Comparison of 18F-FDG PET/CT and MDCT for staging/restaging of non-small cell lung cancer.

UNLABELLED: Multi-detector computed tomography (MDCT) is most commonly used for staging of non-small cell lung cancer (NSCLC). In recent years, 18F- fluorodeoxyglucose positron emission tomography combined with computed tomography (18F-FDG PET/CT) has also been used for the same purpose. Since studies comparing these two methods are scarce, our aim was to determine how the TNM classification and thereby staging of NSCLC compare between 18F-FDG PET/CT and MDCT. 18F-FDG PET/CT and MDCT were collected in 83 patients with NSCLC 3 to 30 days apart (median 17 days). The investigators interpreting 18F-FDG PET/CT were unaware of MDCT results. The Cohen's kappa (κ) was calculated to determine the rate of agreement. The hypothesis was that the strength of agreement between the two methods will be at least moderate (κ>0.40) based on the adopted criteria (κ<0.20 poor; 0.21-0.40 fair; 0.41-0.60 moderate; 0.61-0.80 good; 0.81-1.00 very good agreement). The agreement was moderate for determining the T class (κ=0.45, overall agreement 58%), poor for the N class (κ=0.13, 42%) and fair for the M class (κ=0.22, 58%). The agreement for overall staging of NSCLC was poor (κ=0.20, 45%). The major source of disagreement was that metastases were present more frequently and/or in larger number on 18F-FDG PET/CT than MDCT in the contralateral mediastinal, supraclavicular, and distant lymph nodes, as well as in the bones and suprarenal glands. Since 18F-FDG PET/CT detected more regional and distant metastases than MDCT, we conclude that FDG PET/CT is useful for staging/restaging and planning treatment of patients with NSCLC. KEYWORDS: Non-small cell lung cancer, positron emission tomography, multidetector computed tomography, metastases detection.

Spontaneous pneumothorax: remaining controversies.

Despite many guidelines issued by national and professional societies, a detailed literature survey between the late 1940s and 2010 clearly demonstrates that several aspects of pneumothorax pathogenesis and treatment still remain controversial. Related to pathogenesis of primary pneumothorax, the current manuscript highlights why further studies are needed to explain 1) mechanism of the oxygenation impairment in presence of a large pneumothorax; 2) oxygenation differences between age and sex-matched patients with a pneumothorax of the same size; and 3) sequence of events in tension pneumothorax. Concerning the overall therapeutic approach, video-assisted technology provides a minimally invasive operative treatment. For this reason methods of recurrence prevention are now shared between interventional pulmonologists and thoracic surgeons. Although a significantly higher recurrence rates was reported in patients with primary spontaneous pneumothorax after simple pleural drainage versus thoracoscopic talc poudrage, (34% and 5% respectively), such a policy is still not widely adopted. Certain concerns that relate to the use of talc in relapse prevention are also discussed, showing that they are mostly dependent on the type of the talc used. Concerning secondary pneumothorax, specificities of different forms related to diagnostics and therapeutic approach are also pointed out. Lung tuberculosis as the underlying cause is particularly addressed, due to the challenge of the timely recognition of specific lesions and prompt initiation of the antituberculous medical treatment . Similarly, lung cancer is mentioned as a possible underlying cause in patients with delayed lung expansion.

Clinical patterns and treatment outcome in resected elderly lung cancer patients.

PURPOSE: Lung cancer is the leading cause of cancer related morbidity and mortality worldwide. The aim of this study was to determine the clinical patterns and their impact on surgical resection in patients with non-small cell lung cancer (NSCLC)> 70 years. METHODS: We reviewed the records of 2050 resected lung cancer patients in a 5-year period from 2002-2007, out of whom 93 were > 70 years. RESULTS: There were 73 males and 20 females with median age of 71 years (range 70-78). Nineteen (20.43%) patients underwent pneumonectomy, 6 (6.45%) extended pneumonectomy, 54 (58.06%) lobectomy, 8 (8.61%) extended lobectomy, and 3 (3.23%) bilobectomy and wedge resection each. There were 37 (39.8%) resected patients with locally advanced (IIIA, IIIB) or advanced stage (IV) of NSCLC. A total of 48 complications occurred. The 30-day mortality rate was 1.08% (one patient). Pathological stage (p<0.001) and application of adjuvant therapy (p<0.001) were predictors of long-term survival. The overall 3- and 5-year actuarial survival rates were 46% and 28%, respectively. CONCLUSION: Advanced age should not be considered as a contraindication for NSCLC resection. However, careful preoperative assessment must be undertaken. The presence of comorbidities and extent of resection predict increased operative risk. Pathological stage and application of adjuvant therapy were the only predictors of long-term survival.

Hormonal therapy after the operation for catamenial pneumothorax - is it always necessary?

BACKGROUND: Our recent clinical observations put into question the routine hormonal therapy for pneumothorax recurrence prevention, in patients operated for catamenial pneumothorax (CP). METHODS: Retrospective review of the treatment of four women operated for CP in a recent 32-months period. RESULTS: The four presented patients with CP represent 4.8 % of the overall number of patients operated for spontaneous pneumothorax and 19 % of women operated for pneumothorax in the same period. In all patients, typical multiple diaphragm holes existed. The involved part of the diaphragm was removed with diaphragm suture in three patients, whilst in one patient, a diaphragm placation was done. Endometriosis was histologically confirmed in two patients. During the follow-up period of 6-43 months, none of the patients underwent a postoperative hormonal therapy for different reasons, and in none of them the pneumothorax recurrence occurred. CONCLUSION: The clinical course of these patients, with the absence of the pneumothorax recurrence despite the omission of the hormonal treatment, suggests that the appropriateness of the routine hormonal treatment with gonadotrophin-releasing hormone analogues for 6-12 months, should be reconsidered and re-evaluated in further studies.

Uncertainties in the current understanding of gas exchange in spontaneous pneumothorax: effective lung ventilation may persist in a smaller-sized pneumothorax.

Clinical aspects of spontaneous pneumothorax (SP) are far more clear than some patophysiological issues. The exact mechanism that maintains adequate oxygenation in spontaneous pneumothorax of lesser size is still unclear. Experimental and rare studies in humans could not explicitely confirm whether it is hyperventilation of the nonaffected lung, still effective gas exchange within the affected lung, or hypoxic vasoconstriction. Similarly, it is unclear why the severity of dyspnoea sometimes differs between patients with the same size of SP. The idea that a certain degree of effective lung ventilation might exist in SP of lesser size was based on clinical observation of these patients on admission, on our measurements of pleural pressures and oxygenation in a group of patients with SP of different size and on rare experimental studies. Clinical observation that oxygenation was not significantly impaired in patients with SP of lesser size, without documented hyperventilation, served as a base for critical analysis of possible factors influencing oxygenation in SP of lesser size. Our hypothesis that pleural pressure swings in a partially collapsed lung, but still slightly expanding in inspiration, enable a certain degree of gas exchange, was confirmed both by several experimental studies and by our measurements. On the other hand, our clinical observation that patients with SP of greater size frequently differ in the severity of dyspnoea suggested the need of a more detailed analysis of the causes of hypoxaemia in these patients. The fact that hypoxaemia in these patients usually cannot be abolished by the existing hyperventilation, means that in SP of greater size, despite minimal lung volume, circulation in the pulmonary artery system still exists, causing right to left blood shunting. The fact that the severity of dyspnoea is not equal in all patients with complete SP means that hypoxic vasoconstriction exists only in some of them, following a still unknown pattern. Literature data and our measurements suggest that without further studies of hypoxic vasoconstriction in the acute phase of SP, the exact answer is not possible.

Does preoperatively created right to left shunt adequately reflect hypoxemia during pneumonectomy for lung cancer?

BACKGROUND: No method is currently available for preoperative approximation of the patient's situation to the one existing during pneumonectomy in general anesthesia with alternations of single and double-lung ventilation in the lateral position. We hypothesized that a patient breathing the room air in the sitting position, with the main bronchus occluded by the inflatable catheter (aimed to predict a postpneumonectomy ventilatory function), could, at least in some aspects, simulate the intraoperative situation in certain clinical conditions discussed in the text. To evaluate the hypothesis, we used data of 15 candidates for pneumonectomy at increased risk, who underwent a spirometry with the left man bronchus occluded, as a part of the postoperative lung function prediction. Arterial blood samples (pO2, pCO2, saturation, and pH) were obtained before placement of the Fogarty catheter, than after at least 60s of normal breathing with the main bronchus occluded. Significant drop in pO2 (10.35±1.65 vs. 7.79±1.40 kPa) ensued within 1 min after occlusion of the main bronchus. All patients were able to perform spirometry in presence of induced hypoxemia without dyspnea that would require cessation of the procedure. These results, together with the absence of cardiac rhythm disorders, lead us to believe that they would behave in the same way during a pneumonectomy with alternations of single and double-lung ventilation. Such an assumption is based on the fact that breathing the room air is less favorable from the standpoint of oxygen delivery--the content of oxygen in the room air is smaller in the room air compared to that delivered through endotracheal tube. The practical implication of this hypothesis is that assessment of oxygenation during this procedure, additionally facilitates the preoperative risk assessment in patients undergoing pneumonectomy for lung cancer. Moreover, a slight postoperative oxygenation improvement and smaller loss in FEV1 in patients with moderate COPD, mean that COPD patients are likely to do a little bit better postoperatively than predicted.

Pure red-cell aplasia as the presenting feature of the carcionoid tumor of the thymus: case report.

Acquired pure red-cell aplasia (PRCA) is an uncommon disorder of erythrocytopoiesis that can develop in association with thymic tumors. We present the very rare case of a severely anemic 62-year-old man with PRCA and a concurrent neuroendocrine carcinoid tumor of the thymus. The anterior mediastinal thymus tumor was completely excised, and following histological and immunohistochemical analyses (showing positive staining for cytokeratin, chromogranin A, synaptophysin, and neuron-specific enolase) the diagnosis of a (grade I; T(1)N(0)M(0)) typical carcinoid tumor of the thymus was made. Postoperatively the anemia persisted despite no signs of residual tumor on CT chest. A hematological work up found: normocellularity with <0.5% erythroblasts and preserved megakaryocytopoiesis and granulocytopoiesis in a trephine biopsy; reduced numbers of Colony Forming Unit Erythroid (CFU-E) and normal numbers of Burst-Forming Unit Erythroid (BFU-E) in bone marrow colony-forming assays; a markedly increased level of serum erythropoietin; normal T and B-cell numbers with a normal CD4/CD8 ratio; and no clonal T-cell receptor -gamma and -delta gene rearrangement) The patient responded favorably to a therapeutic trial of glucocorticoid immunosuppressive treatment (prednisone 1 mg/kg/day) with a normalization of the reticulocyte count and hematocrit, suggesting an immunologic mechanism for the PRCA. Though the exact mechanisms underlying the association between the PRCA and the carcinoid tumor of the thymus remain unknown.

[Indications and results of resection surgical approach in localized type of bronchiectasis].

Although the prevalence of bronchiectasis decreased significantly in developed countries, in less developed and in developing countries, it still represents a significant cause of morbidity and mortality. The localised form of bronchiectasis is the indication for surgical treatment if recurrent respiratory infections make normal life and professional activity impossible. Less frequently, the operation is necessary independently on the symptoms duration, if massive hemoptysis are life threatening for the patient. Compared with the period 10-15 years ago, the diagnostics of bronchiectasis changed in terms that bronchography has been replaced by high resolution CT scan. Owing to angiographic studies performed on sufficient number of patients, the patophysiology of bronchiectasis is furtherly highlited, but without significant changes in the process of patient selection. In the text, particular accent was given to situations that usually represent practical problems: billateral bronchiectasis, hemoptysis, bronchiectasis after pleural empyema, abscending bronchiectasis and bronchiectasis in children. The outcome of the surgical treatment is good in 90% patients, with operative mortality thatis comparable to that after lung resections for other indications.

[Complications on skin and subcutaneous tissue among drug addicts caused by non sterile intra venous injections and burns].

The use of psychoactive substances causes various consequences and is harmful for all organs. Some of the health consequences among intravenous drug users are HIV infections, hepatitis C, local tissue infections after drug injection, family, professional and social consequences. Throught the world various harm reduction programs are established in order to educate drug users about safer drug injecting techniques, with the use of sterile needles and materials for disinfection of the drug injecting area. Authors presented epidemiological data, consequences on extremities after non sterile drug injecting and accidental burns, harm reduction programs as well as other guidelines in this field. In three case reports of intravenous drug addicts with surgical complications on the extremities and burns, surgical and anaesthesiological approaches were described. Special emphasis was given to preoperative preparations and the postoperative treatment as well as social-psychiatric aspect.

["I am sorry, I have bad news... "- principles in informing patients on the gravity of a disease and the treatment].

The discovery of the appearance of a serious disease, and the necessity for diagnostics, treatment and rehabilitation, particularly when malignity is involved, represents exceptionally stressful news for the patient and his family. Most often this is a task for the physician. In this paper the authors consider the meaning of bad news in unexpected life events which significantly disturb the individual psycho-social ballance of the patient, as well as the familly dynamics and structure. It presents a review of available literature on the subject of the definition of so-called "bad news", the development of approaches in announcement, and current practical approaches and models which assist physicians in helping suffering patients in professional and humane ways. It points out inadequacies in the education of phisicians for this kind of task, and the variety of approaches. With the aim of improving the education of phisicians, and especially clinicians in surgical fields, the authors recommend a number of educational programs: education in the area od psychological and psychiatric aspects of learning of a serious disease, including acute reactions such as depressive states, reactive psychotic states, consumption of alcohol, etc.; education in the area of the family life cycle, and the effect of the disease as an unexpected life crisis on the family dinamic; education in the area of fundamental principles of psycho-and pharmaco-therapy, as well as the provision of support to the patient and his familly; training in the skills of announcing bad news to the patient and his familly through the explanatory presentation of the case and supervised simulation of sessions.

[Palliative operations for lung cancer].

The goal of the palliative resection can be threefold: relief of symptoms without expected survival benefit, obviation of an urgent situation and maintenance or restoration of a good quality survival. Clear distinction should be made between this type of operation and incomplete resection: in spite of a curative intent, the latter type of operation is characterized either by residual disease or positive most distal lymph node station. Classification of palliative operations for lung cancer based on the underlying pathology seems to be most suitable for clinical use: 1) tumours without extrapulmonary extension; 2) tumours with direct involvement of adjacent organs; 3) metastatic involvement of intrathoracic or distant organs; 4) lung tumours associated with nonmalignant pathology (lung suppuration, pleural empyema). Although palliative operations for lung cancer can be considered in carefully selected patients, they should always be avoided if other, less aggressive non-surgical procedures offer the same quality of palliation.

[Nontraumatic subcutaneous emphysema. Diagnostic and therapeutic problems]. / Netraumski potkozni emfizem. Dijagnosticki i terapijski problem.

Nontraumatic subcutaneous emphysema is less frequent than traumatic. Its occurrence, unless synchronous with the treatment of spontaneous pneumothorax, usually is the consequence of exacerbation of COPD or of the obstruction of major bronchi. However, in routine clinical practice, the occurrence of subcutaneous emphysema without evident underlying disease, in combination with normal chest x-ray, still is a diagnostic and therapeutic problem. In this study typical mechanisms of this phenomenon are presented; air-trapping at the level of the main bronchus caused by endobronchial tumour growth, progressive destruction of alveoles by diffuse lung disease irrespective of its nature, and mechanism of its occurrence during dealing with the urgent clinical problem in the intensive care unit. This study does not deal with subcutaneous emphysema during the attack of severe asthma assuming it as well known situation that usually does not cause a major therapeutic problem. The sequence of necessary diagnostic and therapeutic steps is discussed taking account of possible pitfalls that usually exist in all of three described pathophysiological situations.

[The effect of performance of diagnostic and therapeutic procedures on successful treatment of hemopneumothorax in isolated thoracic trauma]. / Uticaj sprovedenih dijagnostickih postupaka i primenjene terapije na uspeh lecenja hemopneumotoraksa pri izolovanoj traumi grudnog kosa.

Influence of performed diagnostic and therapeutic procedures on the outcome of the treatment of traumatic hemopneumothorax during isolated chest trauma. The aim of this study is the assessment of the influence of performed diagnostic and therapeutic procedures on the outcome of hemopneumothorax as a part of isolated chest trauma. The main group consists of 51 patients with hemopneumothorax. Patients with pneumothorax without effusion represent the first control group; the second control group consist of patients treated because of iatrogenic pneumothorax. In the main and control groups the analysis of clinical, roentgenographic and functional parameters was made, together with the analysis of particular therapeutic procedures, the estimation of the success of the treatment was based on roentgenographic and functional parameters. The higher incidence of hemopneumothorax compared with control groups during chest trauma in the analyzed material is statistically significant. The occurrence of bilateral hemopneumothorax in 10% of cases emphasizes the need of adequate roentgenographic assessment of injured patients. Regardless of the intensity of the trauma, symptoms do not always indicate the existence of hemopneumothorax. The number of fractured ribs is not of significant importance in terms of the occurrence of hemopneumothorax or pneumothorax. Severe dyspnea can be accompanied even with a smaller collapse of the lung independently of the amount of blood in the pleural cavity. Oxygenation in the arterial blood is impaired with the great and small pulmonary collapse. Hemodynamic disorders existed in 14% all cases. The higher frequency of operative treatment in the main group is statistically significant. The majority of cases of traumatic hemopneumothorax can be successfully treated by the conservative treatment. Accompanying complications do not have greater influence on the outcome.

Diffuse primary plasmacytoma of the lung.

Primary plasmacytoma of the lung is a rare tumor, thus presenting a diagnostic challenge to the clinician. So far, approximately 20 cases have been verified by immunohistochemistry. We describe an elderly patient presenting with progressive dyspnea on exertion, dry cough, weight loss and malaise. The main finding on plain chest radiography was a diffuse infiltration of pulmonary parenchyma in the lower parts of both lungs and in the middle part of the right lung. The histology of the open lung biopsy of the right middle lobe revealed massive and diffuse infiltration by well differentiated plasma cells with extracellular deposits of amyloid. The plasma cells and amyloid expressed a monoclonal lambda light chain. No monoclonal spike was shown by serum and urine immunoelectrophoresis. A skeletal survey and bone marrow biopsy specimen excluded a disseminated disease and a diagnosis of extramedullary plasmacytoma was made. The patient was considered for VI courses of VMCP chemotherapy after which a complete regression on chest roentgenography was evident. Almost five years after the diagnosis the patient is still alive without any evidence of disease recurrence or dissemination.

[Prognostic factors in resectable non-small-cell bronchial carcinoma]. / Prognosticki faktori resektabilnog primarnog nemikrocelularnog karcinoma bronha.

This study represents the univariate and multivariate analysis of prognostic factors of resectable non small cell-lung cancer (NSCLC) that included 360 patients who underwent a surgical treatment because of primary (NSCLC) in the aforementioned institution in a period between 1985 and 1992. Patients with incomplete resection were rejected, perioperative deaths were not included in the analysis. In the analysed group there were 2931 (81.38%) males and 67(18.62%) females--M:F ratio 4.37:1. Age of the operated patients was 36-75 years with the mean age of 55.15 years. Right-sided tumours existed in 197(54.72%) patients, left-sided tumours in 163(45.28%) patients. Based on pTNM, 157, 65, 114, 18 and 6 patients were classified into stages I, II, IIIA, IIIB and IV respectively. In the univariate analysis, survival curves were obtained using the life table method, with the statistical analysis of the obtained data using the Gehan-Wilcoxon method. In the multivariate analysis--Cox regression analysis was performed. Multivariate analysis found only T-stage, N-stage and the stage of the disease as significant independent prognostic factors. Mode of influence of factors that were found significant in the univariate analysis (age 60 years, tumour diameter 60 mm, involvement of the visceral pleura, indirect tumour signs) is discussed and compared with literature data. Survival differences depending on other factors (tumour location, bronchoscopic aspect, extent of the resection), although without statistical significance, can be useful for the clinician, in the same time contributing to the better comprehension of informations obtained by basical investigations, especially of lymphatic spread of the disease and tumour pathology.