[The prognostic effect of natural killer cell infiltration to tumoral tissues in stage I non-small cell lung cancer]. / Evre I küçük hücreli disi akciger kanserinde tümör dokusuna natural killer hücre infiltrasyonunun prognoza etkisi.

Lung cancer is the most common type of cancer among males and females in developed countries. Currently, the five-year survival rate of lung cancer patients is 14%. Immune system has been considered to play an important role in the development and metastasis of lung cancer. In this study, natural killer (NK) cell infiltration was evaluated in the tumor tissues of 40 patients with stage I non-small cell lung cancer (NSCLC) to evaluate its effect on the prognosis. The evaluation included the tissue samples of 40 patients who underwent resection due to NSCLC between 1994 and 1998 in Ankara University Medical School, Chest Surgery Department. All the patients had stage I squamous cell carcinoma. The patients were followed-up for 4-8 years postoperatively. NK cell counts varied between 1 and 86 (mean: 13.63 +/- 11.86). The patients were divided into two groups according to their cell counts as low (n= 24) and high (n= 16). The mean survival time of the group with low NK cell count was 52 +/- 6 months and the mean five-year survival rate was 51%. The mean survival time of the group with high NK cell count was 58 +/- 4 months and the mean five-year survival rate was 68%. No statistically significant difference was detected between the two groups for five-year survival time (p= 0.15). As a result, in our study we did not find any significant effect of natural killer infiltration on tumoral tissue in prognosis of stage I NSCLC.

Comparison of mersilene mesh-methyl metacrylate sandwich and polytetrafluoroethylene grafts for chest wall reconstruction.

We report the outcomes of patients who underwent reconstruction with Mersilene mesh-methyl methacrylate (MM-MM) sandwich and polytetrafluoroethylene (PTFE) grafts after a large chest wall resection. Between June 1990 and September 2001, 59 consecutive patients (37 men, 22 women; mean age, 48.1 +/- 11.8 years; range 22-74 years) underwent large chest wall resection (greater than 5 cm diameter) and reconstruction with prosthetic material in our department. Twenty-one patients (33%) underwent reconstruction with a PTFE graft (group 2) between 1990 and 1994, and 38 patients (67%) underwent reconstruction with an MM-MM sandwich graft (group 1) between 1994 and 2001. Operative morbidity ratios were 5.2% (2/38) in group 1 and 24% (5/21) in group 2 (p = .036). The paradoxical respiration ratio was significantly higher (p = .018) in group 2 (5/21: 24%) than it was in group 1 (1/38: 2.6%). The operative mortality ratio was 4.5% (1/21) in group 2 and 0% in group 1. Mean hospital stay was 10.6 days (range 5-21 days) in group 1 and 13.3 days (range 7-36 days) in group 2 (p = .015). The MM-MM graft is inexpensive and easy to apply, provides better cosmetic options, and offers minimal morbidity. We therefore recommend that the MM-MM sandwich graft be used rather than the PTFE graft for large defects of the anterolateral chest wall and sternum where successful prevention of paradoxical respiration is required.

Parenchyma-preserving surgery in the management of pulmonary hydatid cysts.

Pulmonary hydatid cysts remain a significant health problem in endemic regions like Turkey. Here, we present our surgical experience in patients with pulmonary hydatid cysts. Between January 1985 and January 2001, 1118 operations were performed in 1032 patients (528 males, 504 females; mean age 32.7 years; range 1-87 years) with pulmonary hydatid cysts in our department. Posterolateral thoracotomy was performed in 1015 (98.3%), two-stage thoracotomy in 34 (3.3%), and median sternotomy in 17 (1.7%) patients. We preferred conservative surgical procedures. As a surgical procedure, cystotomy and capitonnage was performed in 626 (56%), cystotomy alone in 368 (33%), wedge resection in 81 (7%), enucleation in 29 (3%), and decortication in 11 (1%) patients. None of our patients were treated with anatomic resection. During surgery, 949 patients (92%) had unruptured and 83 patients (8%) had ruptured hydatid cyst. The morbidity ratio was 6.7%. Major complications were wound infection (2.3%), prolonged air leak (1.9%), atelectasis (1.2%), pleural effusion (0.8%), postoperative hemothorax (0.6%), and empyema (0.3%). Two patients (0.2%) died within the first month postoperatively. Mean follow-up was 31.2 months. Recurrence was detected in only 35 patients (3.3%). Treatment of pulmonary hydatid cyst is primarily surgical. Medical treatment is indicated for recurrent and multiple hydatid cysts postoperatively. Cystotomy alone, or cystotomy and capitonnage, as parenchyma-preserving surgery, is preferred. Radical surgery including pneumonectomy, lobectomy, and segmentectomy should be avoided.

Prognostic significance of Bax and Fas ligand in erionite and asbestos induced Turkish malignant pleural mesothelioma.

Environmentally exposed erionite is a potent and unique inducer of malignant pleural mesothelioma (MPM) in Central Anatolia in Turkey. Previous studies have shown that erionite induced MPM has different biological behavior than asbestos induced MPM. Although impaired apoptosis has been implicated in tumor biology, the relationship between the type of environmental exposure and apoptosis has not yet been evaluated in MPM. The purpose of this study was to determine the expression of apoptosis regulating proteins and their prognostic significance in erionite and asbestos induced MPM. Thirty-five patients with MPM (16 erionite and 19 asbestos induced), and 17 patients with adenocarcinoma were comparatively evaluated. Expression of Bcl-2, Bax, Fas and Fas Ligand, were assessed by immunohistochemistry. Bcl-2 and Fas did not stain in almost all specimens. The staining extension of Bax was 13.75 +/- 19.27%, 5.89 +/- 14.51% and 7.38 +/- 14.53% for erionite and asbestos induced MPM and adenocarcinoma, respectively (p = 0.566). The staining extension of Fas Ligand was 26.87 +/- 31.87%, 46.10 +/- 37.30% and 26.47 +/- 23.23% for erionite and asbestos induced MPM, and adenocarcinoma, respectively (p = 0.123). Bax negative patients in erionite group had longer survival than Bax positive patients (18 months versus 14 months) (p = 0.06). Fas Ligand positive patients showed statistically better survival than Fas Ligand negative patients in all MPM group (15 months versus 12 months) (p = 0.05). Although all proteins expressed in similar extension in all samples, Bax staining displayed an inverse relation with survival in erionite group. This may implicate a difference in Bax functioning in erionite induced MPM. However, Fas Ligand may be functionally intact to reduce tumor survival.

Use of intrapleural streptokinase in experimental minimal clotted hemothorax.

OBJECTIVE: In clotted hemothorax, both thoracocentesis and closed tube thoracostomy will not be able to evacuate the pleural cavity especially if it is minimal. The aim of this study was to assess the effectiveness of intrapleural administered streptokinase on minimal clotted hemothorax without drainage, in order to accelerate the spontaneous resolution and absorption in blunt thoracic trauma. METHODS: Thirteen adult ewes were used for this experiment. The animals were divided into two groups. First group served as the control group (Group C) (n=5) and did not receive any intrapleural fibrinolytic treatment. In both groups, 200 ml of blood was taken from the left jugular vein and injected into the pleural cavity with a serum line through the scope after pleural abrasion. Streptokinase (150.000 U) was diluted in 100 ml of saline and applied to the second group (Group S) (n=5) in second postoperative day. One ewe in each group was sacrificed with a lethal dose of sodium thiopental in postoperative 2nd, 4th, 6th, 8th, and 10th weeks, respectively. When a left posterolateral thoracotomy was performed, pleural thickening and adhesion were evaluated. The lung and pleural tissue samples were taken for histopathologic examination. The slides were examined in a blinded manner. RESULTS: Thoracentesis was performed in all ewes in the second postoperative day and no fluid was detected. There was no allergic reaction in group S after the injection of streptokinase into the pleural cavity. During postmortem macroscopic evaluation, we observed clot in one of the ewes in group C in second postoperative week. A statistically significant difference was found between Group C and S regarding pleural thickening and adhesion (P=0.05). The ewes of Group S had less pleural thickening and adhesion compared to those of Group C. These results were confirmed with histopathological examination. CONCLUSION: We conclude that intrapleural streptokinase increases resolution of clot in the pleural space and decreases pleural thickening and adhesion in experimental minimal clotted hemothorax in ewes. This study has also demonstrated that intrapleural streptokinase can be used without drainage. Use of intrapleural streptokinase without drainage can be a novel therapeutic option for trauma patients with minimal clotted hemothorax after haemorrhage of other organs was excluded.

Single-stage transthoracic approach for right lung and liver hydatid disease.

OBJECTIVE: Human echinococcosis remains a serious health problem for the Mediterranean countries. Synchronous pulmonary and hepatic hydatid disease may occur in 4% to 25% of cases. Our experience on simultaneous surgical treatment of right lung and liver hydatid disease in patients was reviewed. METHODS: Between 1990 and 2000, 48 patients (33 female patients and 15 male patients) with synchronous right lung and liver dome hydatid cysts were operated with a 1-stage procedure. RESULTS: Six patients had previous surgical treatment of hepatic (n = 2) or pulmonary (n = 4) hydatid cyst. The pulmonary cysts were diagnosed with radiography in 18 patients and thoracic computed tomography scan in 30. The pulmonary cysts of 9 patients were bilateral. Seventy-five pulmonary cysts were seen in radiological examinations. The diagnosis of hepatic cysts was established with ultrasonography in 18 patients and upper abdominal computed tomography in 30. The total number of hepatic cysts was 48. In cases with pulmonary cysts, cystotomy and capitonnage were performed in 32 patients, only cystotomy was done in 14 patients, and wedge resection was performed in 2. Liver cysts were approached to transdiaphragmatically after the lung cysts had been dealt with and were managed with evacuation of the cysts. In the remaining cases, marsupialization (n = 2), pericystectomy (n = 1), and enucleation (n = 1) were performed. Major postoperative complications were hemorrhage (n = 1) and biliocutaneous fistula (n = 1). Hepatic recurrence was seen in 3 patients (6.2%) and pulmonary recurrence in 1 (2.1%). CONCLUSION: Transthoracic approach is a useful and a safe surgical management of both pulmonary and upper surface of hepatic hydatid cysts.

Prognostic value of tumor size in non-small cell lung cancer larger than five centimeters in diameter.

OBJECTIVES: The tumor size is an important prognostic factor in non-small cell lung cancer (NSCLC). However, a criterion for tumor size has remained unchanged for the last 25 years in TNM classification. The purpose of this study was to determine the relationship between tumor size and survival in patients with non-small cell lung cancer. METHOD: Of 550 consecutive patients who underwent operation for NSCLC between 1994 and 1998, we reviewed the medical record of 509 patients. There were 470 men and 39 women. Survivals were compared according to groups of tumor size (Group I: < or = 3 cm, Group II: 3.1-4 cm, Group III: 4.1-5 cm, Group IV: >5 cm, Group A (II + III): 3.1-5 cm, and Group B (IV): >5 cm). The Cox proportional hazard model was used with same variables. RESULTS: The univariate analysis showed that poor pulmonary function test (P < 0.05), pneumonectomy (P < 0.05), limited resection (P < 0.001), tumor size larger than 5 cm (P = 0.006), T factor (P < 0.05), N status (P < 0.001), and advanced staged of disease (P < 0.001) were all significant prognostic factors. Further comparison of survival between tumor size groups demonstrated a significantly poor prognosis for larger tumors. There was a statistically significant difference between Group A (3.1-5 cm) and Group B (> 5 cm), with 5 years survivals of 45.9% and 31.4%, respectively (P = 0.005). CONCLUSION: We emphasize that tumor size is an important prognostic factor in NSCLC. The 5 years survival with tumors larger than 5 cm (31.4%), is significantly less than the tumors 3.1-5 cm (45.9%) (P = 0.005). These initial results should strongly encourage additional studies in different countries on the interaction between tumor size and lung cancer characteristics to better clarity. In future revisions of the TNM classification, 5 cm may be a new threshold.

Lung diseases due to environmental exposures to erionite and asbestos in Turkey.

Asbestos deposits have been used locally by the rural inhabitants of Central and Southeastern Anatolia for domestic purposes for many years. Mineralogical analysis revealed that tremolite is the most prominent asbestos type found in the region. There is in addition another mineral fiber found particularly in three villages located in the Cappadocian region of Central Anatolia (zeolite villages). This is a non-asbestos mineral, which has been identified as the fibrous zeolite, erionite. This fiber is present in the volcanic tuffs, which are used as building stone. Hence, exposure to erionite fibers is always possible in the houses, annexes, and streets of the villages. It has been demonstrated that both asbestos and erionite cause a variety of benign and malignant chest diseases. Among the diseases, calcified pleural plaques (CPP) are the most frequently seen and may be used as an indicator of mineral fiber exposure. Asbestos and erionite exposure are the main causes of malignant mesotheliomas in Turkey. In zeolite villages malignant mesothelioma is responsible for more than 50% of the total deaths. A recent study showed that simian virus 40 is not a cofactor in the pathogenesis of environmental malignant mesothelioma in Turkey. An additional recent genetic-epidemiological study showed that there are some families, which are genetically predisposed to mesothelioma.

Surgical treatment of peripheral lung cancer adherent to the parietal pleura.

OBJECTIVES: The objective of this paper is to assess the results of surgical treatment retrospectively in a consecutive series of 85 patients with peripheral non-small cell lung cancer (NSCLC) invading parietal pleura and chest wall. METHODS: From 1994 to 1998, of the 572 patients having pulmonary resection for NSCLC, 29 patients with neoplasm involving the parietal pleura (group I) and 56 with that invading the chest wall (group II) underwent resection. RESULTS: The operative mortality rate was 3.4% in group I and 1.8% in group II. In groups I and II, pathologic N status was N0 in 20 (69%) cases, N1 in five (17%), N2 in four (13.8%) and 44 (78.6%), seven (12.5%), five (8.9%), respectively. An incomplete resection (R1) was performed in two (6.9%) patients in group I and seven (12.5%) in group II. Postoperative radiotherapy was carried out in 18 patients in group I and 46 in group II. Systemic chemotherapy was also administered in seven patients in group I and eight in group II. There was a significant difference in adjuvant therapy between the groups (P<0.05). Two patients (R1) in group I (7.4%) and 12 patients (seven patients R1+5 R0) in group II (24%) had local recurrence. There was no significant difference in local recurrence between the groups (P=12). Follow-up was completed in 79 cases (28 in group I and 51 in group II). Median survival for groups I and II were 27+/-6 and 16+/-4.6 months, respectively. Five-year survival was longer in group I than in group II (33 vs. 14%), but there was no significant difference (P=13). CONCLUSIONS: We found similar survival rates for extrapleural resection in limited parietal pleura invasion and chest wall resection in exceeded-beyond-parietal pleura invasion. The completeness of resection is important in both groups.

Bilateral multiple pulmonary tuberculous nodules mimicking metastatic disease.

We present CT findings of a young woman who has bilateral pulmonary nodules mimicking metastases. Clinical presentation with active multiple pulmonary macronodules without cavitation responsive to treatment is an atypical manifestation of pulmonary tuberculosis. We reviewed the causes of multiple pulmonary nodules, role of radiological findings in differential diagnosis and parenchymal manifestations of pulmonary tuberculosis in this report.

[The importance of exercise testing for the functional assessment of lung resectional candidates]. / Akciger rezeksiyonu yapilacak hastalarin fonksiyonel degerlendirmesi için egzersiz testinin önemi.

UNLABELLED: Although there are a lot of physiologic tests to evaluate the preoperative cardio-pulmonary reserve in the patients who candidate lung resection, there is no a single gold standard test to suggest the postoperative pulmonary complications. In this study, we researched the importance of the exercise testing in the evaluation preoperative cardio-pulmonary reserve. We analyzed a series of 26 consecutive patients with a resectable lung disease [26 male patients, mean age 51.5 +/- 15.8 (13-78 years), 22 non-small cell lung carcinoma (NSCLC), 2 bronchectasis, 1 hydatid cyst, 1 empyema]. Patients were evaluated by pulmonary function testing (PFT), diffusing capacity of lung for carbonmonoxide (DLCO), and symptom-limited exercise testing. After the functional examination, 26 patients underwent pulmonary resections with standard thoracotomy: 4 segmental or wedge resection, 11 lobectomies, 5 pneumonectomies, and 1 cystotomia. The mean stay in the ICU was 2.6 days (+/- 3.5), the mean hospital stay was 11.9 days (+/- 8.0). Postoperative complications (within 30 days) occurred in 9 (34.6%) patients of whom one died (overall mortality rate was 3.8%). There was no relationship between the presence of complication and physiologic tests (PFT, DLCO). The patients were divided three groups according to peak oxygen consumption (VO(2)/kg peak) (mL/kg/min) (< 10, 10-20, > 20 mL/kg/min). There was no significantly difference among these groups and complication rates (p= 0.056), but the complication rate was higher in the group of VO(2)/kg peak < 10 mL/kg/min (75%). On the other hand, there was a significantly relationship between the presence of only pulmonary complication and VO2/kg peak (p= 0.034). CONCLUSION: We think that the preoperative functional evaluation in the patients with lung resection candidate is prominent to reduce the postoperative mortality and morbidity and especially cardiopulmonary exercise testing has an important role to suggest the postoperative pulmonary complications as a major complication.

Serum levels of alpha-tocopherol, vitamin C, beta-carotene, and retinol in malignant pleural mesothelioma.

The aim of this study was to investigate the possible relationship between antioxidant vitamin levels and malignant pleural mesothelioma (MPM). For this purpose, we measured the serum levels of 4 antioxidant vitamins, ß-carotene, α-tocopherol, retinol, and ascorbic acid, in patients with environmentally induced MPM and in healthy controls from one tremolite village (Kureysler), the biggest erionite village (Tuzkoy) and Ankara. A total of 160 subjects were enrolled in the study, 42 (26.3%) diagnosed with MPM and 118 (73.7%) healthy subjects. A comparison was made between the MPM group and three control groups of which two were exposed and one was unexposed to mineral fibers. The study population consisted of 82 males (51%) and 78 females (49%) with a mean of age of 44.8±14 years (range; 20-65 years). Lowest levels of ß-carotene, ascorbic acid, and α-tocopherol were found in MPM patients (MPM vs control groups combined, p<0.0001 for each antioxidant vitamin), without any relation to age or sex. There was no significant difference between the antioxidant levels of healthy controls of Tuzkoy and Ankara. In conclusion; our findings suggested an increased risk of MPM being associated with low levels of α-tocopherol and ascorbic acid in patients with MPM.

Management of recurrent malignant pleural effusion with chemical pleurodesis.

PURPOSE: Malignant pleural effusion is a common complication of primary and metastatic pleural malignancies. It is usually managed by drainage and pleurodesis, but there is no consensus as to the best method of pleurodesis. We compared the effectiveness, side effects, and cost of different chemical pleurodesis agents used in patients with malignant pleural effusion. METHODS: Between January 1990 and December 2001, 108 patients with malignant pleural effusion underwent chemical pleurodesis in our department. Thoracoscopy was performed in 64 patients (59%), a minithoracotomy in 18 (17%), tube thoracostomy in 11 (10%), and a small-bore catheter was inserted in 15 (14%). Talc was used in 68 (63%) patients, tetracycline in 26 (24%), and bleomycin in 14 (13%). Talc was instilled by insufflation during surgery after drainage, whereas tetracycline and bleomycin were instilled via tube or catheter for pleural analgesia. RESULTS: Talc resulted in significantly earlier tube and catheter removal, after an average 4.1 days versus 5.1 days after tetracyline, and 6.3 days after bleomycin (P = 0.026, P = 0.001, respectively). A significantly lower reaccumulation ratio in 90 days was achieved by the talc group, with nine (13.2%) patients, representing an 86.8% success rate, than in the tetracyline and bleomycin groups, with seven (26.7%) and five (35.7%) patients, respectively, representing 73.8% and 64.3% success rates (P = 0.04). CONCLUSIONS: Talc resulted in the earliest expansion, minimal drainage, and the earliest tube and catheter removal.

Diagnostic value of a dot immunobinding assay for human pulmonary hydatidosis.

The diagnosis of human hydatidosis is primarily made using radiological and serological methods. Radiological methods are generally of low specificity and serological methods lack sensitivity, especially for pulmonary disease. In this study the capabilities of a new rapid test, the hydatid antigen dot immunobinding assay (HADIA), which was developed for the diagnosis of pulmonary hydatidosis, were studied and compared with another immunodiagnostic method, indirect hemagglutination (IHA). The study subjects included 18 patients, 9 women, 9 men; range 7 to 63 years; mean 30 years, with surgically proven pulmonary hydatidosis, a control group comprised of 14 patients; viral respiratory infections (1), cirrhosis (2), connective tissue disease (2), taeniasis (3), and 6 healthy donors. We found that the HA-DIA test had a sensitivity of 67% and specificity of 100%, and that the IHA test had a sensitivity of 50% and specificity of 100%. We conclude that HA-DIA is a simple, rapid, low cost assay that does not require instrumentation and has a higher sensitivity than IHA for the diagnosis of pulmonary hydatidosis.