Prognostic factors and survival in patients undergoing surgery for T4 nonsmall cell lung carcinoma.

BACKGROUND: Surgical treatment of T4 non-small cell lung carcinoma (NSCLC) is controversial. METHODS: Between 1998 and 2011, 70 patients undergoing pulmonary resection for T4 NSCLC were evaluated. The patients were divided into four groups: the large vessels group (n = 28), the carinal group (n = 20), the separate tumor nodules group (n = 13) and the mediastinal fat group (n = 9). RESULTS: Overall mortality and morbidity were 12.9% (n = 9) and 35.7% (n = 25), respectively and there was no significant differences between the four groups (p = 0.961, p = 0.750). Complete resection was possible in 47 patients (67.1%). The pathological nodal status was as follows: N0/1 in 58 patients and N2 in 12 patients. Five-year survival rate was 28.9% for all patients and 49.6%, 18.5%, 0% and 20.5% in the carinal, large vessels, mediastinal fat and separate tumor nodule groups, respectively. The carinal group was significantly different from the other groups in terms of survival (p = 0.05). By multivariate analysis, only two factors significantly and independently influenced survival: nodal status (N0/N1 versus N2; p = 0.01) and complete resection (R0 versus R1; p = 0.06). CONCLUSION: Resection is not a suitable approach for T4 NSCLC patients with N2 disease or incomplete resection. Resectable T4 NSCLC patients with carinal or tracheal involvement have better survival than do other T4 sub-groups.

Minimally invasive excision of multiple cystic lymphangiomas of the mediastinum: a case report.

Mediastinal lymphangioma is one of the rarest benign mediastinal masses. We report the successful minimally invasive surgical treatment of multiple cystic lymphangiomas in a middle-aged man with a familial history of lung cancer. This case report describes cystic lymphangioma as a rare differential diagnosis for a mediastinal mass in an adult.

Very important histopathological factors in patients with resected non-small cell lung cancer: necrosis and perineural invasion.

BACKGROUND: The current staging system provides an anatomical classification of lung tumors; its secondary purpose is to allow the prognostic stratification of patients into homogeneous groups after surgery. In this work, intratumoral perineural invasion, lymphatic and blood vessel invasion together with the necrosis content of the tumor exclusive of the non-small cell cancer staging system were studied. METHODS: During a 4-year period, 152 patients operated for non-small cell lung cancer (NSCLC) at our hospital were analyzed. Mean age of patients was 55.7 +/- 10.1 years. RESULTS: Overall 5-year survival was 42.2 %. Mediastinal lymph node involvement, tumor size, incomplete resection, pneumonectomy, presence of necrosis and perineural invasion were significant prognosticators ( P = 0.03, 0.04, 0.0001, 0.046, 0.0246, < 0.0001, respectively). Multivariate analysis revealed that N status, perineural invasion, and the presence of necrosis were independent prognostic factors ( P = 0.006, P = 0.001, P = 0.001, respectively). Patients who had stage I tumor with necrosis and perineural invasion had a lower survival rate than those with stage IIIA tumor without these histopathological features ( P = 0.04). The presence of these histopathological characteristics in stage IIIA patients was a sign of a poorer prognosis ( P = 0.0001). CONCLUSIONS: Perineural invasion and the presence of necrosis independently indicated a dismal prognosis and their prognostic power is comparable to those of the TNM classification. These factors could be candidates for better survival stratification and the indicators of the need for adjuvant therapy in early stage lung cancer patients.

[Survey of sensory perception and patients' subjective assessment of the application of nasal sprays - the nasal-spray-sensoric-scale]. / Erhebung der sensorischen Wahrnehmung und subjektiven Patienteneinschätzung bei der Verabreichung von Nasenspray - Die Nasen-Spray-Sensorik-Skala.

AIM: The Nasal Spray Evaluation Questionnaire is a standardized means to evaluate hedonicity of nasal sprays in the English speaking countries. To date, there is no such questionnaire for German speaking patients. The here presented study aimed at evaluating the translated questionnaire. Three nasal sprays were tested and the questionnaire was used to estimate sensory hedonicity. Finally, the questionnaire was improved and can now serve as a standardized means to measure nasal sensory perceptions. MATERIAL AND METHODS: The questionnaire was literally translated from English to German. There were three groups of 60 patients each presenting with the sensation of a 'dry nose' to a secondary medical center with a board certified otolaryngologist. The ingredients of the three different nasal sprays varied only in one phytotherapeutic addition. The first evaluation of the nasal spray was conducted immediately after application of the nasal spray, and two minutes after application. A third and optional telephone survey was performed several days later after continuous use of the spray. RESULTS: The different evaluations of nasal sprays were already lined out after the first questionnaire. It could serve as a new, reliable and reproduceable tool for the evaluation of nasal sensory perceptions. DISCUSSION: The questionnaire served as an adequate tool to estimate hedonicity of nasal sprays. First results of the German version show, however, that it could facilitate the evaluation by restructuring the questionnaire. Continuously marking good grades with high points (maximum 100) and negative answers with low points (minimum 0 points) will unify and simplify the questionnaire. CONCLUSION: The translation of the Nasal Spray Evaluation Questionnaire into a German version can serve as a new standard tool for measuring nasal sensation.

[The Extended Deltoid-Split Approach for Plating Four-Part Proximal Humeral Fractures]. / Die Plattenosteosynthese bei proximaler 4-Fragment-Humerusfraktur über den erweiterten Deltoid-Split-Zugang.

The deltoideopectoral approach is established as the gold standard in the surgical treatment of proximal humeral fractures. As an alternative, we demonstrate the extended deltoid approach with an intraoperative video. A direct lateral incision is performed and the anterior parts of the axillary nerve are identified and preserved. In our experience, this approach allows improved visualisation of the greater tuberosity and easier positioning of locking plates. Clinically relevant neurological injuries cannot be seen in our patients or in the literature.

The coincidence of mediastinal tuberculosis lymphadenitis in lung cancer patients.

Mediastinal lymph node enlargement in operable non-small cell lung cancer is of clinical importance since it indicates the high possibility of nodal metastasis. The coincidence of tuberculosis and lung cancer is detected by the mediastinal lymph node staging of lung cancer patients. In our study, we retrospectively re-evaluated the records of patients who had been hospitalized with the diagnosis of lung cancer for the past 10 years. The mean age was 58 +/- 10 years (ranging from 39 to 72). A tuberculous lymphadenitis was detected in 16 of the 315 (5.1%) patients in one and/or multiple stations by either mediastinoscopy or thoracotomy. Inferior paratracheal lymph nodes (4R-4L) were the most frequently affected. None of the patients had a history of primary tuberculosis infection. The cell type was squamous cell carcinoma in ten patients (62.5%) and adenocarcinoma in six patients (37.5%). The tumour was located in the right lung in nine patients (56.2%). The most frequently involved site was the right upper lobe (n = 13, 81.2%). N2 disease was detected in six patients (37.5%). Our study showed that 5.1% of lung patients had tuberculous lymphadenitis coincidentally. The diagnosis and treatment of this latent disease could be considered as important, especially in lung cancer patients who would potentially receive radiotherapy or chemotherapy which alters the immune system. However, the real value of this finding needs further study.

Emergency surgery for massive haemoptysis.

BACKGROUND: Massive haemoptysis (600 ml in 24 hours) results in considerable mortality and deserves appropriate management. Since it is life threatening, lung resection remains the surgical treatment of choice in unrelenting haemoptysis. MATERIAL AND METHODS: We retrospectively reviewed all patients (n = 29) who were referred to our clinic between January 1994 to September 2001 with massive haemoptysis (> 600 ml/24 h). All patients had uncontrollable haemorrhage and/or failure of conservative treatment. After initial resuscitation, assuring adequate airway and providing adequate intravenous access, emergency thoracotomy was performed in all patients following rigid bronchoscopy (n = 27) in order to localize the bleeding. RESULTS: The most common underlying cause of the massive haemoptysis was pulmonary tuberculosis (n = 10) followed by emphysema in 4, lung cancer in 3, collagenous vascular disease in 2 and aspergilloma in one patient. Seventeen lobectomies (58.6%), 5 pneumonectomies (17.2%), 3 segmentectomies and 3 bilobectomies were done whereas physiological lung exclusion was performed in one patient. Haemoptysis could be controlled in all patients. Rate of operative morbidity and hospital mortality were 27.5% and 11.5% respectively. We recorded one patient with recurrent haemoptysis who was treated by completion pneumonectomy. CONCLUSION: Despite the debate over definition of massive haemoptysis and indication for surgery in these patients, emergency pulmonary resection provides an effective treatment with acceptable morbidity and mortality in patients with massive haemoptysis.

Mediastinitis caused by an infected mandibular cyst.

Descending necrotizing mediastinitis is a potentially fatal condition which may occur seldom as a consequence of oral infections. This report describes the management of a patient with mediastinitis due to an infected dentigerous cyst.

Serum copper and zinc levels and copper/zinc ratio in patients with breast cancer.

Serum copper, zinc levels, and the Cu/Zn ratio were evaluated in 31 patients with breast cancer and 35 healthy controls. Copper and zinc were determined by atomic absorbtion spectrophotometry. The mean serum copper level and the mean Cu/Zn ratio in patients with breast cancer were significantly higher than the control group (p < 0.001 and p < 0.001). In addition, the mean serum zinc level in patients with breast cancer was significantly lower than the control group (p < 0.001). Neither serum copper and zinc levels nor the Cu/Zn ratio were of value in discriminating of the disease activity and severity. Interestingly, the Cu/Zn ratio in premenopausal patients was higher than postmenopausal patients (p < 0.05) and this was not related to age. The further combined biological and epidemiological studies are necessary to investigate the roles of copper and zinc in breast cancer.

Simultaneous bilateral spontaneous pneumothorax report of 12 cases and review of the literature.

Simultaneous bilateral spontaneous pneumothorax (SBSP) is a very rare condition, mainly seen in patients with underlying lung disease. Up to now, there are 65 patients who have been published. Twelve consecutive patients who presented with SBSP as definitive diagnosis were recruited for this study. They represented 1 % of all patients with spontaneous pneumothorax. All patients had immediate bilateral chest tubes on admission. Five of the 12 patients (42%) had no underlying lung disease. In 7 patients, SBSP was secondary to pulmonary metastases, histiocytosis X, undefined interstitial pulmonary disease, tuberculosis, pneumonia and chronic obstructive pulmonary disease. None of the patients died during hospitalization. Eleven patients were treated with chemical pleurodesis, whereas thoracotomy and pleurectomy were necessary in 7 patients. Reexpansion of the lungs was achieved in all patients. Immediate bilateral chest tube insertion and pleurodesis are of major importance in the treatment of SBSP although a subset of patients needed surgical pleurectomy. Combination of these treatments provides successful and uneventful treatment of the disease.

Treatment of multiloculated empyema thoracis using minimally invasive methods.

INTRODUCTION: The purpose of this study was to investigate the results of minimally invasive treatment modalities in early stage multiloculated empyema thoracis. METHODS: The minimally invasive treatment modalities of 114 patients with Class 5 thoracic empyema were retrospectively reviewed. The patients' demographics, symptoms, diagnostic studies, treatment options and complications were evaluated. RESULTS: A total of 47 patients underwent tube thoracostomy, 23 patients underwent fibrinolytic therapy with streptokinase and 44 patients underwent video-assisted thoracoscopic surgery (VATS) deloculation and debridement. No statistical differences were found in the patients' age, gender, Gram stain and antibiotherapy before intervention among the groups. Illness days before intervention was significantly longer in the tube thoracostomy group than in the others. The VATS group had a shorter drainage time and hospital stay than the others. The VATS and fibrinolytic therapy groups had lower complication rates and less open decortication requirements than the tube thoracostomy group. Success rates were 66, 95 and 100 percent in the tube thoracostomy, fibrinolytic therapy and VATS groups, respectively. In total, there were 35 patients with complications. The most frequent complication was air space. Two inhospital mortalities occurred. CONCLUSION: In patients with early stage multiloculated empyema, VATS deloculation and debridement is superior to tube thoracostomy alone and fibrinolitic therapy in reducing drainage time and hospital stay. It has a relatively high success rate without significant morbidity. Therefore, VATS decortication may be recommended as a first-line therapy in early stage multiloculated empyema thoracis.

Surgical treatment of superior sulcus tumors: results and prognostic factors.

BACKGROUND: This study aims to investigate the treatment modalities and factors influencing survival in surgically treated superior sulcus tumors. PATIENTS AND METHOD: Sixty-five cases of surgically treated non-small cell carcinoma of the lung occurring as superior sulcus tumors between 1994 and 2007 were retrospectively reviewed. Twenty-five patients underwent induction radiotherapy (RT), 10 had induction chemoradiotherapy (CT/RT). In thirty patients surgery was performed directly. The mortality rate was 6.2 %. Pathological stage was T3 in 55, T4 in 10, N0 in 52, and N1 in 5 and N2 in 8 patients. RESULTS: Overall 5- and 10-year survival rates were 31 % and 28 %, respectively. Complete resection rate was 90 % for patients who received induction CT/RT and 80 % for patients who either received induction RT alone or patients in whom surgery was performed directly. In patients who received neoadjuvant therapy with complete tumor resection, the median survival time was 33 months (28 months for patients who received induction RT alone and 36 months for patients who received induction CT/RT), and the 5-year survival rate was 41 %. Median survival time and 5-year survival rate of patients treated by direct surgery with complete resection was 24 months and 37 %, respectively ( P = 0.87). Five-year survival and 10-year survival rates were significantly higher after complete resection than after incomplete resection (38 % and 34 % vs. 0 %, P = 0.0001). In multivariate analysis, only N2 disease ( P = 0.04) and incomplete resection ( P = 0.03) were found to be poor prognostic factors. CONCLUSION: The presence of N2 disease and incomplete resection are the two most important factors affecting survival. Induction CT/RT may increase the ability to achieve complete surgical resection.

Factors affecting morbidity in chronic tuberculous empyema.

BACKGROUND: Chronic empyema is not a rare complication of pulmonary tuberculosis. Various treatment modalities ranging from open drainage to pneumonectomy, depending on the status of the disease, have been used to treat this complication. However, the best strategy for this disease remains unknown. This study examined the results of different treatment strategies for chronic tuberculous empyema. METHODS: Between January 1993 and December 2002, 36 patients (29 male and 7 female) with an average age of 29.3 years (range 13 - 52 years) presented with chronic tuberculous empyema characterized by empyema cavity and persistent pleural infections that were secondary to tuberculosis. The series consisted of patients who had had tube thoracostomy and underwater drainage without complete re-expansion. All patients were treated with open drainage. Of these, 6 patients had Eloesser flap for complete drainage of pleural pus and resolution of pleural infection. RESULTS: Eloesser-flap drainage resulted in a higher morbidity compared to the open-drainage-only method ( P = 0.011). Pneumonectomy, used as a final therapeutic option, resulted in more complications postoperatively ( P = 0.034). Antituberculosis therapy lasting six months or longer reduced the morbidity rate (54 % vs. 33.3 %), but the difference was not significant. CONCLUSIONS: Our findings indicate that open drainage leads to better results compared to those of Eloesser flap in patients with chronic tuberculous empyema. Patients who underwent pneumonectomy were expected to have higher complication rates and the procedure must therefore be avoided when possible.

Is lobe-specific lymph node dissection appropriate in lung cancer patients undergoing routine mediastinoscopy?

BACKGROUND: The extent and the necessity of lymph node dissection has yet to be defined after resectional surgery for lung cancer. We aimed to analyze the lobe-specific extent of lymph node positivity in patients who underwent preoperative mediastinoscopy as a routine strategy. METHODS: A total of 280 patients with non-small cell lung cancer with negative mediastinoscopy were operated on in our center between January 1997 and June 2003. Hilar and mediastinal lymphadenectomy was performed in every patient. RESULTS: The most commonly involved lymph nodes were found to be paratracheal station lymph nodes (n = 83; 96.5 %) for right upper lobe tumors, subcarinal station lymph nodes (n = 52; 88.1 %) for right lower lobe carcinomas, aorticopulmonary lymph nodes (n = 62; 92.5 %) for left upper lobe and subcarinal station lymph nodes (n = 49; 96.0 %) for left lower lobe tumors. In the patients with right upper lobe, right lower lobe and left lower lobe tumors, the presence of a tumor at these stations was found to be an indicator for poor prognosis ( P = 0.033, P = 0.0038 and P = 0.0016, respectively). Patients with multiple station N2 disease did not survive beyond 3 years. CONCLUSIONS: In patients who underwent routine mediastinoscopy, lobe-specific lymph node dissection could be recommended. Patients with multilevel N2 involvement did not seem to benefit from resectional surgery.

Thoracic surgical operations performed under local anesthesia and sedation for diagnosis and treatment.

Generally, the operative procedures for the diagnosis or treatment of mediastinal, intrathoracic and/or chest wall lesions requiring rib resection are performed under general anesthesia. Although evidence suggests that thoracoscopy can be performed under local anesthesia, no report has indicated that some major thoracic procedures can be accomplished without general anesthesia. In our study, we advocate that certain surgical procedures could be performed under local anesthesia with a performance similar to that of general anesthesia. Thirty patients underwent thoracic procedures with local anesthesia and sedation for diagnosis and treatment. Seventeen of the patients were men, and the mean age of the patients was 49.6 years (range 16 to 71 years). There were 13 diagnostic procedures, and 17 procedures were for treatment purposes. The operative procedures performed using only local anesthesia were mini-thoracotomy (n = 9), mediastinotomy (n = 4), revision of a full-thickness posterolateral thoracic incision (n = 7), resection of the chondroma (n = 4), Eloesser flap (n = 1), metastasectomy of the chest wall (n = 3), empyectomy (n = 1), and video-assisted thoracoscopy (n = 2). Severity of pain was evaluated by VAS. There were no oral or intravenous analgesic requirements in the early postoperative period. No complications attributable to the procedure were observed. Thoracic surgical procedures for diagnosis and treatment performed under local anesthesia are simple, effective, economical and comfortable for the patient.

Transcutaneous electric nerve stimulation for the treatment of postthoracotomy pain: a randomized prospective study.

BACKGROUND: Insufficient relief of postthoracotomy pain is a major cause of increased rates of postoperative complications including inadequate coughing, mucous plugging, hypoxia, compromised ventilation or even bacterial lung infection. We aimed to assess the efficacy of transcutaneous electric nerve stimulation (TENS) in patients with postthoracotomy pain. METHODS: Forty patients scheduled to undergo posterolateral thoracotomy were randomly allocated to receive either TENS or patient-controlled intravenous morphine. Postoperative pain was evaluated using a visual analogue scale (VAS) and the Prince Henry pain scale. Pulmonary function was evaluated and an intergroup comparison was done. RESULTS: On the first three days following surgery, the VAS intensity of the TENS group did not differ significantly from that of the morphine group ( P > 0.05), and on the first two days following thoracotomy, the Prince Henry scale of the TENS group was not statistically significantly different. However, the VAS intensity was significantly lower than that of the control group on the fourth ( P = 0.044), fifth ( P = 0.016), sixth ( P = 0.009), seventh ( P = 0.008), eighth ( P = 0.004), ninth ( P = 0.002), tenth ( P = 0.001), fifteenth ( P = 0.002), thirtieth ( P < 0.001), forty-fifth ( P < 0.001) and sixtieth ( P < 0.001) days. The Prince Henry scale of the TENS group was found to be significantly diminished from the 3rd to the 60th day. TENS significantly reduced the analgesic requirements from day 5 to 60 ( P < 0.01). No noticeable side effect was observed in the TENS group during the study period. CONCLUSION: This study demonstrated that TENS provided a better pain relief and comfort compared to PCA from the fourth postoperative day onwards, and this pain-reducing effect continued for at least two months postoperatively.

Preoperative prediction of postoperative complications.

The value of history taking, physical examination and routine laboratory tests as predictors of postoperative complications was investigated in 100 patients undergoing major surgery. Major and minor risk markers were identified and compared with major and minor postoperative complications. The results proved this approach to be a simple, inexpensive and reliable method for the prediction of postoperative complications.