increase, this was accompanied by concomitantly positive Merieaux test in 44.5% of cases. Quiescence or complete remission has appeared to occur together with high CD16 values, progression with high CD8 and low CD16 values.

Diagnosis controversies for adrenal ganglioneuroma.

The authors report a case of adrenal ganglioneuroma which was incidentally diagnosed performing preoperative examination for a sigmoid carcinoma. The authors took this finding as a starting point to underline the rarity of this condition and its chance discovery, this being due to the rare presence of signs and symptoms and its frequent association with other synchronous neoplasms; all this makes differential diagnosis rather difficult.

Carcinoma of the duodenum: management and survival in 14 cases.

AIMS: The aim of this study is to evaluate the role of surgery in the treatment of adenocarcinoma of the duodenum. METHODS: From 1955 to 1994, 14 patients with primary adenocarcinoma of the duodenum underwent surgical treatment in our department. Presenting signs and symptoms were mainly related to obstruction and bleeding. Upper gastrointestinal contrast study, Computed Tomography (CT) and duodenoscopy were the primary diagnostic procedure modalities. All diagnoses were confirmed histologically. The tumors were staged pathologically according to the new TNM classification (UICC, 1992). Eight patients received palliative treatment or exploratory laparotomy. The remaining 6 patients were resectable for cure. RESULT: Operative mortality was 35.7%. The 5-year survival rate for patients who underwent curative resection was 33.3%. None of the patients who underwent palliative procedures or exploratory laparotomy survived for more than 11 months. CONCLUSIONS: In the management of resectable adenocarcinomas of the duodenum surgical radicality including lymphadenectomy should be pursued. Unresectable adenocarcinomas treated with palliative procedure had a very poor prognosis.

Lung cancer in young patients.

Despite the increasing frequency of lung cancer, the percentage occurring in young patients is very low (1.3-5.5% of all lung cancers). In 1992, of the 78,124 cases observed in Italy, 2.8% involved patients under 40 years of age. We reviewed a series of 800 patients with histologically proven lung cancer, candidates to a long-term follow-up. Of these, 23 (2.9%) were under 40 years of age, with a low male/female ratio (1.87:1). Fifty-two percent were smokers and 82.6% presented symptoms as the time of diagnosis. The most frequent histologic types were adenocarcinoma and large-cell type, which carried a better outcome (10-year survival of 28.5%) than epidermoid and small-cell types (p = 0.013). These tumors detected in 13% and 17.4% of cases, were unresectable (except for one epidermoid carcinoma), with a survival expectancy of 0% at two years. Considering all patients, resection was possible in nine cases, being curative in seven, with an overall 10-year survival rate of 44.4% (p = 0.002 vs non-resected patients). Stage I-II had the best prognosis with a 10-year survival rate of 80% (p = 0.022 vs resected stage III-IV). Patients undergoing primary chemotherapy and/or radiotherapy had the worst prognosis with no survivors at 30 months. In young patients clinical and pathological parameters had almost the same distribution except for sex and histologic type and offered almost the same survival probability as in patients over 40 years of age. When prognostic findings were tested by univariate analysis, only resectability was found to have an independent favourable impact on survival (hazard risk: 7.47; 95% confidence interval: 1.50-37.14).

Ventilation-perfusion mismatching as prognostic factor of respiratory failure after pulmonary resection.

This paper reports the results of a retrospective study undertaken to assess the reliability of regional ventilation-perfusion pulmonary scanning in predicting the remaining respiratory function (pFEV1), and the early and long-term outcome of 33 patients with chronic airways disease, submitted to pulmonary resection at the 1st Department of Surgery. All patients had been diagnosed as resectable with the traditional tools and had a traditional pFEV1 (tpFEV1) greater than 800 ml. All pFEV1 were re-calculated (npFEV1) with our new formula which also includes as lost for function all lung areas not to be resected with V/Q mismatching. Normal perfusion and ventilation distribution was found in 24.2% of patients in the lesion area and in 33.3% in the remaining pulmonary areas. An impairment of perfusion was observed in the lesion area in 72.7% of patients, in the remaining areas in 48.4%. An impairment of ventilation was observed in the same regions in 66.6% and 48.5% of patients, respectively. Abnormality in ventilation/perfusion matching occurred in the lesion area in 15.2% of cases, in the ipsilateral lung areas in 18.2%, in the contralateral lung in 48.4% of cases. In predicting postoperative FEV1, and early and long-term mortality among our resectable patients, the tpFEV1 showed an accuracy of 91%, an index of resectability of 93.7%, of unresectability of 0%. Our npFEV1 reached an accuracy of 94.4%, an index of resectability of 100% and an index of unresectability of 66.7%.

Results of surgical treatment of stage IIIA non-small cell lung cancer.

From 1975 to 1993, 665 patients with non-small cell lung carcinoma (NSCLC) were studied in our Unit. Of the 55 stage IIIA patients submitted to resection, 50 were followed-up in order to evaluate the effectiveness of surgery and to identify which variables had a prognostic impact on survival. The expectancy of survival at 3,5 and 10 years was 31.7, 19.5 and 13.7%, respectively. When the analysis was limited to N2 patients, 3,5- and 10-year survival rates were 20.9, 14 and 7%, respectively. Regarding the "TN" factor, the T3N0 subset presented the highest expected survival (24.8 and 18.6% at 5 and 10 years). With regard to the "T3" factor and type of surgery, peripheral tumors submitted to en bloc resection of the chest wall showed the best 5-year survival rate (42.9%), whereas extrapleural resections--even for tumors confined to the parietal pleura--showed a 5-year survival rate of 14.3%. A slightly higher risk of death was observed in tumors originating in the superior sulcus (SST). No patients with mediastinal pleura and pericardium involvement survived more than 34 months. With univariate analysis, "N2" was the variable most significantly associated with a negative prognosis when related to T3 (T3N2 vs T3N0 0.025 < P < 0.05) or non-epidermoid tumor (no survivors at 3 years; N2 epidermoid vs N2 non-epidermoid tumor P < 0.05). Applying multivariate analysis, epidermoid cell type, even if exclusively for N2 tumors, was an independent prognostic factor, showing a favorable impact on survival expectancy (27.8% at 90 months).

Local and/or distant recurrences in T1-2/N0-1 non-small cell lung cancer.

Data from a series of 181 patients subjected to long-term follow-up after surgical resection for non-small cell stage I and II lung cancer were analyzed to evaluate the statistical incidence and the prognostic factors of recurrence. The recurrence rate/year was particularly high in the first 2 years after surgery: the 2-year recurrence rate was 35.1% in stage I tumors and 51.8% in stage II, whereas the 5- and 7-year recurrence rates were 46.1 and 55.9% and 65.8 and 70.7%, respectively, for the same groups. Recurrences were observed more frequently in non-epidermoid carcinomas with multiple nodules (100% at 5 years) and in carcinomas classified as stage II (70.7% at 5-7 years), particularly when defined as adenocarcinoma (100% at 3 years). In the overall recurrence rate we observed no significant difference dependent on the type of resection even though limited segmental or wedge resection appeared to be related to a higher risk rate (true recurrence rate ratio: 0.6). Over two-thirds of the first observed recurrences were located at a distant site, with a slightly higher incidence of non-epidermoid carcinoma (72.5%). Isolated local recurrence mostly occurred in epidermoid carcinoma (47.6%). The most frequent sites of recurrence were the brain, bone and mediastinum. On multivariate analysis, independently significant adverse prognostic factors regarding the recurrence incidence were: tumor size greater than 3 cm, bronchial or hilar lymph node involvement, tumor histologically defined as adenocarcinoma, and the presence of satellite nodules.

Technetium-99m tetrofosmin single photon emission computed tomography in the evaluation of suspected lung cancer.

Technetium-99m-tetrofosmin is a radiopharmaceutical employed for myocardial imaging, which has recently emerged as useful in the visualization of tumors. In this study technetium-99m-tetrofosmin was evaluated for its accuracy in differentiating malignant from benign pulmonary lesions, and in detecting mediastinal node metastasis due to lung cancer. Eighty-one patients with a solitary lung lesion on the chest radiograph and/or CT scan were submitted to chest single photon emission computed tomography after technetium-99m-tetrofosmin injection (740 MBq i.v.). The scintigraphic findings were correlated to the final histopathological diagnosis, demonstrating abnormal tracer accumulation in 51 of 54 malignant lesions (sensitivity 94%) and in 4 out of 27 benign conditions (specificity 85%), yielding an accuracy of 91%. Mediastinal lymph-node involvement was evaluated in 35 patients with non small cell lung cancer who underwent mediastinoscopy and/or surgery. Tetrofosmin accuracy (89%) was significantly higher than that of CT (69%, p < 0.05); the false negative scintigraphic results were in nodes sized less than 1 cm. In conclusion, technetium-99m-tetrofosmin imaging is useful in distinguishing malignant from benign pulmonary lesions, and in non-invasively assessing mediastinal node metastases from non small cell lung cancer, especially in patients with enlarged nodes by CT scan.

Surgical approach to non-small cell lung cancer involving the chest wall.

Treatment of NSCLC invading the chest wall (T3) remains controversial. Surgery is undoubtedly the only chance for these neoplasms, but its role regarding the T3N2 tumors is highly questionable. Between 1975 and 1994, 710 NSCLC patients underwent surgery in our department. Of these, 38 with tumor involvement of the chest wall underwent curative resection: en bloc resection or extrapleural resection, and 31 of these patients (19 with T3N0 tumors and 12 with T3N1-N2 tumors) were available for estimating long-term survival. The overall survival was 20.5% at 5 years and 15.4% at 10 years. Patients without lymph-node involvement had a survival rate of 26.2% at 5 years and 19.27% at 10 years. No patient with T3N2 tumor was alive 5 years after surgery. Patients with T3N1 tumor had a survival rate of 16.7% at both 5 and 10 years. The difference between T3N0 and T3N2 tumors was statistically significant. Neither histologic type nor depth of chest wall involvement had a significant impact on survival. En bloc or extrapleural resection, if curative, can be effective in T3N0-N1 tumors. Surgery is inadequate for the treatment of T3N2 tumors with chest wall involvement.

Subcutaneous metastasis of pancreatic cancer in the site of percutaneous biliary drainage.

A subcutaneous metastatic lesion from a carcinoma of the pancreas or common bile-duct along the tract of a percutaneous transhepatic biliary drainage is a rare finding. Prompted by a case that came to our observation by chance, we reviewed the literature and analysed the 29 cases collected. Neoplastic cell seeding along a percutaneous drainage tract, albeit rare, must be kept in mind. The complication can be avoided if patients at risk, whenever possible, undergo endoscopic drainage.

Bronchioloalveolar carcinoma: clinical, radiographic, and pathological findings. Surgical results.

BACKGROUND: Bronchioloalveolar carcinoma (BAC) remains one of the most controversial of lung cancer subtypes. METHODS: From 1980 to 1998, 374 resected patients for NSCLC were followed up in our department. Of the 147 cases histologically defined as adenocarcinoma, 34 were pure BAC. The records of these 34 patients were retrospectively reviewed in order to evaluate patient and tumor characteristics and to identify which variables had a prognostic impact on survival and recurrence rate. RESULTS: Patient age, sex, smoking habits and symptoms were not differentiating characteristics when related to radiographic presentation or to natural history. Mucinous cell-type (23.6% of cases) was more frequent with non-smokers, presence of a single nodule or mass and stage I. Favorable characteristics were: a) the prevalence of stage I and N0 cases (59% and 76.7% of cases, respectively) with a mean survival time of 66 and 77 months, respectively; and b) the radiographic presentation of a solitary pulmonary nodule or mass (76.4% of cases), that, independently of nodal involvement, showed a higher mean survival time (62 months). Independently significant adverse prognostic factors were: stage II-IV, lymph node involvement, and patient age over sixty years. The radiographic presence of multiple or satellite nodules was related to a significantly adverse prognosis (mean survival time: 18 months) by univariate analysis; this was not confirmed by multivariate analysis. CONCLUSIONS: In our experience BAC was the NSCLC subtype more frequently associated with a good outcome after resection; surgery should not to be denied also in patients with multiple nodules, when under sixty years of age and no lymph node involvement.

Pericardial cysts of the mediastinum.

Pericardial cysts are an uncommon benign disease. Their treatment, in the past, was based on excision by thoracotomy or, in selected cases, on percutaneous aspiration. The progress of video-assisted thoracoscopy gave new possibilities, but most surgeons still consider the thoracotomic approach as the treatment of choice. The aim of this study is to report our experience and to discuss the role of different therapeutic procedures in the management of pericardial cysts. Between 1970 and 1996, 24 patients with pericardial cysts were treated at the first Department of Surgery of the University of Rome <>. Of 24 cysts, six were located in the right cardiophrenic angle, three in the left cardiophrenic angle, two in the subcarenal areas, one in the paracardiac area and one on the posterior mediastinum. Ten patients were asymptomatic. Diagnosis was performed preoperatively only in patients with cysts typically located in the cardiophrenic angle. Twenty-three patients were surgically treated by a standard posterolateral thoracotomy or limited thoracotomy with sparing of muscles. One patient underwent CT-guided transparietal fine-needle aspiration. There were no cases of operative mortality. Morbidity was 12.5% and consisted of retained secretions, moderate hypoxemia and partial atelectasis. All patients were submitted to a long-term follow-up and no cyst recurrences were found. We conclude that excision via thoracotomy is an optimal treatment for pericardial cysts. Limited thoracotomy with sparing muscles offers a good cosmetic result and a rapid functional respiratory recovery. Percutaneous cyst aspiration may be, in selected patients, an attractive alternative to surgery.

Lung cancer surgery in elderly patients.

AIMS AND BACKGROUND: Bronchogenic carcinoma is the major cancer-related cause of death in patients aged 70 years and over, and its incidence is rising. The aim of our study was to compare the incidence and the prognostic effect of the parameters characterizing resected patients with non-small-cell lung cancer (NSCLC) when stratified by age. Of 283 NSCLC patients candidates to a long-term follow-up program and who underwent pulmonary resection in our Unit, 34 (12%) were older than 70 years. METHODS: All patients had been preoperatively selected to exclude those with severe or multiple organ system disease and staged in accordance with the UICC classification. RESULTS: When univariate and multivariate analyses were performed within the elderly group, exclusively epidermoid carcinoma and multiple tumor nodules emerged as independent poor prognostic factors (hazard risk, 5.77 and 7.33, respectively). In comparing the older and younger groups, a higher incidence of previous primary neoplastic disease (P = 0.001), epidermoid carcinoma (P < 0.05) and multiple tumor nodules (P < 0.001) was observed in the elderly. Postoperative death was similar (3% vs 4.8%) in the two age groups, as was survival expectancy when stratified by stage. However, univariate analysis showed that epidermoid carcinoma (P = 0.001) and pneumonectomy (P = 0.00001) had a worse outcome in the older early stage subset than in the younger group. When multivariate analysis was performed in all early stage patients, only lymph node involvement and multiple tumor nodules were independently related to survival (hazard risk, 1.82 and 3.76, respectively) and had a poor prognosis. In more advanced disease, elderly and younger patients had a similar outcome. CONCLUSIONS: Our results confirm that a patient's advanced age is not a risk factor in deciding on pulmonary resection, at least for stage I and II NSCLC, and suggest that in all patients, irrespective of age, stage and histologic cell type, the presence of multiple tumor nodules is the only true prognostic factor with a very low survival rate.