Evaluation of prognostic factors in the surgical treatment of pulmonary metastases.

AIM OF THE STUDY: The resection of pulmonary metastases is a routine practice of thoracic surgery wards; however, clear protocols or prognostic factors defining the surgical treatment criteria are still not available. The aim of the study is to evaluate the prognostic factors associated with long-term survival in a group of patients who underwent resection of pulmonary metastases. MATERIAL AND METHODS: A retrospective analysis was conducted on a group of 250 patients admitted to the Wroclaw Thoracic Surgery Centre for radical resection of pulmonary lesions in the years 1996-2010. RESULTS: The patients included in the study (n = 250) underwent 339 thoracotomies in total. The overall five-year survival was 52.8%. The univariate data analysis showed that the survival rate was significantly better in patients subjected to more than one thoracotomy (p = 0.01674). Among the other data, such as sex, tumour histology, disease-free interval (DFI) ≤ 12 and > 12 months, DFI ≤ 36 and > 36 months, age, number of tumours identified in CT and number of tumours subject to resection, operated side, resection type, radicality of resection, extent of lymphadenectomy, and adjuvant therapy, no statistical significance was observed in univariate and multivariate analysis (p > 0.05). CONCLUSIONS: Outcomes of re-metastasectomy are satisfactory if patients meet the baseline criteria for surgical treatment. None of the evaluated factors potentially influencing the patient survival was demonstrated to have any prognostic value. Further research, including the biology of tumours with pulmonary metastases, is necessary to select the group of patients that will benefit most from surgical treatment.

Different intensities and directions of hyporheic water exchange in habitats of aquatic Ranunculus species in rivers-a case study in Poland.

Hyporheic water exchange driven by groundwater-surface water interactions constitutes habitat conditions for aquatic biota. In our study, we conducted a field-research-based analysis of hyporheic water exchange to reveal whether the hyporheic water exchange differentiates particular Ranunculus sp. habitats. We measured the density of the stream of upwelling and hydraulic gradients of water residing in the hyporheic zone in 19 Polish rivers. We revealed that R. peltatus and R. penicillatus persist in habitats of considerably higher hyporheic water exchange upwelling flux (respectively 0.0852 m3∙d-1∙m-2 and 0.0952 m3∙d-1∙m-2) than R. circinatus, R. fluitans, and a hybrid of R. circinatus × R. fluitans (respectively m3∙d-1∙m-2; 0.0222 m3∙d-1∙m-2 and 0.0717 m3∙d-1∙m-2). The presented results can be used to indicate aquatic habitat suitability in the case of protection and management of ecosystems settled by Ranunculus sp.

Pediatric Monteggia Fracture Outcome Assessment - Preliminary Report.

BACKGROUND: The term Monteggia fracture refers to a class of injuries encompassing the fracture of the proximal end of the ulna with subluxation or dislocation of the radial head. These injuries account for 0.4-1% of all forearm fractures in children. Despite its low incidence, Monteggia fractures require particular attention, since as much as 30-50% of the cases may be unrecognized, which subsequently leads to complications. The purpose of this paper is to evaluate treatment outcomes of Monteggia fractures in children. Both conservative treatment and surgery were analyzed. MATERIAL AND METHODS: 15 children (7 boys and 8 girls) between the ages of 4-16.3 years (mean age 8.3 years) with Monteggia fractures were hospitalized at our center in the years 2015-2020. Closed reduction and immobilization in a cast were performed in 12 patients, while three children underwent surgical treatment with internal fixation of the ulna. The radial head dislocation was reduced successfully in every patient. RESULTS: Every child from the study group who received conservative treatment regained full elbow mobility as well as normal forearm supination and pronation. Only one of the patients who underwent the surgery demonstrated a 20° deficit in elbow flexion that did not affect limb function. CONCLUSIONS: 1. Our experience shows that closed reduction together with immobilization in a cast is usually a sufficient treatment in Monteggia fractures. 2. However, the dislocated radial head should be properly reduced in all patients. 3. Correct diagnosis and treatment followed by appropriate rehabilitation result in full recovery and no mobility limitations in children and teenagers.

Treatment of benign lesions of humerus with resection and non-vascularised, autologous fibular graft.

The aim of this study was to analyse the long-term results of surgical en bloc resection and replacement with non-vascularised, autologous fibular graft for the treatment of large benign humeral lesions without fixation. We retrospectively reviewed data of seven females and 13 males with unilateral benign lesions where steroid injection, curettage and bone grafting or pathological fracture failed to restore integrity. Subperiosteal, en bloc resection of the cystic lesion with a margin of the normal bone was performed. The average age of the patients at the time of operation was 11.8 years (range 4-28 years). All patients were skeletally mature at last follow-up. Aneurysmal bone cysts were histologically identified in seven cases, solitary cysts in 11 and fibrous dysplasia in two cases. No recurrence of the pathology, pain, graft fracture or limitation in range of motion was noted. In three patients in whom the cyst was adjacent to the proximal growth plate of the humerus, there was shortening of the bone at the last follow-up examination measuring 2 cm, 4.5 cm and 6 cm, respectively. Two cases had a valgus deformity of 10° and 15°, respectively, which was evident radiographically at the time of last follow-up. The results of en bloc resection with non-vascularised, autologous fibular graft for the treatment of large benign humeral lesions without fixation are encouraging. The risk of associated complications is low. In our opinion this should be the method of choice in the treatment of large, multi-chamber benign bone lesions of the humerus which fail more "conservative" treatment.

Assessment of adequacy of intraoperative nodal staging and factors influencing the lack of its compliance with recommendations in the surgical treatment of non-small cell lung cancer (NSCLC).

BACKGROUND: Adequate pathological status of lymph nodes sampled during resection of NSCLC determines prognosis and decides on further therapeutic actions. The areas of analysis are the factors affecting evaluation of pN accuracy, and the convergence of recommendations with actual intraoperative sampling of lymph nodes. METHODS: The data of 3,215 patients with NSCLC consecutively operated with the intention of radical resection in 2007-2017, were analyzed. Accuracy of nodal sampling and influencing factors were compared with Union for International Cancer Control (UICC) guidelines, which recommend that to confirm pN0 status at least six lymph nodes/stations free of the disease must be removed. Three should be sampled from mediastinum (including subcarinal) and three from N1 stations. RESULTS: A significant number of patients were found to have an adequate staging, especially after 2009, in terms of recommended quantity of nodes/nodal stations (P<0.0001). Age ≥64 (P=0.048), left side (P<0.0001), sublobar resection (P<0.0001), T1 tumors (P=0.019) are the factors affecting inadequacy of staging. Patients with inaccurate staging were found to have a considerably lower pN1 (7.2% vs.15.9%, P<0.001) and pN2 (9.7% vs.13.4%, P<0.001) status. Survival of patients with inadequate staging were found to be significantly worse (P=0.0002), which resulted in worse survival of those patients in stage I (P=0.00004), stage II (P=0.023) and stage III (P=0.031) of NSCLC. CONCLUSIONS: UICC recommendations led to an increased adequacy of nodal sampling. The factors affecting insufficient number of sampled nodes include advanced age, left side, sublobar resections and T1 stage. Inaccuracy of intraoperative nodal staging results in incorrect prognosis.

Left main bronchus separation after blunt trauma.

Tracheobronchial damage is very rare in clinical practice and represents no more than 1% of all injuries caused by blunt trauma. Nearly 80% of patients die before reaching the hospital. Most ruptures are observed in the right main bronchus and are located within 2 cm of the carina trachea. The highest mortality rate applies to patients with bilateral bronchial injuries. Nonspecific symptoms, additionally masked by complaints regarding other damaged organs, delay the diagnosis and surgical treatment. The aim of this article is to present one particular clinical case and to discuss it in conjunction with a literature review.

[Five year remission of GHRH secreting bronchial neuroendocrine tumor with symptoms of acromegaly. Utility of chromogranin A in the monitoring of the disease]. / Piecioletnia remisja guza neuroendokrynnego oskrzela wydzielajacego GHRH z objawami akromegalii. Przydatnosc oznaczania chromograniny A w monitorowaniu przebiegu choroby.

Acromegaly is usually caused by excess GH (growth hormone) secretion by pituitary adenoma. Extremely rare (< 1% of cases) acromegaly can be a result of ectopic GHRH (growth hormone releasing hormone) secretion by bronchial tubes, lung, pancreatic or intestinal tumor. The aim of this description is to present the case of successfully treated acromegaly caused by ectopic GHRH secretion by bronchial neuroendocrine tumor and the usefulness of chromogranin A assay in the disease monitoring. The diagnosis of acromegaly in 61-year old woman was based on typical clinical picture and elevated GH and IGF-1(insulin-like growth factor-1) levels. MRI (magnetic resonance imaging) images revealed no tumor in the pituitary but only the pituitary enlargement. Moreover, the right lung tumor (10 cm size) and elevated GHRH level were documented. The secretion of GH, IGF-1 and GHRH were normalized and progression of acromegaly was stopped after the carcinoid tumor surgery. Currently, 5 year after surgery, acromegaly is still in the remission, as the normal levels of GH, IGF-1, chromogranin A and normal chest and pituitary images confirm. The authors emphasize usefulness of measurement of chromogranin A concentration for the evaluation of the tumor remission in case the routine GHRH assay is not accessible.

Evaluation of new classifications of N descriptor in non-small cell lung cancer (NSCLC) based on the number and the ratio of metastatic lymph nodes.

BACKGROUND: The aim of the study was to evaluate the prognostic power of new classifications of N descriptor created basing on the number (NLN) and the ratio of metastatic lymph nodes (RLN) in NSCLC compared to the current classification (CLN). METHODS: The data of 529 patients with NSCLC operated with the intention of radical resection, were analyzed. The new categories of N descriptor were created as follows: 1) NLN - median number of metastatic nodes was 3, thus in NLN0 the number of metastatic nodes =0, in NLN1 1-2, in NLN2 ≥ 3, 2) RLN - median ratio (number of metastatic lymph nodes to all nodes removed) was 12.4 %, thus in RLN0 the ratio was 0, in RLN1 < 13 %, in RLN2 > 13 %. The prognostic value of each classification was calculated on the basis of hazard ratios defined in multivariate Cox proportional hazard model. RESULTS: The new classifications of N descriptor turned out to be an independent strong prognostic factor (p <0.001) with a 5-year survival rate NLN0-62 %, NLN1-39 %, NLN2-26 % and RLN0-62 %, RLN1-37 % and RLN2-26 %. For 5-year survival rates in CLN0-62 %, CLN1-42 %, CLN2-24 % (p < 0.001), a higher prognostic value of new classifications was not demonstrated, the hazard ratio amounted to 2.22, 2.08, 2.49 for NLN2, RLN2 and CLN2 respectively. CONCLUSION: Despite the significantly high prognostic power, the new classifications cannot be considered superior over CLN. There are some deficiencies in the current classification, therefore further studies on its improvement are needed.

Comparison Analysis of Autologous Conditioned Plasma.

BACKGROUND: Autologous Conditioned Plasma (ACP) has a wide range of potential uses in modern orthopaedics. The aim of this study was to examine the characteristics of proprietary ACP and compare them with those of ACP produced using a commercially available kit. MATERIAL AND METHODS: In the hospital laboratory, 20 samples of ACP taken from patients and prepared according to the commercially available kit protocol with a double syringe system were compared with 40 ACP preparations made using disposable sterile equipment available in the hospital. RESULTS: The mean platelet concentration in the ACP samples prepared according to the Arthrex protocol was 2.02 (range 1.16 to 2.64) times greater than in peripheral blood, while the concentration in the proprietary preparation was 1.61 (range 0.82 to 2.52) times higher. However, the mean platelet density in the proprietary preparation (n = 24) was 1.98 (range 1.48 to 2.52) times that of peripheral blood within 20 minutes of collection, and 1.41 (range 0.84 - 1.87) times after 20 minutes (n = 16). Therefore, the proprietary method of producing ACP is comparable to that of the commercial kit with regard to platelet density (p>0.05). CONCLUSION: Using disposable hospital equipment and with a relatively short time between ACP preparation and testing, it is possible to obtain a suitable proprietary platelet-rich preparation comparable to one produced using a commercial system.

Stage IIIa cancer of the right lung ingrowing via right lower pulmonary vein to the left heart atrium.

Computed tomography is performed in every patient before lung tumour resection. The presented case realises how important it is to perform this study with contrast. In a 75-year-old male we detected a tumour ingrowing from the right lung through the right lower pulmonary vein into the left atrium of the heart. The patient was qualified for primary sternotomy with extracorporeal circulation and resection of the intracardiac part of the tumour. In the second stage, right-sided thoracotomy was performed, and right lower lung lobectomy was done. Mixed heterogeneous lung cancer was diagnosed (squamous cell and non-small cell endocrine) in stage IIIa. The perioperative period was uncomplicated. The patient, due to renal failure, was not eligible for adjuvant chemotherapy. If the patient were qualified for lobectomy based directly on computed tomography without contrast, there would have been a high risk of perioperative death due to embolic incidents and heart failure. Effective multidisciplinary collaboration allowed us to avoid this sort of complication.

Skin reactivity to histamine and expression of histamine receptors mRNA in lymphocytes of healthy subjects and non-small-cell lung cancer patients before and after surgery.

Histamine modulates an immunological response through stimulation of appropriate receptor--H1R proinflammatory or H2R suppressive. The participation of histamine in regulation of an immunological response in the course of neoplastic disease is determined by the expression of particular receptor. The aim of our work was the investigation of the expression of mRNA of two types of histamine receptors in peripheral blood lymphocytes and the evaluation of skin-prick test with histamine in lung cancer patients before and after surgery. The investigation was performed on 15 patients qualified to surgery before and 7-10 days after treatment and on 12 healthy subjects. Reverse transcriptase polymerase chain reaction (RT-PCR) with primers labeled with fluorescent dyes was performed. Intensity of fluorescence was expressed as relative fluorescence units (RFU). The data were analysed using ABI Prism 310 GeneScan collection software Version 3.1. Skin-prick test with histamine was evaluated after 10 min by measuring the diameter of the weal. The expression of H1R and H2R mRNA in healthy subjects was not significantly different in contrast to the lung cancer patients in which a significant prevalence of H2R mRNA expression was observed before surgery and only slightly decreased after (P < 0.001). Skin-prick test--negative in one patient before surgery, after treatment was positive in all patients and the diameter of histamine weal was significantly increased (P < 0.001). One may assume that the prevalence of the expression of H2R mRNA in patients reflects the status of immunosuppression caused by cancer. Since histamine exerts its suppressive activity trough H2R it seems reasonably to include the antagonists of this receptor to the cancer therapy which may restore a relative balance between accessibility of both types of histamine receptors.

Causes and management of postpneumonectomy empyemas: our experience.

OBJECTIVE: Infection of the pleural cavity and development of empyema are potential dangers after pneumonectomy. In spite of decrease in frequency of postpneumonectomy empyemas (PPE) formation, this is still a serious complication. The aim of this study was: analysis the mechanisms of postpneumonectomy empyema formation and attempt the elaboration of the optimal management of these patients. METHODS: 1148 pneumonectomies were performed at the Thoracic Surgery Centre between 1984 and 2002. PPE occurred in 76 (6.6%) patients between the ages of 25-77. For statistical purposes the chi2 test was used. RESULTS: The causes of PPE showed that in 56/76 (73.7%) patients its formation was due to a postoperative complications. In 4/76 (5.3%) cases the cause of empyema was associated with intraoperative infection during the operation. In 3/76 (3.9%) patients a long period of treatment at the intensive care unit due to postoperative shock predisposed to the infection. In 13/76 (17.1%) patients the cause was not established. Statistically significant PPE was associated with postoperative complication (P=0). Postoperative complication caused by one factor was more frequent than those caused by 2 or 3 factors (P=0). PPE was the most often diagnosed in the second postoperative week (P=0.0001). 13 (17.1%) patients died during the 30 days after beginning of the treatment of PPE. The course of complication was more impetuous and more deaths were noted in patients diagnosed during the first week after operation. Only 8 patients from 34, who were selected for thoracentesis and lavage with deposition of antibiotics into the pleural cavity recovered. Jointly 68 (89.5%) patients underwent chest tube drainage. After 2-3 weeks the tube was removed in 16 patients. 17 (22.4%) patients were not qualified for operation. 35 (46.1%) patients underwent different operative procedures: 20 fenestrations, 12 fenestrations with myoplasty and 3 thoracoplastic operations with myoplasty. CONCLUSIONS: The most common causes of PPE were postoperative complications, mainly bronchopleural fistula. The scheme of therapeutic management in PPE was elaborated as a result of our experience.

[Cathepsin B activity and concentration of elastase and alpha-1 proteinase inhibitor complex in non-small-cell lung cancer: 2 year follow-up study]. / Aktywnosc katepsyny B i stezenie kompleksu elastazy z inhibitorem alpha 1-proteinaz w niedrobnokomórkowym raku pluca--obserwacja dwuletnia.

In 21 patients with non-small-cell lung cancer subjected to radical surgery followed by 3 cycles of chemotherapy, serum cathepsin B activity and plasma E-alpha 1IP concentration in peripheral blood and tumour arterial and venous blood were studied. Cathepsin B activity was determined by a fluorometric assay. E-alpha 1IP concentration was measured with an ELISA kit. The measurements were performed before surgery, before each chemotherapy cycle and every 60 days after chemotherapy completion, for 2 years. All the patients (n = 21) were divided into 2 subgroups: without metastases n = 16 and with metastases n = 5. There was no significant difference between preoperative serum cathepsin B activity and E-alpha 1IP plasma values in peripheral blood and blood coming from tumour artery and vein. The surgery and chemotherapy caused a statistically significant decrease of serum cathepsin B activity and plasma E-alpha 1IP concentration both in the whole group and in the subgroup without metastases. A significant increase of cathepsin B activity in comparison to initial values was observed 2,5-4 months before cerebral metastasis appeared in the subgroup with metastases. The elevation of E-alpha 1IP concentration preceded the increase of cathepsin B activity in this subgroup. It was not statistically significant. A decrease of cathepsin B and E-alpha 1IP values was observed after cerebral metastasis excision.

[Tumor markers TPA and Cyfra 21.1 in patients with non-small cell lung cancer after surgery and chemotherapy]. / Markery nowotworowe TPA i Cyfra 21.1 u chorych na raka niedrobnokomórkowego pluca po leczeniu chirurgicznym i chemioterapii.

In 27 patients with operable non-small cell lung cancer (NSCLC) submitted to radical surgery followed by 3 cycles of chemotherapy (cht) serum concentrations of Cyfra 21.1 and TPA were studied. The measurements were performed before and 14 days after surgery, before each cht and every 60th day after cht was completed, for 2 years. Seven patients died during the follow up. There was no significant correlation between preoperative cyfra 21.1 and TPA serum concentrations and stage of diseases or histologic types of NSCLC. Initial concentrations of the two markers had no prognostic meaning. A significant decrease of 2 markers was observed after surgery in the whole group and in patients with therapy success. While adjuvant cht did not influence significantly serum concentrations of the markers, we showed a significant elevation of 2 markers about 4 months before death. It seems that establishing of values of Cyfra 21.1 and TPA in the patient's follow up may be useful in recognition of tumour relapse.

[Post-pneumonectomy empyemas: causes, clinical course, management]. / Ropniaki komory poresekcyjnej: przyczyny, przebieg kliniczny, postepowanie.

Between 1984 and 2000 in the Thoracic Surgery Centre pneumonectomies were performed in 947 patients. Postpneumonectomy empyema (PE) occurred in 67 (7%) patients. The aim of this paper were: analysis the reasons of postpneumonectomy empyema appearance, defined bacterial flora, clinical course and optimal management. The causes of PE were: pleural cavity haematoma (20 patients-29.8%), wound suppuration (18 patients-26.8%), bronchial fistula (31 patients-46.2%). These complications appeared singly or together in 49 (73.1%) patients. In 2 (3.0%) patients a long treatment in the Intensive Care Unit because of postoperative shock was the cause of infection. In 3 (4.5%) cases the cause of empyema was associated with infection during the operation. In 13(19.4%) cases the cause of empyema was not established. In 55 patients infections of pleural cavities were diagnosed in the first 8 weeks after operations. In 12 patients empyemas were established later. 12 (17.9%) patients died during the analyzed 1 year period after operation. In 18 (26.9%) patients infections were caused by only one bacterial strain and in 49 (73.1%) by two or three bacterial strains. The different methods of treatment (thoracentesis, drainage, operation) depending on general condition of patient were done.

[Pulmonary tuberculosis after 11 years of observation in a patient suffering from advanced squamous lung cancer cured by radical radiotherapy--a case report]. / Przypadek gruzlicy pluc po 11 latach obserwacji u chorego na zaawansowanego raka plaskonablonkowego pluca wyleczonego radykalna radioterapia.

Advanced lung cancer is a neoplasm of a poor prognosis. The treatment may improve it to a certain degree but not satisfactory. A case of squamous- cell lung cancer, in a stage III B of TNM classification, which was by cured completely radiotherapy is described. The 11 years post-treatment observation was performed without any symptoms of recurrence. Actually patient is hospitalised due to active tuberculosis. No evidence for lung cancer was found until now.

Treatment of recurrent primary spontaneous pneumothorax - own experience.

UNLABELLED: Primary spontaneous pneumothorax could be a serious therapeutic problem in case of recurrence. Lack of therapeutic standards sometimes leads to delay in definitive surgical treatment and could cause respiratory complications. The aim of the study was the evaluation of treatment results in patients with recurrence of primary spontaneous pneumothorax and looking for optimal therapeutic method after first recurrence (surgical treatment vs. pleural drainage). MATERIAL AND METHODS: Between 01.01.2009 and 31.07.2010 fifty four patients with recurrent primary spontaneous pneumothorax was hospitalized in Wroclaw Thoracic Surgery Centre (24.3% of all patients with pneumothorax). The recurrence was treated surgically in 24 cases, in 30 pleural drainage was performed: simple drainage (n=14) or drainage with chemical pleurodesis (n=16). Mean age of patients treated without surgery was higher than surgically treated (p=0,012). RESULTS: In surgery group no recurrence was found, in drainage group 11 recurrences occurred (p=0.0009). In group of 11 patients with second recurrence, pleurodesis was performed four times (36%) vs. 12 times (63%) in 19 patients without a recurrence of the disease. 70% of non-surgically treated patients vs. 50% of surgically treated were afraid of recurrence (p=0.01). Among 11 patients in drainage group, nine underwent surgery at the second episode of recurrence. CONCLUSIONS: The optimal treatment method in case of first recurrence of primary spontaneous pneumothorax is surgical treatment. When it is not possible chemical pleurodesis should be performed during pleural drainage. Most of the patients after second recurrence are treated surgically anyway. The surgical treatment significantly reduces patient's fears for future recurrence of the disease. Younger patients are most often surgically treated.

RANTES and chemotactic activity in synovial fluids from patients with rheumatoid arthritis and osteoarthritis.

A massive accumulation of inflammatory cells in synovial tissues is a major pathological feature of rheumatoid arthritis (RA). Neutrophiles dominate synovial fluid while rheumatoid synovium is infiltrated with mononuclear cells. Mechanisms regulating influx of particular subpopulations of leukocytes into articular cavity and synovium compartment are not completely defined. An increasing amount of data supports a crucial role of a C-C chemokine RANTES in the RA pathogenesis. Our objective is to evaluate chemotactic activity for neutrophils (NCA), lymphocytes (LCA), and monocytes (MoCA) in SFs obtained from patients with RA and osteoarthritis (OA). We also aimed to characterise the relation between chemotactic activity, RANTES, and percentage distribution of leukocytes in SF. SFs from 11 patients with RA and 6 with OA were included in the study. Modified microchamber Boyden method was employed to assess chemotactic activity. Cytological and biochemical analysis of SF was performed. RANTES was measured with ELISA. Rheumatoid SFs were rich in cells with predominance of neutrophiles while osteoarthritic fluids were lymphocytic. RA SFs were also characterised by increased lactoferrin level. Both NCA and LCA were higher in SF from patients with RA (62 +/- 12 and 24 +/- 6 cells/HPF, resp) as compared to patients with OA (23 +/- 6; P < .05 and 6 +/- 2 cells/HPF; P < 0.05). The chemoattractive effect of RA SF was more pronounced on neutrophiles than on lymphocytes. RA SF expressed high RANTES levels (145+/- 36 pg/mL), while OA SF was characterised by only trace amount of this chemokine (2 +/- 1 pg/mL). We found positive correlation of RANTES with chemotactic activity for mononuclear cells (LCA + MoCA; R = 0.61; P < .05). Surprisingly, RANTES correlated also positively with neutrophiles number (R = 0.77; P < 0.001). Rheumatoid SF possesses strong chemotactic potency for leukocytes. RANTES is overexpressed in RA SF and is a potential mediator influencing intensity and composition of cellular infiltration in joints affected with inflammatory arthritis.